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From the 12/31/2007 release of VAERS data (an older release, current is 10/15/2021):

This is VAERS ID 290655



Case Details

VAERS ID: 290655 (history)  
Form: Version .0  
Age: 0.2  
Sex: Male  
Location: Unknown  
Vaccinated:2007-08-30
Onset:2007-09-11
   Days after vaccination:12
Submitted: 2007-09-14
   Days after onset:3
Entered: 2007-09-17
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B132BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF162AA / 0 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC - / 0 LL / IM

Administered by: Unknown       Purchased by: Unknown
Symptoms: Apnoea, Body temperature decreased, Cyanosis, Death, Hypothermia
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2007-09-11
   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:
Preexisting Conditions: Family history of atrial fibrillation in the father of the child and allergies in an otherwise healthy 7-year-old sibling.
Allergies:
Diagnostic Lab Data: Body temperature (results: 92.2 deg. F.) was done on 11-Sep-2007.
CDC Split Type:

Write-up: This is a 7-day report. This case was unblinded, the patient received Prevnar. Information regarding Prevnar was received from an investigator regarding a 2-month-old male participant in a study who experienced death. The participant received the first do"se on 30-AUG-2007. On 11-Sep-2007, the patient was found in the crib at Day Care on his back, unresponsive, blue and not breathing. Day Care workers initiated cardiopulmonary resuscitation and contacted 911 emergency response. Upon emergency medical respo


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