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This is VAERS ID 417899

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2011

VAERS ID: 417899
VAERS Form:
Age:0.3
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 4/13/2011

VAERS ID: 417899 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Bradycardia, Bronchopulmonary dysplasia, Condition aggravated, Death, Encephalopathy, Hypopnoea, Pulmonary valve stenosis, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Weight decreased, Body height below normal, Head circumference abnormal, Congenital pulmonary valve disorder, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 5/13/2011

VAERS ID: 417899 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Bradycardia, Bronchopulmonary dysplasia, Condition aggravated, Death, Encephalopathy, Hypopnoea, Pulmonary valve stenosis, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Weight decreased, Body height below normal, Head circumference abnormal, Congenital pulmonary valve disorder, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 5/13/2013

VAERS ID: 417899 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 6/14/2014

VAERS ID: 417899 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 2/14/2017

VAERS ID: 417899 Before After
VAERS Form:
Age:0.3 0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 4/14/2017

VAERS ID: 417899 Before After
VAERS Form:
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 9/14/2017

VAERS ID: 417899 Before After
VAERS Form:(blank) 1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
Entered:2011-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3815AA / 1 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915704 / 1 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1269Z / 0 1 - MO / PO

Administered by: Other      Purchased by: Public
Symptoms: Apnoeic attack, Condition aggravated, Death, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 2/14/2018

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 6/14/2018

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 8/14/2018

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 9/14/2018

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 10/14/2018

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 12/24/2020

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 12/30/2020

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 5/7/2021

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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.


Changed on 5/14/2021

VAERS ID: 417899 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:D.C.
Vaccinated:2011-02-23
Onset:2011-02-24
Submitted:2011-03-02
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, Hypopnoea, Pulse absent, Respiratory rate decreased, Resuscitation, Vomiting, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-02-24
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: 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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