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This is VAERS ID 315516

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

VAERS ID: 315516
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007H / 2 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Enema administration, Abdominal X-ray

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type':

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant me"dication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/1


Changed on 12/8/2009

VAERS ID: 315516 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007H / 2 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Full blood count normal, Intussusception, Laparotomy, Pain, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': (blank) WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant me"dication. medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''''s patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/1 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 3/2/2010

VAERS ID: 315516 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B54007H / 2 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Full blood count normal, Intussusception, Laparotomy, Pain, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 4/7/2010

VAERS ID: 315516 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B54007H / 2 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Full blood count normal, Intussusception, Laparotomy, Pain, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 8/31/2010

VAERS ID: 315516 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B54007H / 2 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Full blood count normal, Intussusception, Laparotomy, Pain, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 5/13/2013

VAERS ID: 315516 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 2 LL / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Full blood count normal, Intussusception, Laparotomy, Pain, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 4/14/2017

VAERS ID: 315516 Before After
VAERS Form:
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 2 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Appendicectomy, Barium enema abnormal, Crying, Full blood count normal, Intussusception, Laparotomy, Pain, Vomiting, Enema administration, Abdominal X-ray, Oral intake reduced

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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 9/14/2017

VAERS ID: 315516 Before After
VAERS Form:(blank) 1
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 2 3 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 2 3 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 2 3 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 2 3 - MO / PO

Administered by: Other      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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 2/14/2018

VAERS ID: 315516 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 3 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 3 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 3 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 3 MO / PO

Administered by: Other      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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 6/14/2018

VAERS ID: 315516 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 3 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 3 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 3 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 3 MO / PO

Administered by: Other      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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 8/14/2018

VAERS ID: 315516 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 3 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 3 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 3 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 3 MO / PO

Administered by: Other      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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 9/14/2018

VAERS ID: 315516 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 3 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 3 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 3 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 3 MO / PO

Administered by: Other      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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home


Changed on 10/14/2018

VAERS ID: 315516 Before After
VAERS Form:1
Age:0.4
Sex:Male
Location:Florida
Vaccinated:2007-09-28
Onset:2008-01-08
Submitted:2008-06-06
Entered:2008-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B115AA / 3 RL / UN
HIBV: HIB (PEDVAXHIB) / MERCK & CO. INC. 0066U / 3 LL / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B54007H / 3 LL / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0877U / 3 MO / PO

Administered by: Other      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? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None. PMH: RAD
Allergies:
Diagnostic Lab Data: None. Labs and Diagnostics: Barium Enema (+) for IS. Abd X-ray 1/19/08 WNL. CBC and Chem unremarkable.
CDC 'Split Type': WAES0806USA00031

Write-up: Information has been received from a physician assistant (PA) concerning an approximately 6 to 7 month old patient with no medical history or allergies who on unspecified dates was vaccinated po with all three doses of ROTATEQ. There was no concomitant medication. The PA reported the patient experienced intussusception and was hospitalized (no time frame was available). The patient''s outcome was not reported. Additional information has been requested. 6/16/2008 MR received for 2 ER visits 1/8/08 and 1/19/2008 with DX: Intussusception. 2nd visit for not eating well s/p IS. infant presented with 12 hr hx of vomiting as well as crying as if in pain. Taking nothing po. IS noted on Barium enema but uncuccessful at reducing. Transfered to higher level of care. 7/10/2008 MR received for DOS 1/9-11/2008 with D/C Dx Intussusception s/p reduction and appendectomy. Infant received for transfer s/p unsuccessful BE reduction. Pt taken to OR for laparotomy and reduction with appendectomy and lymph node biopsy. Did well post-op and d/c home

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