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This is VAERS ID 286714

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 286714
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08692A / 1 RA / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records inc"luding vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returne


Changed on 12/8/2009

VAERS ID: 286714 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08692A / 1 RA / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Unknown Private
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Laparoscopy, Mucous stools, Pyrexia, Surgery, Vomiting, Enema administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records inc"luding including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returne Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 3/2/2010

VAERS ID: 286714 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08692A / 1 RA / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Laparoscopy, Mucous stools, Pyrexia, Surgery, Vomiting, Enema administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 4/7/2010

VAERS ID: 286714 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08692A / 1 RA / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Laparoscopy, Mucous stools, Pyrexia, Surgery, Vomiting, Enema administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 8/31/2010

VAERS ID: 286714 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08692A / 1 RA / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Laparoscopy, Mucous stools, Pyrexia, Surgery, Vomiting, Enema administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 5/13/2013

VAERS ID: 286714 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 1 RA / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Laparoscopy, Mucous stools, Pyrexia, Surgery, Vomiting, Enema administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 2/14/2017

VAERS ID: 286714 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 1 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Abdominal distension, Abdominal pain, Barium enema, Computerised tomogram abnormal, Haematochezia, Intussusception, Laparoscopy, Mucous stools, Pyrexia, Surgery, Vomiting, Enema administration, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 9/14/2017

VAERS ID: 286714 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 1 2 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 1 2 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 1 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 1 2 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 1 2 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 2/14/2018

VAERS ID: 286714 Before After
VAERS Form:1
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 2 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 2 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 2 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 6/14/2018

VAERS ID: 286714 Before After
VAERS Form:1
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 2 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 2 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 2 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 8/14/2018

VAERS ID: 286714 Before After
VAERS Form:1
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 2 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 2 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 2 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 9/14/2018

VAERS ID: 286714 Before After
VAERS Form:1
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 2 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 2 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 2 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.


Changed on 10/14/2018

VAERS ID: 286714 Before After
VAERS Form:1
Age:0.3
Gender:Male
Location:Georgia
Vaccinated:2007-04-26
Onset:2007-07-04
Submitted:2007-07-31
Entered:2007-08-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2650AA / 2 LL / IM
HBHEPB: HIB + HEP B (COMVAX) / MERCK & CO. INC. 1415F / 2 RL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0872 / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08692A / 2 RA / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1239F / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Barium enema, Computerised tomogram abnormal, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Cystic Fibrosis Birth Hx: no problems but was screened for cystic fibrosis at birth. (+) cystic fibrosis gene. PMH: 1/07 dx w/cystic fibrosis, mild.
Allergies:
Diagnostic Lab Data: CT ABO, BE, Abdominal surgery LABS: X-ray c/w intussusception. Air enema reveled IS.
CDC 'Split Type':

Write-up: This is just for statistical information. This baby developed intussusception 7/4/07 at 6 months of age. He had two doses of Rotateq at 2 and 4 months of age (with other shots). He had not received the third dose. 8/10/07 Received pcp medical records including vax records which confirm RO dose & lot # as reported. Records reveal patient experienced good development & was healthy on day of vax. Seen in ER on 7/4 s/p vomiting & bloody stools. CT confirmed IS. BE could not reduce & had surgery. Returned to office on 7/30 for post op check & doing well. 8/24/07 Received hospital medical records which reveal patient experienced nonbilious emesis, abdominal pain & distention, low grade fever & jelly like stool x 2 days. Admitted 7/5-7/6/07. Air enema x 3 unable to reduce IS. Taken to OR for laproscopic reduction of IS. Progressed well & d/c to home. FINAL DX: Ileocolic intussusception, surgically reduced.

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