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From the 1/14/2022 release of VAERS data:

This is VAERS ID 263554

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Case Details

VAERS ID: 263554 (history)  
Form: Version 1.0  
Age: 0.17  
Sex: Unknown  
Location: West Virginia  
Submitted: 2006-09-22
   Days after onset:22
Entered: 2006-09-26
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Other
Symptoms: Respiratory distress, Viral infection
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2006-08-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data: Stool rotavirus antigen 08/31/06 positive for rotavirus.
CDC Split Type: WAES0609USA03169

Write-up: Information has been received from a physician concerning a 2-3 month old pt who in 2006 was vaccinated PO with the first 2.0 ml dose of Rotavirus G1 G2 G3 G4 P1 reassortant vaccine live (human Bovine). the physician reported that on approximately 8/31/06, the pt was hospitalized in the ICU with respiratory distress and died. The physician also reported that the pt had tested positive for rotavirus. The physician also considered respiratory distress and rotavirus to be life threatening. The reporting physician, via a follow up telephone call, indicated that she was not the pts physician and did not have any additional information to provide. She did not have the pts name as this was reported to her second hand by an employee at a hospital. No further information is available.

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