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

This is VAERS ID 419371

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Case Details

VAERS ID: 419371 (history)  
Form: Version 1.0  
Age: 0.5  
Sex: Female  
Location: Illinois  
Vaccinated:2011-03-16
Onset:2011-03-17
   Days after vaccination:1
Submitted: 2011-03-23
   Days after onset:6
Entered: 2011-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3774AA / 3 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E55587 / 3 LL / IM

Administered by: Private       Purchased by: Public
Symptoms: Cardiac arrest, Death, Pulse absent
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-03-17
   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: none
Current Illness: Stuffy nose x 3 days
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Arrived at hospital ER at 1:59AM pulseless, in asystole.


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