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From the 9/17/2021 release of VAERS data:

This is VAERS ID 287915



Case Details

VAERS ID: 287915 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Male  
Location: Iowa  
Vaccinated:2007-08-02
Onset:2007-08-06
   Days after vaccination:4
Submitted: 2007-08-13
   Days after onset:7
Entered: 2007-08-14
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF117AA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B20510B / 1 RL / IM

Administered by: Private       Purchased by: Public
Symptoms: Autopsy, Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2007-08-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Preterm Birth HX: mother required 1 mo hospitalization prior to birth & had uterine rupture during delivery. Seen on weekly basis by pcp & HH nurse. Had no signs of illness prior to death.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 8/6/07 presumed SIDS, autopsy pending. 8/23/07 Received prelim autopsy report from coroner. COD is pending. Patient was 34 wk preemie twin. Mother had been hospitalized x 1 mo prior to delivery for uterine rupture. Patient was on home monitor. Found lying on side co-sleeping w/twin in crib. 10/5/07 Reviewed autopsy report which states COD as SIDS with prone sleeping position; twin gestation & manner of death as natural. Pathologic dx include: premature birth (34 wk), mild right ventricular dilatation and pulmonary edema.


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