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This is VAERS ID 460006

Case Details

VAERS ID: 460006 (history)  
Form: Version 1.0  
Age: 0.17  
Sex: Female  
Location: New Hampshire  
Vaccinated:2012-06-07
Onset:2012-06-28
   Days after vaccination:21
Submitted: 2012-07-18
   Days after onset:20
Entered: 2012-07-24
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4190AA / 1 LL / UN
HEP: HEP B (ENGERIX-B) / GLAXOSMITHKLINE BIOLOGICALS AHBVC093AA / 2 LL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F53376 / 1 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1710AA / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Cardiac arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-06-28
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: See attached
CDC Split Type: NH072420128

Write-up: 6/28 - Pt. rushed to ER in cardiac arrest.


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