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

This is VAERS ID 422773

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Case Details

VAERS ID: 422773 (history)  
Form: Version 1.0  
Age: 0.37  
Sex: Female  
Location: Alabama  
Vaccinated:2011-04-27
Onset:2011-05-03
   Days after vaccination:6
Submitted: 2011-05-12
   Days after onset:9
Entered: 2011-05-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3800 / 2 UN / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 914972 / 2 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1653Z / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Respiratory arrest, Sudden infant death syndrome, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-05-03
   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:
Current Illness: No
Preexisting Conditions: No
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: SIDS. Was found not breathing and unresponsive in crib after nap.


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