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This is VAERS ID 453867

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History of Changes from the VAERS Wayback Machine

First Appeared on 5/12/2012

VAERS ID: 453867
VAERS Form:
Age:0.4
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 1 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 5/13/2013

VAERS ID: 453867 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 1 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 6/14/2014

VAERS ID: 453867 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 1 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 3/14/2015

VAERS ID: 453867 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 1 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 2/14/2017

VAERS ID: 453867 Before After
VAERS Form:
Age:0.4 0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 1 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 1 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 9/14/2017

VAERS ID: 453867 Before After
VAERS Form:(blank) 1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 1 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 1 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 1 2 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 2/14/2018

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 6/14/2018

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 8/14/2018

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 9/14/2018

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 10/14/2018

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 12/24/2020

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 12/30/2020

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 5/7/2021

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.


Changed on 5/21/2021

VAERS ID: 453867 Before After
VAERS Form:1
Age:0.43
Sex:Male
Location:New Hampshire
Vaccinated:2012-04-04
Onset:2012-04-14
Submitted:2012-04-17
Entered:2012-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315D / 2 LL / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH399AB / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0040AE / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2012-04-14
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: None
Current Illness:
Preexisting Conditions: Hx - NICU - drug withdrawal
Allergies:
Diagnostic Lab Data: None
CDC 'Split Type': NH041720126

Write-up: Hx - child in NICU r/t drug withdrawal.

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