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

This is VAERS ID 267630

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Case Details

VAERS ID: 267630 (history)  
Form: Version 1.0  
Age: 0.2  
Sex: Female  
Location: New Hampshire  
Vaccinated:2006-10-20
Onset:2006-10-21
   Days after vaccination:1
Submitted: 2006-11-16
   Days after onset:26
Entered: 2006-11-22
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B070AA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UE932AA / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B086918 / 1 LA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0577F / 1 MO / PO

Administered by: Other       Purchased by: Other
Symptoms: Sudden infant death syndrome
SMQs:, Neonatal disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2006-10-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNK
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: WAES0611USA02595

Write-up: Information has been received from a physician concerning a 2 month old female who was vaccinated with a 2ml dose of Rotavirus vaccine. On the next day, the pt died. The physician stated that the infant received all of her vaccines on time and wad in perfect health. The medical examiner ruled the cause of death as sudden infant death syndrome. Unspecified medical attention was sought. No product quality complaint was involved. NO other information was provided. The reporter considered the pts reaction to be immediately life threatening. Additional information has been requested. 12/28/06 Received autopsy report which reveals COD as Category II SIDS, cosleeping with parents in adult bed. Manner of death undetermined.


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