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This is VAERS ID 291810

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 291810
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B9728313 / 1 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Unknown
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type':

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On"that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour histor

Changed on 12/8/2009

VAERS ID: 291810 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B9728313 / 1 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Unknown Other
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': (blank) WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On"that On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour histor history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 3/2/2010

VAERS ID: 291810 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B9728313 / 1 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 4/7/2010

VAERS ID: 291810 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B9728313 / 1 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 8/31/2010

VAERS ID: 291810 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B9728313 / 1 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 5/13/2013

VAERS ID: 291810 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 1 RL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 2/14/2017

VAERS ID: 291810 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 1 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 - / PO

Administered by: Public      Purchased by: Other
Symptoms: Abdominal pain, Barium enema, Haematochezia, Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 9/14/2017

VAERS ID: 291810 Before After
VAERS Form:(blank) 1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 1 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 1 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 1 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 1 2 - MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 2/14/2018

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 6/14/2018

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 8/14/2018

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 9/14/2018

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 10/14/2018

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 12/24/2020

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

Changed on 12/30/2020

VAERS ID: 291810 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:California
Vaccinated:2007-09-04
Onset:2007-09-12
Submitted:2007-10-01
Entered:2007-10-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B124AA / 2 LL / -
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 1273F / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B9728313 / 2 RL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0972U / 2 MO / PO

Administered by: Public      Purchased by: Other
Symptoms: Intussusception

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? No
Previous Vaccinations:
Other Medications: None
Current Illness: 10/22/07-records received-well baby visits with c/o stuffy nose and cough.
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: Unknown 10/15/07-records received-BE positive for intussusception without complete reduction. TX successful reduction by air enema.
CDC 'Split Type': WAES0709USA03910

Write-up: Information has been received from a physician concerning a 5 month old male who on 04-SEP-2007 was vaccinated with a dose of Rotateq (no lot number provided). There was no concomitant medication. On 12-SEP-2007 the patient experienced intussusception. On that same day, the patient was examined by a physician and taken to the ER. At the time of this report the outcome was unknown. Additional information has been requested. 10/15/07-records received from facility-for DOS 09/12/07-patient with 36 hour history of abdominal pain, vomiting and passage of currant jelly stool times 1 today, BE positive for intussusception without complete reduction. TX successful reduction by air enema. 10/22/07-office notes received, lot#u055 included. well baby visits with c/o stuffy nose and cough.

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