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

This is VAERS ID 353395

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Case Details

VAERS ID: 353395 (history)  
Form: Version 1.0  
Age: 0.33  
Sex: Male  
Location: Unknown  
Vaccinated:2009-07-15
Onset:2009-07-19
   Days after vaccination:4
Submitted: 2009-08-07
   Days after onset:19
Entered: 2009-08-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B173AA / UNK UN / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF569AA / UNK LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D37015 / UNK RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA782A / UNK MO / PO

Administered by: Other       Purchased by: Other
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2009-07-19
   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:
Current Illness: Unknown
Preexisting Conditions: 10/5/09 Medical records received w/PMH: left clavicle fx at birth.
Allergies:
Diagnostic Lab Data: UNK
CDC Split Type: A0800503A

Write-up: This case was reported by a healthcare professional, via a GSK representative and described the occurrence of death nos in a 4-month-old male subject who was vaccinated with ROTARIX (GlaxoSmithKline). Concurrent vaccination included Haemophilus influenza type b vaccine (non-gsk) (non-GSK manufacturer) given on 15 July 2009; PEDIARIX (GlaxoSmithKline) given on 15 July 2009; PREVNAR (non-gsk) (non-GSK manufacturer) given on 15 July 2009. On 15 July 2009 the subject received unspecified dose of ROTARIX (details unknown). On 19 July 2009, 4 days after vaccination with ROTARIX, the subject experienced death nos. The healthcare professional considered the event was possibly related to vaccination with ROTARIX. The subject died on 19 July 2009; cause of death was not specified. It was unknown whether an autopsy was performed. No further details were reported. 8/13/09 Received PCP medical records of 3/24/09- Records reveal patient seen in office on 7/7/09 for wet cough, nasal congestion, rhinitis, eating difficulty. Dx viral URI. Sick family member. RTC 7/9/09 w/vomiting, cough, decreased appetite x 3 days. Dx viral gastroenteritis. RTC 7/15, well child visit w/shots. Immediately after shots had emesis x 1 then perioral cyanosis w/recovery in 5 min. ER records of 7/18/09 included which reveal patient arrived in full arrest approx 9 hr after being put to bed w/Tylenol, in asystole & unable to intubate due to rigor. 10/5/09 ER records received for 7/18/09 which had been previously received.


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