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This is VAERS ID 483009

Case Details

VAERS ID: 483009 (history)  
Form: Version 1.0  
Age: 0.18  
Sex: Male  
Location: New Hampshire  
Vaccinated:2012-12-12
Onset:2012-12-31
   Days after vaccination:19
Submitted: 2013-01-30
   Days after onset:30
Entered: 2013-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B370BA / UNK LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH549AC / 1 RL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F72495 / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. H011458 / 1 MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Blood bilirubin, Blood gases, Death, Respiratory disorder
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2012-12-31
   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: 10-23-2012 - Nystatin; mouth throat suspension
Current Illness: No
Preexisting Conditions: Twin; Mucocele oral; Neonatal feeding problems 10-18-12 resolved 10-27-2012; History of neonatal hyperbilirubinemia that was resolved on 10-27-2012
Allergies:
Diagnostic Lab Data: Umbilical Vbg; bilirubin
CDC Split Type: NH0906201212

Write-up: 12-17-2012 - Acute Respiratory Illness, ? SIDS.


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