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This is VAERS ID 490219

Case Details

VAERS ID: 490219 (history)  
Form: Version 1.0  
Age: 0.18  
Sex: Male  
Location: Virginia  
Vaccinated:2013-04-17
Onset:0000-00-00
Submitted: 2013-04-23
Entered: 2013-04-29
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C4378AA / UNK LL / IM
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. H020604 / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH768AA / UNK LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR H1605 / UNK LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH F45132 / UNK RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. J000034 / UNK MO / PO

Administered by: Private       Purchased by: Public
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2013-04-21
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: None
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: No known reaction to vaccine. Patient passed away 4.21.13.


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