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From the 1/14/2022 release of VAERS data:

This is VAERS ID 454460

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Case Details

VAERS ID: 454460 (history)  
Form: Version 1.0  
Age: 0.34  
Sex: Male  
Location: Colorado  
Vaccinated:2012-03-30
Onset:2012-04-07
   Days after vaccination:8
Submitted: 2012-04-26
   Days after onset:19
Entered: 2012-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315AA / 1 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0958AA / 1 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 916977 / 1 UN / UN

Administered by: Public       Purchased by: Public
Symptoms: Hypotonia, Resuscitation, Unresponsive to stimuli
SMQs:, Peripheral neuropathy (broad), 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), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-04-07
   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: none
Preexisting Conditions: none
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Father of baby said baby suddenly went limp and unresponsive, was transported to hospital via ambulance CPR in progress.


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