This is VAERS ID 293965

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2007

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC	B58845F / 2	UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal distension, Barium enema, Diarrhoea, Enema administration, Cow''s milk intolerance

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - /"cleared the intussusception/"; stool rotavirus RNA 09/12/07 negat
CDC 'Split Type':

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U re"spectively). Concomitant vaccines included Hib conj vaccine (lot#''''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 1

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Changed on 12/8/2009

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHE: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC	B58845F / 2	UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal distension, Barium enema, Cow's milk intolerance, Diarrhoea, Flatulence, Gastrooesophageal reflux disease, Haematocrit decreased, Haemoglobin decreased, Intussusception, Irritability, Mouth ulceration, Mucous stools, Pyrexia, Screaming, White blood cell count increased, Enema administration, Laboratory test normal, Rotavirus test negative, Cow''s milk intolerance

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - /"cleared "cleared the intussusception/"; intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': (blank) WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U re"spectively). respectively). Concomitant vaccines included Hib conj vaccine (lot#''''s53523/0063U (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''''s #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''''s #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records

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Changed on 3/2/2010

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC	B58845F / 2	UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Cow's milk intolerance, Diarrhoea, Flatulence, Gastrooesophageal reflux disease, Haematocrit decreased, Haemoglobin decreased, Intussusception, Irritability, Mouth ulceration, Mucous stools, Pyrexia, Screaming, White blood cell count increased, Enema administration, Laboratory test normal, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records

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Changed on 4/7/2010

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC	B58845F / 2	UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Cow's milk intolerance, Diarrhoea, Flatulence, Gastrooesophageal reflux disease, Haematocrit decreased, Haemoglobin decreased, Intussusception, Irritability, Mouth ulceration, Mucous stools, Pyrexia, Screaming, White blood cell count increased, Enema administration, Laboratory test normal, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records

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Changed on 8/31/2010

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH	B58845F / 2	UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Cow's milk intolerance, Diarrhoea, Flatulence, Gastrooesophageal reflux disease, Haematocrit decreased, Haemoglobin decreased, Intussusception, Irritability, Mouth ulceration, Mucous stools, Pyrexia, Screaming, White blood cell count increased, Enema administration, Laboratory test normal, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records

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Changed on 5/13/2013

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 2	UN / UN
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Cow's milk intolerance, Diarrhoea, Flatulence, Gastrooesophageal reflux disease, Haematocrit decreased, Haemoglobin decreased, Intussusception, Irritability, Mouth ulceration, Mucous stools, Pyrexia, Screaming, White blood cell count increased, Enema administration, Laboratory test normal, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records

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Changed on 4/14/2017

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 2	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2	- / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal distension, Barium enema, Cow's milk intolerance, Diarrhoea, Flatulence, Gastrooesophageal reflux disease, Haematocrit decreased, Haemoglobin decreased, Intussusception, Irritability, Mouth ulceration, Mucous stools, Pyrexia, Screaming, White blood cell count increased, Enema administration, Laboratory test normal, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

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Changed on 9/14/2017

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 2 3	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 2 3	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 2 3	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 2 3	- MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Flatulence, Intussusception, Mucous stools, Pyrexia, Screaming, Enema administration, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

---

Changed on 2/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 3	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 3	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 3	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 3	MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Flatulence, Intussusception, Mucous stools, Pyrexia, Screaming, Enema administration, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

---

Changed on 6/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 3	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 3	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 3	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 3	MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Flatulence, Intussusception, Mucous stools, Pyrexia, Screaming, Enema administration, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

---

Changed on 8/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 3	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 3	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 3	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 3	MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Flatulence, Intussusception, Mucous stools, Pyrexia, Screaming, Enema administration, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

---

Changed on 9/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 3	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 3	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 3	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 3	MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Flatulence, Intussusception, Mucous stools, Pyrexia, Screaming, Enema administration, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

---

Changed on 10/14/2018

Vaccin­ation / Manu­facturer	Lot / Dose	Site / Route
DTAPHEPBIP: DTAP + HEPB + IPV (PEDIARIX) / GLAXOSMITHKLINE BIOLOGICALS	AC21B124AA / 3	UN / UN
HIBV: HIB (NO BRAND NAME) / UNKNOWN MANUFACTURER	1126F / 3	UN / UN
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH	B58845F / 3	UN / UN
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC.	0875U / 3	MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, Diarrhoea, Flatulence, Intussusception, Mucous stools, Pyrexia, Screaming, Enema administration, Rotavirus test negative

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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data: barium enema X-ray 10/05/07 - "cleared the intussusception"; stool rotavirus RNA 09/12/07 negat LABS: BE reduced IS. LABS: WBC 16.1, H/H 12.5/34.8. Chemistry WNL.
CDC 'Split Type': WAES0710USA02336

Write-up: Information has been received from health professionals concerning a 7 month old male who received his first dose on 17-APR-2007, second dose 20-JUN-2007, and a third dose, 2 ml oral 21-AUG-2007, of Rotateq (lot #655866/1110F; 56385/0030U; 656381/0875U respectively). Concomitant vaccines included Hib conj vaccine (lot#''s53523/0063U and 654679/1126F respectively), PREVNAR (lot #''s B08691F; B08690H; and B58845F respectively), and PEDIARIX (lot #''s AC21B096A; AC21B114CA; and AC21B124AA respectively). On 11-SEP-2007, the patient''s mother phoned the office reporting that the patient had developed a fever, loose stools, was gassy, and was screaming every 1 1/2 hours at night. He was seen in the office and stool samples on 12-SEP-2007 were negative for Rota virus. The reporter stated that he continued to experience symptoms "on and off over the next couple of weeks." He was seen in the office again on 04-OCT-2007, after developing loose stools with mucous and low grade fever "on and off". On 05-OCT-2007, he was hospitalized and underwent an x-ray with barium enema "which cleared the intussusception". He was seen in the office in follow up to his hospitalization and reportedly was "doing fine". The reporter stated "the admission to the hospital and enema administration was intervention to prevent serious criteria". No product quality complaint was reported. The patients experiences were considered to be other important medical events by the reporter. This is one of two reports from the same source. Additional information has been requested. 10/23/07 Patient demographics provided by CDC. 10/23/07 Recieved contrast enema report from CDC which reveals patient had ileocolic IS at hepatic flexure & was successfully reduced. 10/23/07 Received vax record from pcp & VAERS database updated w/same. 12/4/07 Received ER medical records which reveal patient experienced irritability, fever & distended abdomen. BE reduced IS but transferred to higher level of care for continued observation. FINAL ER DX: Intussusception. Records faxed to CDC. 12/7/07 Reviewed hospital medical records which reveal patient experienced abdominal discomfort for approx 1 month starting w/ulcerations in mouth & throat & progressed to nightly abdominal pain, large amounts of gas, low grade fever intermittently. PCP tested for rotavirus which was neg. Initially had increased WBC. GI consult done as outpatient 1 week prior to admit who dx GERD, tx w/antacid & antibiotic. Transferred from outlying ER s/p BE revealed IS. Admitted 10/6 & d/c same day. To f/u w/PCP & have GI small bowel series done as outpatient. FINAL DX: abdominal pain, possible formula intolerance, unlikely intussusception. Records faxed to CDC.

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