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This is VAERS ID 286500

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 286500
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO869OC / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Abdominal X-ray

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Rece"ived hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX:


Changed on 12/8/2009

VAERS ID: 286500 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO869OC / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Haematochezia, Intussusception, Surgery, Vomiting, Enema administration, Abdominal X-ray, Rotavirus test negative

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Rece"ived Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 3/2/2010

VAERS ID: 286500 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC BO869OC / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Haematochezia, Intussusception, Surgery, Vomiting, Enema administration, Abdominal X-ray, Rotavirus test negative

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 4/7/2010

VAERS ID: 286500 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC BO869OC / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Haematochezia, Intussusception, Surgery, Vomiting, Enema administration, Abdominal X-ray, Rotavirus test negative

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 8/31/2010

VAERS ID: 286500 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH BO869OC / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Haematochezia, Intussusception, Surgery, Vomiting, Enema administration, Abdominal X-ray, Rotavirus test negative

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 5/13/2013

VAERS ID: 286500 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO869OC / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Haematochezia, Intussusception, Surgery, Vomiting, Enema administration, Abdominal X-ray, Rotavirus test negative

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 2/14/2017

VAERS ID: 286500 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO869OC / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Appendicectomy, Blood culture negative, Culture stool negative, Culture urine negative, Haematochezia, Intussusception, Surgery, Vomiting, Enema administration, Abdominal X-ray, Rotavirus test negative

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 9/14/2017

VAERS ID: 286500 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 1 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 1 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 1 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO869OC / 1 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 2 3 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Surgery

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


Changed on 2/14/2018

VAERS ID: 286500 Before After
VAERS Form:1
Age:0.3
Gender:Female
Location:Virginia
Vaccinated:2007-06-01
Onset:2007-06-17
Submitted:2007-07-31
Entered:2007-08-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (INFANRIX) / GLAXOSMITHKLINE BIOLOGICALS AC148056BA / 2 LL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF100AA / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0548 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH BO869OC / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1365F / 3 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Surgery

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: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: LABS: BE unsuccessful. Abdominal x-ray revealed probable IS. Urine, blood, stool c/s neg. Stool for rotavirus neg.
CDC 'Split Type':

Write-up: Infant received ROTATEQ 2nd dose on 6/1/07; on 6/17/07diagnosed and operated on for intussusception in hospital. 8/3/07 Received vax record which provided RO lot # 1365F & dose #2. Prevnar Lot # should be B08690C. Database updated w/same. 8/28/07 Received hospital medical records from CDC which reveal patient experienced vomiting & bloody stool x 1 day. Admitted 6/17-6/19/07. BE diagnosed IS but unable to reduce. To OR for reduction of ileocolic IS & appendectomy. Progressed well post op. FINAL DX: Ileocolic IS, surgical reduction.


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