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This is VAERS ID 416354

(NOTE: This result is from the 9/14/2017 version of the VAERS database)

Case Details

VAERS ID: 416354 (history)  
Form: Version 1.0  
Age: 0.62  
Gender: Female  
Location: Michigan  
Vaccinated:2010-10-22
Onset:2011-01-03
   Days after vaccination:73
Submitted: 2011-02-07
   Days after onset:35
Entered: 2011-02-08
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B250BA / 3 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1486Y / 3 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70436 / 2 UN / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 3 MO / PO

Administered by: Other       Purchased by: Other
Symptoms: Barium enema, Intussusception
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown
CDC Split Type: WAES1101USA03537

Write-up: Information has been received from a physician concerning a 7 month old female patient who on 11-MAY-2010 was vaccinated with the first dose of ROTATEQ (Lot # 665273/0204Z, expire date not reported), per oral. On 31-AUG-2010, the patient was vaccinated with the second dose of ROTATEQ (Lot # 667991/0726Z, expire date not reported), per oral. Suspect secondary therapy included third dose of ROTARIX (Lot # A41FB098A, expire date and route not reported) administered on 22-OCT-2010, first dose of Hib conj vaccine (manufacturer unknown) and first dose of hepatitis B vaccine (manufacturer unknown) both administered on 11-MAY-2010, second dose of Hib conj vaccine administered on 31-AUG-2010, second dose of hepatitis B vaccine (manufacturer unknown) and third dose of Hib conj vaccine both administered on 22-OCT-2010. Concomitant vaccines included DTAP, poliovirus vaccine and PREVNAR. Physician stated that on 03-JAN-2011, the patient was admitted to the hospital and was diagnosed with intussusception. Physician added that a barium enema was successful in releasing the intussusception. The patient recovered and on 06-JAN-2011, the patient was discharged from the hospital. This is one of two reports from the same source. Additional information has been requested.


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