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This is VAERS ID 441125

Case Details

VAERS ID: 441125 (history)  
Form: Version 1.0  
Age: 1.28  
Sex: Male  
Location: New Hampshire  
Vaccinated:2011-10-28
Onset:2011-10-31
   Days after vaccination:3
Submitted: 2012-11-25
   Days after onset:391
Entered: 2012-12-03
   Days after submission:8
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B136BB / 1 RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT4118CA / 1 RL / IM
HIBV: HIB (HIBERIX) / GLAXOSMITHKLINE BIOLOGICALS AHIBC263BA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916617 / 4 LL / IM

Administered by: Private       Purchased by: Public
Symptoms: Death, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2011-10-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Sodium fluoride
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: See medical examiner''s report
CDC Split Type:

Write-up: Was seen for 15 mo well child visit 10/28/2011 received DTaP, HIB, PCV 13 and influenza vaccines approximately 5pm exam was normal. Patient was at daycare 10/31/11 and found to be unresponsive after being put down for a nap. Brought to ER, pronounced dead after unsuccessful resuscitation attempt.


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