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This is VAERS ID 291299

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 291299
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08666E / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/1"5/2007.


Changed on 12/8/2009

VAERS ID: 291299 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08666E / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Unknown Other
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, Intussusception, Large intestinal obstruction reduction, Rectal haemorrhage, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/1"5/2007. 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 3/2/2010

VAERS ID: 291299 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08666E / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, Intussusception, Large intestinal obstruction reduction, Rectal haemorrhage, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 4/7/2010

VAERS ID: 291299 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08666E / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, Intussusception, Large intestinal obstruction reduction, Rectal haemorrhage, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 8/31/2010

VAERS ID: 291299 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08666E / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, Intussusception, Large intestinal obstruction reduction, Rectal haemorrhage, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 5/13/2013

VAERS ID: 291299 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08666E / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, Intussusception, Large intestinal obstruction reduction, Rectal haemorrhage, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 2/14/2017

VAERS ID: 291299 Before After
VAERS Form:
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08666E / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 - / PO

Administered by: Private      Purchased by: Other
Symptoms: Appendicectomy, Barium enema, Chest X-ray, Ileus, Intussusception, Large intestinal obstruction reduction, Rectal haemorrhage, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 9/14/2017

VAERS ID: 291299 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 1 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 1 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08666E / 1 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 1 2 - MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Barium enema, Chest X-ray, Intussusception, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


Changed on 2/14/2018

VAERS ID: 291299 Before After
VAERS Form:1
Age:0.3
Gender:Male
Location:California
Vaccinated:2007-04-25
Onset:2007-06-12
Submitted:2007-09-21
Entered:2007-09-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B092AA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0071U / 2 LL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08666E / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1238F / 2 MO / PO

Administered by: Private      Purchased by: Other
Symptoms: Barium enema, Chest X-ray, Intussusception, Surgery, Urinary system X-ray, Vomiting, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: 6/13/07 KUB, cross table (lateral) of abdomen, chest x-ray; 6/13/07 Barium enema. Labs and Diagnostics: Barium enema x2 (+) for IS. KUB (+) for Ileus.
CDC 'Split Type':

Write-up: Patient received Rotavirus vaccine on 2/23/2007 and 4/25/07. Patient seen at clinic 6/12/07 with vomiting on and off for 6 hrs. Patient admitted to hospital 6/12/07. Pt diagnosed with intussusception and had corrective surgery 6/13/2007. Pt discharged 6/15/2007. 10/02/2007 Vax record received and data corresponds with what was reported on VAERS form./pc 10/26/2007 D/C Summary received for hospital DOS 6/12-15/2007 for DX Ileoileal and Ileocolic Intussusception. Infant presented with bilious emesis and blood per rectum. Barium enema performed which demonstrated IS to the cecum from mid transverse colon but was unsuccessful in reduction. Repeat BE only partially successful at reduction. Infant then had a Laparoscopic Reduction of Intussusception and Appendectomy. Post-operatively the pt developed an marked ileus which resolved on POD #2 when the pt began tolerating po and had a non-bloody BM.


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