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From the 1/14/2022 release of VAERS data:

This is VAERS ID 337130

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Case Details

VAERS ID: 337130 (history)  
Form: Version 1.0  
Age: 0.3  
Sex: Male  
Location: Texas  
Vaccinated:2008-12-23
Onset:2008-12-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2009-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B204BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF517AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D16279 / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1169X / 2 MO / PO

Administered by: Private       Purchased by: Private
Symptoms: Autopsy
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2008-12-24
   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: 33 week premature twin PMH: 33 week preemie twin, NICU x 3 weeks Family hx: parents w/hypothyroidism & psoriasis; others w/protein S factor deficiency, DM, HTN, asthma
Allergies:
Diagnostic Lab Data: Autopsy - report not available.
CDC Split Type:

Write-up: Pt. examined and vaccinated on 12/23/08 for well visit - normal exam. Pt found by parent in crib morning of 12/24 apneic - SIDS is preliminary cause of death - coroner''s report not available. 2/2/09 Received Autopsy Report which states COD as sudden unexplained death in an infant & manner of death as undetermined. 2/2/09 Autopsy report also states patient experienced cold s/s. Last seen by PCP on 12/23/08 for vaccinations, had been given Tylenol x 3 doses. Was fed & had been placed in crib face down w/head turned to side & 2 blankets on. 2/4/09 Received PCP office & vaccine records. Records reveal patient in good health on 12/23/08 w/only dry patchy areas on legs & back & left eye turning intermittently.


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