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This is VAERS ID 487403

Case Details

VAERS ID: 487403 (history)  
Form: Version 1.0  
Age: 0.36  
Sex: Male  
Location: Florida  
Vaccinated:2013-03-07
Onset:2013-03-09
   Days after vaccination:2
Submitted: 2013-03-19
   Days after onset:9
Entered: 2013-03-21
   Days after submission:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B357 / UNK UN / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR H1123 / UNK UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 918175 / UNK UN / UN

Administered by: Unknown       Purchased by: Unknown
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2013-03-09
   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: The patient had been chronically ill with a history of T fistula with esophageal atresia which was repaired, traceomalacia, PDA (not specified) PFO (not specified), and cardiac issues.
Allergies:
Diagnostic Lab Data: Not reported
CDC Split Type: 201303977

Write-up: Initial report was received 11 March 2013 from a health care professional. A four-month-old male patient had received an injection of ACTHIB lot number UH609AA (corresponding sanofi pasteur SA lot number H1123-1), PEDIARIX (manufacturer GSK, lot number AC21B357 and PREVNAR (manufacturer Pfizer, lot number 918175) on 07 March 2013, and two days later on the evening of 09 March 2013, the patient passed away. He had previously received a first dose of RSV vaccine on an unspecified date. The patient had been chronically ill with a history of T fistula with esophageal atresia which was repaired, traceomalacia, PDA (patent ductus arteriosus), PFO (patent foramen ovale), and cardiac issues. He had no known allergies. The event outcome was fatal. Documents held by sender: None.


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