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This is VAERS ID 379398

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/5/2010

VAERS ID: 379398
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 3/2/2010

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 4/7/2010

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 7/31/2010

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 8/31/2010

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 4/13/2011

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 5/13/2011

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 6/11/2011

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 5/13/2013

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 3/14/2015

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Blood culture negative, CSF culture negative, Death, Petechiae, Sudden infant death syndrome, X-ray normal, Visceral congestion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 2/14/2017

VAERS ID: 379398 Before After
VAERS Form:
Age:0.3 0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 9/14/2017

VAERS ID: 379398 Before After
VAERS Form:(blank) 1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 1 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 1 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 1 2 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 2/14/2018

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 6/14/2018

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 8/14/2018

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 9/14/2018

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 10/14/2018

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 12/24/2020

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 12/30/2020

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 5/7/2021

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.


Changed on 5/21/2021

VAERS ID: 379398 Before After
VAERS Form:1
Age:0.34
Sex:Male
Location:Iowa
Vaccinated:2009-12-30
Onset:0000-00-00
Submitted:2010-01-27
Entered:2010-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPIPVHIB: DTAP + IPV + HIB (PENTACEL) / SANOFI PASTEUR C3565AB / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH E06427 / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FA963A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2010-01-16
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:
Current Illness: Ear infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: None stated.

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