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This is VAERS ID 336841

History of Changes from the VAERS Wayback Machine

First Appeared on 12/8/2009

VAERS ID: 336841
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C68309 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 3/2/2010

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC C68309 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 4/7/2010

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C68309 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 8/31/2010

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH C68309 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 5/13/2013

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 6/14/2014

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 3/14/2015

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 2/14/2017

VAERS ID: 336841 Before After
VAERS Form:
Age:0.2 0.21
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 3/14/2017

VAERS ID: 336841 Before After
VAERS Form:
Age:0.21
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Nasopharyngitis, Pneumonia, Pyrexia, Unresponsive to stimuli, Autopsy, Inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 4/14/2017

VAERS ID: 336841 Before After
VAERS Form:
Age:0.21 0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:2009-01-09 0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Pre-maturity Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 9/14/2017

VAERS ID: 336841 Before After
VAERS Form:(blank) 1
Age:0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 0 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 0 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 0 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 0 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 0 1 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 2/14/2018

VAERS ID: 336841 Before After
VAERS Form:1
Age:0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 6/14/2018

VAERS ID: 336841 Before After
VAERS Form:1
Age:0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 8/14/2018

VAERS ID: 336841 Before After
VAERS Form:1
Age:0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 9/14/2018

VAERS ID: 336841 Before After
VAERS Form:1
Age:0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

Changed on 10/14/2018

VAERS ID: 336841 Before After
VAERS Form:1
Age:0.17
Gender:Female
Location:Illinois
Vaccinated:2008-11-18
Onset:2008-12-04
Submitted:0000-00-00
Entered:2009-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2956AA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF515AA / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0836 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C68309 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0641X / 1 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death, Intussusception, Unresponsive to stimuli, Autopsy

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-12-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None except runny nose
Preexisting Conditions: Prematurity
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient found unresponsive in crib by parents. No symptoms prior - autopsy revealed intussusception. Pronounced dead at ER. 1/23/09 Autopsy report states COD as complications of intussusception. Also states: six areas of IS of small intestine; changes of distant intestine present; early pneumonia; inflammation of lung tissue & small airways. Patient had been found unresponsive in crib after recent history of cold like symptoms with fever.

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