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This is VAERS ID 413980

History of Changes from the VAERS Wayback Machine

First Appeared on 1/4/2011

VAERS ID: 413980
VAERS Form:
Age:0.4
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 1 LL / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 4/13/2011

VAERS ID: 413980 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 1 LL / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Sudden death, Autopsy, Necrotising colitis, Lymphoid tissue hyperplasia, Cardiac valve vegetation, Postoperative adhesion, Peritoneal disorder, Toxicologic test normal, Culture negative, Histology abnormal, Respiratory tract infection viral, Endocarditis noninfective

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 5/13/2011

VAERS ID: 413980 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 1 LL / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Sudden death, Autopsy, Necrotising colitis, Lymphoid tissue hyperplasia, Cardiac valve vegetation, Postoperative adhesion, Peritoneal disorder, Toxicologic test normal, Culture negative, Histology abnormal, Respiratory tract infection viral, Endocarditis noninfective

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 5/13/2013

VAERS ID: 413980 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 1 LL / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 2/14/2017

VAERS ID: 413980 Before After
VAERS Form:
Age:0.4 0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 1 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 1 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 9/14/2017

VAERS ID: 413980 Before After
VAERS Form:(blank) 1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 1 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 1 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 1 2 - MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 2/14/2018

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 6/14/2018

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 8/14/2018

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 9/14/2018

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 10/14/2018

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 12/24/2020

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 12/30/2020

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 5/7/2021

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.


Changed on 5/14/2021

VAERS ID: 413980 Before After
VAERS Form:1
Age:0.35
Sex:Male
Location:Louisiana
Vaccinated:2010-12-16
Onset:2010-12-17
Submitted:2011-01-03
Entered:2011-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3739AA / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 915065 / 2 LL / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB096A / 2 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Cardiac arrest, Death, Irritability, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-12-17
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:
Current Illness: None
Preexisting Conditions: s/p repair of duodenal perforation
Allergies:
Diagnostic Lab Data: autopsy - grossly normal
CDC 'Split Type':

Write-up: Became fussy with feeds 24 hours after vaccines given then went into cardiac arrest.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=413980&WAYBACKHISTORY=ON

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