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This is VAERS ID 294705

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 294705
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47440 / 0 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Haematochezia, Intussusception, 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)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07.

Changed on 12/8/2009

VAERS ID: 294705 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B47440 B474420 / 0 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Unknown Public
Symptoms: Haematochezia, Intussusception, Vomiting, X-ray abnormal, Enema administration, 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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 3/2/2010

VAERS ID: 294705 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B474420 / 0 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Haematochezia, Intussusception, Vomiting, X-ray abnormal, Enema administration, 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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 4/7/2010

VAERS ID: 294705 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B474420 / 0 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Haematochezia, Intussusception, Vomiting, X-ray abnormal, Enema administration, 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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 8/31/2010

VAERS ID: 294705 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B474420 / 0 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Haematochezia, Intussusception, Vomiting, X-ray abnormal, Enema administration, 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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 5/13/2013

VAERS ID: 294705 Before After
VAERS Form:
Age:0.2
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 0 UN / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Haematochezia, Intussusception, Vomiting, X-ray abnormal, Enema administration, 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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 2/14/2017

VAERS ID: 294705 Before After
VAERS Form:
Age:0.2 0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 0 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 - / PO

Administered by: Other      Purchased by: Public
Symptoms: Haematochezia, Intussusception, Vomiting, X-ray abnormal, Enema administration, 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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 9/14/2017

VAERS ID: 294705 Before After
VAERS Form:(blank) 1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 0 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 0 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 0 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 0 1 - MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 2/14/2018

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 6/14/2018

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 8/14/2018

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 9/14/2018

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 10/14/2018

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 12/24/2020

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

Changed on 12/30/2020

VAERS ID: 294705 Before After
VAERS Form:1
Age:0.18
Sex:Male
Location:California
Vaccinated:2007-09-11
Onset:2007-10-24
Submitted:2007-10-29
Entered:2007-10-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B090AA / 1 UN / IM
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0079U / 1 UN / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B474420 / 1 UN / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 1167F / 1 MO / PO

Administered by: Other      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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Xray tests LABS: abdominal x-ray & US c/w ileocolic IS. Air reduction enema successfully reduced IS.
CDC 'Split Type':

Write-up: Hospitalized with intussusception on 10/24/07. 12/4/07 Reviewed vax record which confirms dose & lot numbers as reported. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced vomiting & bloody stool. Had been seen at outlying ER & transferred to higher level of care. Admitted 10/24/2007 & d/c to home same day. FINAL DX: Intussusception, enema reduced. Records faxed to CDC.

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