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This is VAERS ID 365428

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History of Changes from the VAERS Wayback Machine

First Appeared on 12/8/2009

VAERS ID: 365428
VAERS Form:
Age:0.3
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC D05881 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th
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.


Changed on 3/2/2010

VAERS ID: 365428 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC D05881 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th
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.


Changed on 4/7/2010

VAERS ID: 365428 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC D05881 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th
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.


Changed on 8/31/2010

VAERS ID: 365428 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH D05881 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th
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.


Changed on 5/13/2013

VAERS ID: 365428 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D05881 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th
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.


Changed on 2/14/2017

VAERS ID: 365428 Before After
VAERS Form:
Age:0.3 0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D05881 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th
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.


Changed on 4/14/2017

VAERS ID: 365428 Before After
VAERS Form:
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D05881 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 - / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability, Sudden infant death syndrome, Respiratory tract inflammation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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 th 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.


Changed on 9/14/2017

VAERS ID: 365428 Before After
VAERS Form:(blank) 1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
Entered:2009-11-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B153BA / 1 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH D05881 / 0 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA681A / 1 2 - MO / PO

Administered by: Unknown      Purchased by: Unknown
Symptoms: Choking, Death, Irritability

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 2/14/2018

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 6/14/2018

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 8/14/2018

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 9/14/2018

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 10/14/2018

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 12/24/2020

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 12/30/2020

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 5/7/2021

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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.


Changed on 5/21/2021

VAERS ID: 365428 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Montana
Vaccinated:2008-10-16
Onset:2008-11-05
Submitted:2009-11-05
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2008-11-05
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: 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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