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This is VAERS ID 473737

Case Details

VAERS ID: 473737 (history)  
Form: Version 1.0  
Age: 0.35  
Sex: Male  
Location: Kansas  
Vaccinated:2012-05-18
Onset:2012-05-21
   Days after vaccination:3
Submitted: 2012-10-23
   Days after onset:155
Entered: 2012-11-09
   Days after submission:17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C4221AA / 2 RL / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F89912 / 2 RL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1847AA / 2 MO / PO

Administered by: Private       Purchased by: Unknown
Symptoms: Death, Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-05-21
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died from unknown cause within 3 days of vaccine series. Death deemed SIDS.


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