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This is VAERS ID 290933

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

VAERS ID: 290933
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type':

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lo"t #''''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. T


Changed on 12/8/2009

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': (blank) WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lo"t #''''s (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. T The patient was brought to the emergency room and then transferred to a children''s hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 3/2/2010

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to a children''s hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 4/7/2010

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to a children''s hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 8/31/2010

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to a children''s hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 1/7/2013

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to a children''s hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 2/13/2013

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to a another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 5/13/2013

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 6/14/2014

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 3/14/2015

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 2/14/2017

VAERS ID: 290933 Before After
VAERS Form:
Age:0.3 0.33
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 4/14/2017

VAERS ID: 290933 Before After
VAERS Form:
Age:0.33
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Barium double contrast, Barium enema, Dehydration, Diarrhoea haemorrhagic, Intussusception, Lethargy, Pallor, Vomiting, X-ray abnormal, Enema administration

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 9/14/2017

VAERS ID: 290933 Before After
VAERS Form:(blank) 1
Age:0.33
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 1 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 1 2 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 1 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 1 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 1 2 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea haemorrhagic, Intussusception, Vomiting, X-ray abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 2/14/2018

VAERS ID: 290933 Before After
VAERS Form:1
Age:0.33
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 2 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea haemorrhagic, Intussusception, Vomiting, X-ray abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 6/14/2018

VAERS ID: 290933 Before After
VAERS Form:1
Age:0.33
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 2 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea haemorrhagic, Intussusception, Vomiting, X-ray abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.


Changed on 8/14/2018

VAERS ID: 290933 Before After
VAERS Form:1
Age:0.33
Gender:Female
Location:Pennsylvania
Vaccinated:2007-07-12
Onset:2007-09-04
Submitted:2007-09-19
Entered:2007-09-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2655AA / 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF163AA / 2 LL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR Z0873 / 2 RL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH B58845H / 2 LL / -
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0551U / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea haemorrhagic, Intussusception, Vomiting, X-ray abnormal

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray - tx IT
CDC 'Split Type': WAES0709USA02063

Write-up: Information has been received from a registered nurse concerning a 25-week-old female with no pertinent medical history and no drug reactions/allergies who on 16-MAY-2007 and 12-JUL-2007 was vaccinated PO with the first and second 2mL doses of Rotateq (Lot #''s 656385/0030U and 657292/0551U, respectively). There was no concomitant medication. On 04-SEP-2007 the patient experienced symptoms of intussusception. The patient initially experienced vomiting that was followed by bloody diarrhea 12 hours later. The patient was brought to the emergency room and then transferred to another hospital. The intussusception was treated with a barium enema and the patient was discharged on 05-SEP-2007. On 05-SEP-2007, the patient recovered from intussusception. There were no lab diagnostic studies performed. No further information is available. There was no product quality complaint. The event was considered to be immediately life-threatening and other important medical event by the reporter. Additional information has been requested. 9/28/07 Received hospital x 2 medical records which reveal patient seen in outlying ER for intermittent abdominal pain, vomiting, lethargy, pallor, dehydration & bloody diarrhea. Transferred to higher level of care for successful air contrast enema reduction. Admitted & d/c on 9/5/2007 w/o complication. FINAL DX: Intussusception, enema reduced. 10/5/07 Received vax record. VAERS database updated w/same. Records faxed to CDC.

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