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This is VAERS ID 458862

Case Details

VAERS ID: 458862 (history)  
Form: Version 1.0  
Age: 1.11  
Sex: Female  
Location: Unknown  
Vaccinated:2011-04-27
Onset:2011-08-28
   Days after vaccination:123
Submitted: 2012-05-22
   Days after onset:268
Entered: 2012-07-09
   Days after submission:48
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3747AB / 4 UN / UN

Administered by: Unknown       Purchased by: Unknown
Symptoms: Aspiration, Choking, Death, Respiratory arrest, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: MMR, other mfr, D1, 01/JUL/2011
Current Illness:
Preexisting Conditions: The patient had dose one, two and three of PENTACEL on 20 May 2010, 22 July 2010 and 23 September 2010 respectively. The lot number for dose one was C3556AA and the lot number for dose two and three was C3634AA.
Allergies:
Diagnostic Lab Data: Not reported
CDC Split Type: 201109818

Write-up: Initial report was received on 12 October 2011 from an investigator participating in the study under the reference number M5A11. A 17 month-old female patient with no reported past medical history experienced respiratory arrest due to aspiration (resulting from vomiting) 123 days after receiving dose four of PENTACEL, lot number C3747AB (route and site of administration not reported) on 27 April 2011. Additional vaccine history included a first dose of MMR, lot number 1644Z (route and site of administration not reported) received on 01 July 2011. According to the investigator, a representative from the coroner''s office was told that the "child likely choked on a ravioli as fed by a parent". No autopsy was performed as it was not a coroner''s case. The outcome was fatal. According to the investigator, the event was not related to the trial product. Documents held by sender: none.


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