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

This is VAERS ID 365428

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Case Details

VAERS ID: 365428 (history)  
Form: Version 1.0  
Age: 0.34  
Sex: Male  
Location: Montana  
Vaccinated:2008-10-16
Onset:2008-11-05
   Days after vaccination:20
Submitted: 2009-11-05
   Days after onset:365
Entered: 2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D05881 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 2 MO / PO

Administered by: Unknown       Purchased by: Unknown
Symptoms: Choking, Death, Irritability
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypersensitivity (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2008-11-05
   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: Patient was on Amoxicillan since birth due to slight hydronephrosis in his left kidney
Current Illness: None, the week prior he had a viral outbreak of sores in his mouth/ throat, physician thought he would be fine to vaccinate the next week
Preexisting Conditions: He had hydronephrosis in his left kidney, was on amoxicillan for it
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was fussy on 11/04/2009, he was hard to calm down in the morning at approx 4 am I awoke to sounds of him choking, I picked him up and then he was fine, I took him to daycare that morning and received the phone call at 4:30 pm that he was being rushed to the ER. 12/22/09 Death Certificate Received, DOD 11/05/08, Cause of Death: Sudden Infant Death Syndrome (SIDS) at daycare. 12/22/09 Autopsy received. Cause of Death: Sudden Infant Death Syndrome (SIDS). Additional information abstracted: Had been fussy and more congested lately. Chronic inflammation in the large airways likely due to viral infection.


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