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This is VAERS ID 409111

History of Changes from the VAERS Wayback Machine

First Appeared on 12/7/2010

409111
VAERS Form:
Age:0.8
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
ROT: ROTAVIRUS (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UN / UN

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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: unknown
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


Changed on 1/4/2011

409111 Before After
VAERS Form:
Age:0.8
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
ROT: ROTAVIRUS (NO BRAND NAME) / UNKNOWN MANUFACTURER - / - UN / UN
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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: unknown
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


Changed on 5/13/2013

409111 Before After
VAERS Form:
Age:0.8
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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: unknown
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


Changed on 6/14/2014

409111 Before After
VAERS Form:
Age:0.8
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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: unknown
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


Changed on 2/14/2017

409111 Before After
VAERS Form:
Age:0.8 0.76
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


Changed on 4/14/2017

409111 Before After
VAERS Form:
Age:0.76
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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: unknown
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


Changed on 9/14/2017

409111 Before After
VAERS Form:(blank) 1
Age:0.76
Gender:Male
Location:Indiana
Vaccinated:2010-10-05
Onset:2010-10-19
Submitted:2010-11-17
Entered:2010-11-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A4IDB094A / - UNK - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium double contrast, Diarrhoea, Haematochezia, Intussusception, Somnolence, Surgery, Urinary system X-ray, Vomiting, Decreased appetite

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: unknown
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: KUB, contrast enema
CDC 'Split Type':

Write-up:Presented to ER on 10/19/2010 with vomiting, anorexia, somnolence, and loose bloody stools. Irreducible ileocolonic intussusception noted with contrast enema. Surgical reduction was required.


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