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From the 1/7/2022 release of VAERS data:

This is VAERS ID 105621

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Case Details

VAERS ID: 105621 (history)  
Form: Version 1.0  
Age: 0.4  
Sex: Male  
Location: Kentucky  
Vaccinated:1997-11-10
Onset:1997-11-10
   Days after vaccination:0
Submitted: 1997-11-11
   Days after onset:1
Entered: 1997-12-11
   Days after submission:30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (NO BRAND NAME) / UNKNOWN MANUFACTURER 6C81349 / 2 RL / -
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER M195RF / 2 LL / -
IPV: POLIO VIRUS, INACT. (NO BRAND NAME) / UNKNOWN MANUFACTURER M0843 / 2 RL / -

Administered by: Public       Purchased by: Unknown
Symptoms: Acidosis, Apnoea, Hypotension, Sudden infant death syndrome
SMQs:, Anaphylactic reaction (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Neonatal disorders (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 1997-11-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: ~ ()~~~In patient
Other Medications: NONE
Current Illness: cold
Preexisting Conditions: NONE
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recv vax 12noon & returned to daycare;put down for nap 350Pm;checked on baby 415PM & not breathing resuscitated in local ER, transferred to another hosp;cont profoundly hypotensive w/severe metabolic acidosis & expired @ 0647 11NOV97;


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