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This is VAERS ID 413591

History of Changes from the VAERS Wayback Machine

First Appeared on 1/4/2011

VAERS ID: 413591
VAERS Form:
Age:0.2
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 4/13/2011

VAERS ID: 413591 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Petechiae, Pulmonary oedema, Sudden infant death syndrome, Bed sharing

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 5/13/2011

VAERS ID: 413591 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Petechiae, Pulmonary oedema, Sudden infant death syndrome, Bed sharing

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 5/13/2013

VAERS ID: 413591 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 0 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 2/14/2017

VAERS ID: 413591 Before After
VAERS Form:
Age:0.2 0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 0 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 9/14/2017

VAERS ID: 413591 Before After
VAERS Form:(blank) 1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B254BA / 0 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1246Z / 0 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E87535 / 0 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0982Z / 0 1 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 2/14/2018

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 6/14/2018

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 8/14/2018

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 9/14/2018

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 10/14/2018

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 12/24/2020

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 12/30/2020

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 5/7/2021

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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.


Changed on 5/14/2021

VAERS ID: 413591 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:Kentucky
Vaccinated:2010-12-07
Onset:2010-12-14
Submitted:2010-12-15
Entered:2010-12-28
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-14
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:
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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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=413591&WAYBACKHISTORY=ON

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