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This is VAERS ID 414719

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2011

VAERS ID: 414719
VAERS Form:
Age:0.2
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Irritability, Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 4/13/2011

VAERS ID: 414719 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Death, Irritability, Somnolence, Mitral valve atresia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 5/13/2011

VAERS ID: 414719 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Cardiac arrest, Death, Irritability, Somnolence, Mitral valve atresia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 5/13/2013

VAERS ID: 414719 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Irritability, Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 6/14/2014

VAERS ID: 414719 Before After
VAERS Form:
Age:0.2
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Irritability, Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 2/14/2017

VAERS ID: 414719 Before After
VAERS Form:
Age:0.2 0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Irritability, Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 4/14/2017

VAERS ID: 414719 Before After
VAERS Form:
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Irritability, Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 9/14/2017

VAERS ID: 414719 Before After
VAERS Form:(blank) 1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
Entered:2011-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3582AA / 0 1 LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. 0657Z / 1 2 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914515 / 0 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB110A / 0 1 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death, Irritability, Somnolence

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 2/14/2018

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 6/14/2018

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 8/14/2018

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 9/14/2018

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 10/14/2018

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 12/24/2020

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 12/30/2020

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 5/7/2021

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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.


Changed on 5/14/2021

VAERS ID: 414719 Before After
VAERS Form:1
Age:0.15
Sex:Female
Location:Pennsylvania
Vaccinated:2011-01-11
Onset:2011-01-12
Submitted:2011-01-14
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-01-13
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: 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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