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This is VAERS ID 288471

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 288471
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Unavailable
CDC 'Split Type':

Write-up: Prelim reported that pt''''s vomited and gone to respiratory arrest.


Changed on 12/8/2009

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Unknown Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''''s pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 3/2/2010

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 4/7/2010

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 8/31/2010

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 4/13/2011

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 5/13/2011

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 6/11/2011

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 5/13/2013

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 0 - / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 5/14/2017

VAERS ID: 288471 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 0 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Fatigue, Respiratory arrest, Vomiting, Toxicologic test abnormal, Adrenogenital syndrome

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 9/14/2017

VAERS ID: 288471 Before After
VAERS Form:(blank) 1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 0 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 0 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 0 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 0 1 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 2/14/2018

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 6/14/2018

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 8/14/2018

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 9/14/2018

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 10/14/2018

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 12/24/2020

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 12/30/2020

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 5/7/2021

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.


Changed on 5/14/2021

VAERS ID: 288471 Before After
VAERS Form:1
Age:0.2
Sex:Female
Location:California
Vaccinated:2007-08-16
Onset:2007-08-17
Submitted:2007-08-20
Entered:2007-08-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B114BB / 1 - / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0077U / 1 - / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08700H / 1 - / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Respiratory arrest, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2007-08-17
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Infant Tylenol
Current Illness: None
Preexisting Conditions: None Umbilical hernia
Allergies:
Diagnostic Lab Data: Unavailable Autopsy Findings: Acetaminophen level 13 mg/L & CAH 17-OHP level abnormal.
CDC 'Split Type':

Write-up: Prelim reported that pt''s vomited and gone to respiratory arrest. 8/21/07 Spoke w/MD who states patient was in good health on day of vax. Looked tired but exam was WNL. Family concerned only about umbilical hernia. 8/21/07 Received pcp medical records & vax records which confirm RO dose & lot # as reported. Records indicate patient was in good health on day of vax w/only medical concern umbilical hernia. 3/11/08 Autopsy report states COD as undetermined.

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