National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 416354

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2011

VAERS ID: 416354
VAERS Form:
Age:0.6
Gender:Female
Location:Michigan
Vaccinated:2010-10-22
Onset:2011-01-03
Submitted:2011-02-07
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B250BA / 2 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1486Y / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70436 / 1 UN / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Intussusception

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


Changed on 4/13/2011

VAERS ID: 416354 Before After
VAERS Form:
Age:0.6
Gender:Female
Location:Michigan
Vaccinated:2010-10-22
Onset:2011-01-03
Submitted:2011-02-07
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B250BA / 2 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1486Y / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70436 / 1 UN / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abnormal faeces, Barium enema, Blood albumin decreased, Blood calcium increased, Blood iron decreased, Blood potassium increased, Chest X-ray abnormal, Diarrhoea, Ear infection, Failure to thrive, Haematochezia, Intussusception, Irritability, Protein total increased, Pyrexia, Small intestinal intussusception reduction, Vomiting, Enema administration, Platelet count increased, Ultrasound abdomen abnormal, Urine ketone body present, Barium double contrast abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


Changed on 5/13/2011

VAERS ID: 416354 Before After
VAERS Form:
Age:0.6
Gender:Female
Location:Michigan
Vaccinated:2010-10-22
Onset:2011-01-03
Submitted:2011-02-07
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B250BA / 2 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1486Y / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70436 / 1 UN / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abnormal faeces, Barium enema, Blood albumin decreased, Blood calcium increased, Blood iron decreased, Blood potassium increased, Chest X-ray abnormal, Diarrhoea, Ear infection, Failure to thrive, Haematochezia, Intussusception, Irritability, Protein total increased, Pyrexia, Small intestinal intussusception reduction, Vomiting, Enema administration, Platelet count increased, Ultrasound abdomen abnormal, Urine ketone body present, Barium double contrast abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


Changed on 5/13/2013

VAERS ID: 416354 Before After
VAERS Form:
Age:0.6
Gender:Female
Location:Michigan
Vaccinated:2010-10-22
Onset:2011-01-03
Submitted:2011-02-07
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B250BA / 2 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1486Y / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70436 / 1 UN / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 2 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Intussusception

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


Changed on 2/14/2017

VAERS ID: 416354 Before After
VAERS Form:
Age:0.6 0.62
Gender:Female
Location:Michigan
Vaccinated:2010-10-22
Onset:2011-01-03
Submitted:2011-02-07
Entered:2011-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B250BA / 2 UN / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1486Y / 2 UN / UN
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH E70436 / 1 UN / UN
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB098A / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Intussusception

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


Changed on 9/14/2017

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

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Intussusception

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


Changed on 2/14/2018

VAERS ID: 416354 Before After
VAERS Form:1
Age:0.62
Gender:Female
Location:Michigan
Vaccinated:2010-10-22
Onset:2011-01-03
Submitted:2011-02-07
Entered:2011-02-08
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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     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.


New Search

Link To This Search Result:

http://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=416354&WAYBACKHISTORY=ON


Copyright © 2018 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166