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From the 10/15/2021 release of VAERS data:

This is VAERS ID 413591



Case Details

VAERS ID: 413591 (history)  
Form: Version 1.0  
Age: 0.18  
Sex: Male  
Location: Kentucky  
Vaccinated:2010-12-07
Onset:2010-12-14
   Days after vaccination:7
Submitted: 2010-12-15
   Days after onset:1
Entered: 2010-12-28
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 1 MO / PO

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-12-14
   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:
Current Illness: None
Preexisting Conditions: None; Late PNC (No PNC until 6 mo gestation); Had not been to MD until 2 mo of age.
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: None stated.


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