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From the 11/26/2021 release of VAERS data:

This is VAERS ID 414719

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Case Details

VAERS ID: 414719 (history)  
Form: Version 1.0  
Age: 0.15  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2011-01-11
Onset:2011-01-12
   Days after vaccination:1
Submitted: 2011-01-14
   Days after onset:2
Entered: 2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Death, Irritability, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-01-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: DIGOXIN; ASA; LASIX; POLYVISOL w/Iron
Current Illness: fussy per parents day before vaccines
Preexisting Conditions: Double outlet right ventricle; mitral atresia; pulmonary atresia; s/p aortopulmonary shunt 11/19/2010
Allergies:
Diagnostic Lab Data: Not available
CDC Split Type:

Write-up: Day after vaccines pt. sleepy, fussy. Two days after vaccines pt died.


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