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This is VAERS ID 453732

History of Changes from the VAERS Wayback Machine

First Appeared on 5/12/2012

VAERS ID: 453732
VAERS Form:
Age:0.2
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 5/13/2013

VAERS ID: 453732 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 0 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 6/14/2014

VAERS ID: 453732 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 3/14/2015

VAERS ID: 453732 Before After
VAERS Form:
Age:0.2
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 2/14/2017

VAERS ID: 453732 Before After
VAERS Form:
Age:0.2 0.16
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 0 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 0 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 0 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 9/14/2017

VAERS ID: 453732 Before After
VAERS Form:(blank) 1
Age:0.16
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 0 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 0 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 0 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 0 1 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 2/14/2018

VAERS ID: 453732 Before After
VAERS Form:1
Age:0.16
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.


Changed on 6/14/2018

VAERS ID: 453732 Before After
VAERS Form:1
Age:0.16
Gender:Female
Location:Missouri
Vaccinated:2012-03-22
Onset:2012-04-09
Submitted:2012-04-16
Entered:2012-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B315DA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1310AA / 1 LL / IM
PNC13: PNEUMO (PREVNAR13) / PFIZER/WYETH 917243 / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41P024DA / 1 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intestinal perforation, Intussusception, Enema administration, Ultrasound abdomen abnormal

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 36     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None at time of vaccination
Current Illness: None
Preexisting Conditions: Bilateral club feet; hyperbilirubinemia after birth (resolved)
Allergies:
Diagnostic Lab Data: 4/10/12 Ultrasound abdomen: right upper quadrant intussusception, likely ileocolic
CDC 'Split Type':

Write-up: Ileocolic intussusception with perforation after attempted reduction via air enema. Intussusception occurred 18.5 days after vaccination.

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