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

This is VAERS ID 338821

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Case Details

VAERS ID: 338821 (history)  
Form: Version 1.0  
Age: 1.01  
Sex: Female  
Location: Washington  
Vaccinated:2009-01-21
Onset:2009-01-22
   Days after vaccination:1
Submitted: 2009-02-02
   Days after onset:11
Entered: 2009-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HEP A (HAVRIX) / GLAXOSMITHKLINE BIOLOGICALS AHAVB258AA / UNK RL / UN
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1120X / UNK UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D05879 / UNK UN / UN
VARCEL: VARICELLA (VARIVAX) / MERCK & CO. INC. 1389X / UNK UN / UN

Administered by: Private       Purchased by: Public
Symptoms:
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2009-01-22
   Days after onset: 0
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Unknown
Preexisting Conditions: No concomitant medications were noted in chart by parents. No relevant medical history. No noted adverse events following previous vaccinations. PMH: none
Allergies:
Diagnostic Lab Data: UNK. Labs: Tox screen (-). Blood cx (+) for Strep salivarius (contaminant). Lower respiratory cx (+) for moderate growth of Strep pneumoniae and heavy growth routine resp flora.
CDC Split Type: A0766166A

Write-up: This case was reported by a healthcare professional and described the occurrence of death nos in a 12-month-old female subject who was vaccinated with HAVRIX (GlaxoSmithKline), MMR II (strain not specified), VARIVAX and PREVNAR. On 21 January 2009 at 07:43, the subject received unspecified dose of HAVRIX (.5 ml, unknown, right thigh), unspecified dose of MMR II (unknown), unspecified dose of VARIVAX (unknown), and unspecified dose of PREVNAR (unknown). On 22 January 2009, 1 day after vaccination with HAVRIX, after vaccination with MMR II, PREVNAR, and VARIVAX, the subject experienced death nos. The healthcare professional considered the event was disabling, life threatening and clinically significant (or requiring intervention). The subject died on 22 January 2009 from death nos. It was unknown whether an autopsy was performed. It was reported the subject had "no history of illness or medical problems. Not on medications at time of death. Medical examiner stated undetermined cause of death on death certificate". 3/5/09 Autopsy report received with COD: Undetermined. Manner of Death: Undetermined. Child had presented to PCP earlier on the DOD with fever and URI sx. 4 vax given taht day. Child remained cranky and put down to nap. Approx 1 hour later found face down without pulse or respirations. Resuscitation unsuccessful.


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