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This is VAERS ID 413829

History of Changes from the VAERS Wayback Machine

First Appeared on 1/4/2011

VAERS ID: 413829
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Denies
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 4/13/2011

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Body temperature increased, Constipation, Intussusception, Vomiting projectile, X-ray abnormal, Enema administration, Urine output decreased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Denies
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 5/13/2011

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Body temperature increased, Constipation, Intussusception, Vomiting projectile, X-ray abnormal, Enema administration, Urine output decreased, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Denies
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 2/13/2013

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Denies None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 5/13/2013

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
ROTH1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 6/14/2014

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 3/14/2015

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 2/14/2017

VAERS ID: 413829 Before After
VAERS Form:
Age:0.4 0.39
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 - / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 9/14/2017

VAERS ID: 413829 Before After
VAERS Form:(blank) 1
Age:0.39
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 1 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 1 2 - MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 2/14/2018

VAERS ID: 413829 Before After
VAERS Form:1
Age:0.39
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).


Changed on 6/14/2018

VAERS ID: 413829 Before After
VAERS Form:1
Age:0.39
Gender:Male
Location:New York
Vaccinated:2010-12-17
Onset:2010-12-21
Submitted:2010-12-30
Entered:2010-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS AC21B256BA / 2 RL / IM
RV1: ROTAVIRUS (ROTARIX) / GLAXOSMITHKLINE BIOLOGICALS A41FB109A / 2 MO / PO

Administered by: Private      Purchased by: Private
Symptoms: Intussusception, Vomiting projectile, X-ray abnormal, 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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: Abdominal Xray revealed intussusception 4 days post ROTARIX vaccine, enema given to dx intussusception & treat.
CDC 'Split Type':

Write-up: On 12/17/10 pt received ROTARIX vaccine. On 12/21/10 pt''s mother reported projectile vomiting. Pt''s mother monitored pt and called back due to continued vomiting. Pt sent to ER for evaluation. Abdominal xray at Hospital revealed intussusception. Pt admitted and dc''d on 12/24/10. (3 days in pt.).

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