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From the 11/12/2021 release of VAERS data:

This is VAERS ID 417899

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Case Details

VAERS ID: 417899 (history)  
Form: Version 1.0  
Age: 0.34  
Sex: Male  
Location: D.C.  
Vaccinated:2011-02-23
Onset:2011-02-24
   Days after vaccination:1
Submitted: 2011-03-02
   Days after onset:6
Entered: 2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 1 MO / PO

Administered by: Other       Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Endotracheal intubation, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting
SMQs:, Acute pancreatitis (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-02-24
   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: ZANTAC; POLY-VI-SOL
Current Illness: none
Preexisting Conditions: Prematurity (25 wks); GERD; apnea; BPD; ichthyosis; pulm valve stenosis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Threw up after a feed, then apnea monitor kept alarming. To ED - found to have slow, shallow respirations. Became apneic/pulseless - unable to resuscitate despite intubation/CPR. Time of death 4:31 PM.


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