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This is VAERS ID 421972

History of Changes from the VAERS Wayback Machine

First Appeared on 5/13/2011

VAERS ID: 421972
VAERS Form:
Age:0.3
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 0 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 0 LL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 7/12/2011

VAERS ID: 421972 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 0 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 0 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 0 1 LL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 5/13/2013

VAERS ID: 421972 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 1 LL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 6/14/2014

VAERS ID: 421972 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 1 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 2/14/2017

VAERS ID: 421972 Before After
VAERS Form:
Age:0.3 0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 1 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 4/14/2017

VAERS ID: 421972 Before After
VAERS Form:
Age:0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 1 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 9/14/2017

VAERS ID: 421972 Before After
VAERS Form:(blank) 1
Age:0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 1 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 1 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 1 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 0 1 - MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 2/14/2018

VAERS ID: 421972 Before After
VAERS Form:1
Age:0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 1 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 6/14/2018

VAERS ID: 421972 Before After
VAERS Form:1
Age:0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 1 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 8/14/2018

VAERS ID: 421972 Before After
VAERS Form:1
Age:0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 1 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).


Changed on 9/14/2018

VAERS ID: 421972 Before After
VAERS Form:1
Age:0.31
Gender:Female
Location:California
Vaccinated:2011-04-04
Onset:2011-04-08
Submitted:2011-04-29
Entered:2011-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B277BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UH254AA / 2 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 915572 / 2 LL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB094A / 1 MO / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Barium double contrast, Intussusception, Surgery, Enema administration, Ultrasound abdomen

Life Threatening? Yes
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: U/S abdomen; Air contrast enema
CDC 'Split Type':

Write-up: 4 days after receiving delays 2 mo vaccines, including ROTARIX, pt developed intussusception that needed to be surgically reduced. (DTap-HBV-POL, HIB, PCV 13, ROT 1).

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