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From the 9/3/2021 release of VAERS data:

This is VAERS ID 857115



Case Details

VAERS ID: 857115 (history)  
Form: Version 2.0  
Age: 1.08  
Sex: Female  
Location: Montana  
Vaccinated:2020-01-14
Onset:2020-01-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2020-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR UJ058AB / 4 RL / SYR
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UT6647JA / 1 RL / SYR
HEP: HEP B (RECOMBIVAX HB) / MERCK & CO. INC. R013540 / 3 LL / SYR
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH AL8457 / 1 LL / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-01-16
   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: Acetaminophen (Tylenol) 160 mgi/5mL Solution
Current Illness: None
Preexisting Conditions: None
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient arrived to hospital by EMS, CPR in progress. On arrival, patient had no spontaneous cardiac activity or respirations.


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