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This is VAERS ID 441125

History of Changes from the VAERS Wayback Machine

First Appeared on 11/14/2011

VAERS ID: 441125
VAERS Form:
Age:1.3
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2011-11-02
Entered:2011-11-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
PPV: PNEUMO (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
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: no
Preexisting Conditions: no
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Found in cardiac arrest 2 hours after being put in pack and play for a nap.


Changed on 7/7/2013

VAERS ID: 441125 Before After
VAERS Form:
Age:1.3
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2011-11-02
Entered:2011-11-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
FLU: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -
PPV: PNEUMO (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Private      Purchased by: Other
Symptoms: Cardiac arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
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: no
Preexisting Conditions: no
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Found in cardiac arrest 2 hours after being put in pack and play for a nap.


Changed on 3/14/2014

VAERS ID: 441125 Before After
VAERS Form:
Age:1.3
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2011-11-02 2012-11-25
Entered:2011-11-02 2012-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) DTAP (INFANRIX) / UNKNOWN MANUFACTURER GLAXOSMITHKLINE BIOLOGICALS - AC14B136BB / - 0 - RL / - IM
FLU3: INFLUENZA (SEASONAL) (NO BRAND NAME) INFLUENZA (SEASONAL) (FLUZONE) / UNKNOWN MANUFACTURER SANOFI PASTEUR - UT4118CA / - 0 - RL / - IM
HIBV: HIB (NO BRAND NAME) HIB (HIBERIX) / UNKNOWN MANUFACTURER GLAXOSMITHKLINE BIOLOGICALS - AHIBC263BA / - 0 - LL / - IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916617 / 3 LL / IM
PPV: PNEUMO (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - - / -

Administered by: Private      Purchased by: Other Public
Symptoms: Cardiac arrest, Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Sodium fluoride
Current Illness: no None
Preexisting Conditions: no None
Allergies:
Diagnostic Lab Data: See medical examiner''s report
CDC 'Split Type':

Write-up: Found in cardiac arrest 2 hours 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 in pack and play down for a nap. Brought to ER, pronounced dead after unsuccessful resuscitation attempt.


Changed on 6/14/2014

VAERS ID: 441125 Before After
VAERS Form:
Age:1.3
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B136BB / 0 RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT4118CA / 0 RL / IM
HIBV: HIB (HIBERIX) / GLAXOSMITHKLINE BIOLOGICALS AHIBC263BA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916617 / 3 LL / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 3/14/2015

VAERS ID: 441125 Before After
VAERS Form:
Age:1.3
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B136BB / 0 RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT4118CA / 0 RL / IM
HIBV: HIB (HIBERIX) / GLAXOSMITHKLINE BIOLOGICALS AHIBC263BA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916617 / 3 LL / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 2/14/2017

VAERS ID: 441125 Before After
VAERS Form:
Age:1.3 1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B136BB / 0 RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT4118CA / 0 RL / IM
HIBV: HIB (HIBERIX) / GLAXOSMITHKLINE BIOLOGICALS AHIBC263BA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916617 / 3 LL / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2017

VAERS ID: 441125 Before After
VAERS Form:(blank) 1
Age:1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC14B136BB / 0 1 RL / IM
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR UT4118CA / 0 1 RL / IM
HIBV: HIB (HIBERIX) / GLAXOSMITHKLINE BIOLOGICALS AHIBC263BA / 0 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916617 / 3 4 LL / IM

Administered by: Private      Purchased by: Public
Symptoms: Death, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 2/14/2018

VAERS ID: 441125 Before After
VAERS Form:1
Age:1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 6/14/2018

VAERS ID: 441125 Before After
VAERS Form:1
Age:1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 8/14/2018

VAERS ID: 441125 Before After
VAERS Form:1
Age:1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2018

VAERS ID: 441125 Before After
VAERS Form:1
Age:1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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.


Changed on 10/14/2018

VAERS ID: 441125 Before After
VAERS Form:1
Age:1.28
Sex:Male
Location:New Hampshire
Vaccinated:2011-10-28
Onset:2011-10-31
Submitted:2012-11-25
Entered:2012-12-03
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2011-10-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? 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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