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This is VAERS ID 487403

History of Changes from the VAERS Wayback Machine

First Appeared on 4/13/2013

VAERS ID: 487403
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B357 / - UN / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR H1123 / - UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 918175 / - UN / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/17/2013

VAERS ID: 487403 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B357 / - UN / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR H1123 / - UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 918175 / - UN / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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. The following information was obtained through follow-up and/or provided by the government. PMH: GERD, multiple genetic anomalies.
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. The following information was obtained through follow-up and/or provided by the government. 6/14/2013 death certificate received for DoD 3/9/2013. COD: 1) cardiac arrest; 2) probable airway obstruction as a consequence of GERD & multiple genetic anomalies.


Changed on 3/14/2015

VAERS ID: 487403 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B357 / - UN / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR H1123 / - UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 918175 / - UN / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Cardiac arrest, Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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. The following information was obtained through follow-up and/or provided by the government. PMH: GERD, multiple genetic anomalies.
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. The following information was obtained through follow-up and/or provided by the government. 6/14/2013 death certificate received for DoD 3/9/2013. COD: 1) cardiac arrest; 2) probable airway obstruction as a consequence of GERD & multiple genetic anomalies.


Changed on 2/14/2017

VAERS ID: 487403 Before After
VAERS Form:
Age:0.4 0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B357 / - UN / UN
HIBV: HIB (ACTHIB) / SANOFI PASTEUR H1123 / - UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 918175 / - UN / UN

Administered by: Unknown      Purchased by: Unknown
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2017

VAERS ID: 487403 Before After
VAERS Form:(blank) 1
Age:0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 2/14/2018

VAERS ID: 487403 Before After
VAERS Form:1
Age:0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 6/14/2018

VAERS ID: 487403 Before After
VAERS Form:1
Age:0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 8/14/2018

VAERS ID: 487403 Before After
VAERS Form:1
Age:0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 9/14/2018

VAERS ID: 487403 Before After
VAERS Form:1
Age:0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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.


Changed on 10/14/2018

VAERS ID: 487403 Before After
VAERS Form:1
Age:0.36
Sex:Male
Location:Florida
Vaccinated:2013-03-07
Onset:2013-03-09
Submitted:2013-03-19
Entered:2013-03-21
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2013-03-09
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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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