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This is VAERS ID 303294

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

VAERS ID: 303294
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC 808666D / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Barium enema, CSF protein normal, Culture urine negative, 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)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos
CDC 'Split Type':

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0"971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximat


Changed on 12/8/2009

VAERS ID: 303294 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC 808666D / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Barium enema, CSF protein normal, Culture urine negative, Full blood count, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Lethargy, Listless, Lumbar puncture normal, Red blood cells CSF positive, Screaming, Vomiting, White blood cell count, Enema administration, Ultrasound abdomen abnormal, Abdominal X-ray, Physical examination normal, Oral intake reduced

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos
CDC 'Split Type': (blank) WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0"971U). 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximat approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 3/2/2010

VAERS ID: 303294 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC 808666D / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, CSF protein normal, Culture urine negative, Full blood count, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Lethargy, Listless, Lumbar puncture normal, Red blood cells CSF positive, Screaming, Vomiting, White blood cell count, Enema administration, Ultrasound abdomen abnormal, Abdominal X-ray, Physical examination normal, Oral intake reduced

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 4/7/2010

VAERS ID: 303294 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC 808666D / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, CSF protein normal, Culture urine negative, Full blood count, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Lethargy, Listless, Lumbar puncture normal, Red blood cells CSF positive, Screaming, Vomiting, White blood cell count, Enema administration, Ultrasound abdomen abnormal, Abdominal X-ray, Physical examination normal, Oral intake reduced

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 8/31/2010

VAERS ID: 303294 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH 808666D / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, CSF protein normal, Culture urine negative, Full blood count, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Lethargy, Listless, Lumbar puncture normal, Red blood cells CSF positive, Screaming, Vomiting, White blood cell count, Enema administration, Ultrasound abdomen abnormal, Abdominal X-ray, Physical examination normal, Oral intake reduced

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 5/13/2013

VAERS ID: 303294 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 808666D / 1 RL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, CSF protein normal, Culture urine negative, Full blood count, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Lethargy, Listless, Lumbar puncture normal, Red blood cells CSF positive, Screaming, Vomiting, White blood cell count, Enema administration, Ultrasound abdomen abnormal, Abdominal X-ray, Physical examination normal, Oral intake reduced

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 4/14/2017

VAERS ID: 303294 Before After
VAERS Form:
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 808666D / 1 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Barium enema, CSF protein normal, Culture urine negative, Full blood count, Haematochezia, Haematocrit decreased, Haemoglobin decreased, Intussusception, Lethargy, Listless, Lumbar puncture normal, Red blood cells CSF positive, Screaming, Vomiting, White blood cell count, Enema administration, Ultrasound abdomen abnormal, Abdominal X-ray, Physical examination normal, Oral intake reduced

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnos Diagnostics: Abd X-ray (+) for distended bowel loops. ABd US (+) for R mid/lower quadrant intussusception. Barium enema (+) for IS
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 9/14/2017

VAERS ID: 303294 Before After
VAERS Form:(blank) 1
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 1 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 1 2 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 1 2 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 808666D / 1 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 1 2 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Physical examination normal

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnostics: Abd X-ray (+) for distended bowel loops. ABd US (+) for R mid/lower quadrant intussusception. Barium enema (+) for IS
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


Changed on 2/14/2018

VAERS ID: 303294 Before After
VAERS Form:1
Age:0.3
Gender:Female
Location:Maryland
Vaccinated:2007-12-28
Onset:2007-12-28
Submitted:2008-01-22
Entered:2008-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR CZ607AA / 2 LL / -
HIBV: HIB (ACTHIB) / SANOFI PASTEUR ME852AA / 2 RL / -
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A0170-2 / 2 LL / -
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH 808666D / 2 RL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0971U / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception, Physical examination normal

Life Threatening? No
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data: barium enema X-ray 01/03/08 intussusception resolved; physical examination 01/14/07 normal. Labs and Diagnsotics: UC (-). LP with CSF with (+) RBCs. CSF protein 47. otherwise WNL. CBC with Hct 30.8, Hgb 10.4, WBCs 13.1. Labs and Diagnostics: Abd X-ray (+) for distended bowel loops. ABd US (+) for R mid/lower quadrant intussusception. Barium enema (+) for IS
CDC 'Split Type': WAES0801USA03165

Write-up: Information has been received from a physician concerning a 17 week old female with no pertinent medical history or drug allergies who on 02-NOV-2007 and 28-DEC-2007 was vaccinated PO with her first and second doses of RotaTeq (lot# 657459/0509U, 656387/0971U). There was no concomitant medication. On 28-DEC-2007 the patient experienced intussusception and was hospitalized on 03-JAN-2008. The intussusception was resolved with a barium enema. The patient did not require surgical interventions. On approximately 06-JAN-2008 2-3 days after hospitalization, the patient was discharged home and was noted to be recovered. On 14-JAN-2008 the patient was seen for a follow-up visit with the physician and her exam was normal. On that same day after the exam, therapy with RotaTeq was discontinued by the physician. There was no product quality complaint. Additional information has been requested. 01/25/2008 Vax record received and data entered. 01/29/2008 MR received for ER visit 1/3/08. Infant to ER with screaming, vomiting, and listlessness. No po intake that day. Impression: Viral syndrome. Vomiting. Child transfered to another facility for further care. 03/27/2008 MR received for DOS 01/4-6/2008 with D/C DX: Intussusception. Infant presented to local hospital with lethargy, decreased po intake and vomiting. Pt later had a bloody stool. IS noted on Abd US. Air contrast enema successful in reducing IS. Pt began taking PO well and became more alert and was d/c home.


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