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This is VAERS ID 292564

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 292564
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08691K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, 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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ /"6 mo/" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 present"ed with crying and abdominal pain. A therapeutic enema was given with sucessful reduction of the ileocolic intussusception.

Changed on 12/8/2009

VAERS ID: 292564 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08691K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Unknown Public
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, Haematochezia, Intussusception, Large intestinal obstruction reduction, Vomiting, Ultrasound abdomen 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ /"6 mo/" "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 present"ed presented with crying and abdominal pain. pain on 10/3/2007. A therapeutic enema was given with sucessful successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 3/2/2010

VAERS ID: 292564 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B08691K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, Haematochezia, Intussusception, Large intestinal obstruction reduction, Vomiting, Ultrasound abdomen 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 4/7/2010

VAERS ID: 292564 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B08691K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, Haematochezia, Intussusception, Large intestinal obstruction reduction, Vomiting, Ultrasound abdomen 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 8/31/2010

VAERS ID: 292564 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B08691K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, Haematochezia, Intussusception, Large intestinal obstruction reduction, Vomiting, Ultrasound abdomen 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 5/13/2013

VAERS ID: 292564 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, Haematochezia, Intussusception, Large intestinal obstruction reduction, Vomiting, Ultrasound abdomen 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 2/14/2017

VAERS ID: 292564 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Abdominal pain, Barium enema, Chest X-ray, Crying, Haematochezia, Intussusception, Large intestinal obstruction reduction, Vomiting, Ultrasound abdomen 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 9/14/2017

VAERS ID: 292564 Before After
VAERS Form:(blank) 1
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 1 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 1 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 1 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 1 2 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intussusception

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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 2/14/2018

VAERS ID: 292564 Before After
VAERS Form:1
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intussusception

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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 6/14/2018

VAERS ID: 292564 Before After
VAERS Form:1
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intussusception

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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 8/14/2018

VAERS ID: 292564 Before After
VAERS Form:1
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intussusception

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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 9/14/2018

VAERS ID: 292564 Before After
VAERS Form:1
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intussusception

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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

Changed on 10/14/2018

VAERS ID: 292564 Before After
VAERS Form:1
Age:0.4
Gender:Male
Location:Georgia
Vaccinated:2007-04-06
Onset:2007-10-03
Submitted:2007-10-04
Entered:2007-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B079BA / 2 LL / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0403F / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B08691K / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1233F / 2 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Intussusception

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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None, PMH of intussusception in 6/2007.
Allergies:
Diagnostic Lab Data: Reduced by radiology by contrast enema. Labs and Diagnostics: CXR/Abd X-ray shows a paucity of gas in the rectum. Ultrasound demonstated intussusception to the level of the mid potion of the transverse colon. Therapeutic enema given with successful reduction. Labs and Diagnostics: Barium enema.
CDC 'Split Type':

Write-up: 1st dose Rotateq given @ 2 mo 2/2/07 2nd dose Rotateq given @ 4 mo 4/6/07 Intussusception 6/18/07 no Rotateq given @ "6 mo" checkup done @ 6/29/07. 10/10/2007 VAERS report submitted with MR attached. Infant with PMH of intussusception in 6/2007 presented with crying and abdominal pain on 10/3/2007. A therapeutic enema was given with successful reduction of the ileocolic intussusception. 10/24/2007 Vax record received. Rotateq Lot # 0403F added to database, otherwise correlates with VAERS submission. 11/05/2007 MR received for DOS 6/17/2007 for D/C DX Intussusception. Child presented to ER with vomiting, abdominal cramping x 12 hrs. Pt had a bloody stool in The ER. Pt had barium enema which sucessfully reduced the IS. D/Cd home same day in good condition. Repeat IS with BE reduction 10/3/07 as above.

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