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This is VAERS ID 321007

History of Changes from the VAERS Wayback Machine

First Appeared on 12/31/2008

VAERS ID: 321007
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C35173 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Unknown
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type':

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN ("Unspecified). The patient experienced /"intussusception/" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that /"patient is fine now./" Unspecified medical attention was sought. No product quality complaint


Changed on 12/8/2009

VAERS ID: 321007 Before After
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C35173 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Unknown Other
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation, Crying, Intussusception, Irritability, Vomiting, Vomiting projectile, Enema administration, Ultrasound abdomen abnormal, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, 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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': (blank) WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN ("Unspecified). (Unspecified). The patient experienced /"intussusception/" "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that /"patient "patient is fine now./" now." Unspecified medical attention was sought. No product quality complaint complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 3/2/2010

VAERS ID: 321007 Before After
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR) PNEUMO (PREVNAR7) / WYETH PHARMACEUTICALS, INC C35173 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation, Crying, Intussusception, Irritability, Vomiting, Vomiting projectile, Enema administration, Ultrasound abdomen abnormal, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, 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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 4/7/2010

VAERS ID: 321007 Before After
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR7) PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC C35173 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation, Crying, Intussusception, Irritability, Vomiting, Vomiting projectile, Enema administration, Ultrasound abdomen abnormal, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, 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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 8/31/2010

VAERS ID: 321007 Before After
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / WYETH PHARMACEUTICALS, INC PFIZER/WYETH C35173 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation, Crying, Intussusception, Irritability, Vomiting, Vomiting projectile, Enema administration, Ultrasound abdomen abnormal, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, 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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 5/13/2013

VAERS ID: 321007 Before After
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 1 LL / IM
ROTHB5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation, Crying, Intussusception, Irritability, Vomiting, Vomiting projectile, Enema administration, Ultrasound abdomen abnormal, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, 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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 4/14/2017

VAERS ID: 321007 Before After
VAERS Form:
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 1 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 - / PO

Administered by: Other      Purchased by: Other
Symptoms: Abdominal pain, Blood creatinine decreased, Blood culture negative, Carbon dioxide decreased, Constipation, Crying, Intussusception, Irritability, Vomiting, Vomiting projectile, Enema administration, Ultrasound abdomen abnormal, Neutrophil percentage increased, Monocyte percentage decreased, Lymphocyte percentage decreased, 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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 9/14/2017

VAERS ID: 321007 Before After
VAERS Form:(blank) 1
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 1 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 1 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 1 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 1 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 1 2 - MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 2/14/2018

VAERS ID: 321007 Before After
VAERS Form:1
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 6/14/2018

VAERS ID: 321007 Before After
VAERS Form:1
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 8/14/2018

VAERS ID: 321007 Before After
VAERS Form:1
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 9/14/2018

VAERS ID: 321007 Before After
VAERS Form:1
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.


Changed on 10/14/2018

VAERS ID: 321007 Before After
VAERS Form:1
Age:0.3
Sex:Female
Location:Tennessee
Vaccinated:2008-06-23
Onset:0000-00-00
Submitted:2008-07-31
Entered:2008-08-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (DAPTACEL) / SANOFI PASTEUR C2934BA / 2 RL / IM
HIBV: HIB (ACTHIB) / SANOFI PASTEUR UF260AB / 2 LL / IM
IPV: POLIO VIRUS, INACT. (IPOL) / SANOFI PASTEUR A480 / 2 RL / IM
PNC: PNEUMO (PREVNAR) / PFIZER/WYETH C35173 / 2 LL / IM
RV5: ROTAVIRUS (ROTATEQ) / MERCK & CO. INC. 0211XDT / 2 MO / PO

Administered by: Other      Purchased by: Other
Symptoms: Intussusception

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: 2     Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: therapy unspecified; PREVACID; REGLAN
Current Illness:
Preexisting Conditions: Gastrooesophageal reflux
Allergies:
Diagnostic Lab Data: Unknown LABS: US of abdomen (+). Gastrografin enema. Neutros 75%(H), lymphs 21%(L), monos 3%(L). CO2 21(L), creatinine 0.27(L). Blood c/s neg.
CDC 'Split Type': WAES0807USA05332

Write-up: Information has been received from a physician concerning a 5 month old patient with a history of gastrooesophageal reflux who was vaccinated with the second dose of ROTATEQ, 1 ml. Concomitant therapy included PREVACID (TAP), routine vaccines and REGLAN (Unspecified). The patient experienced "intussusception" after receiving the second dose of ROTATEQ and had to be hospitalized overnight. It was reported that "patient is fine now." Unspecified medical attention was sought. No product quality complaint. Additional information has been requested. 8/22/08 Reviewed PCP office records of 6/23/2008 FINAL DX: ileocecal intussusception. Records reveal patient experienced vomiting & constipation on day of vaccination. Slept in bassinet w/bottle on side. Next vs of 7/24 was s/p overnight hospitalization for enema reduced IS. Patient had projectile vomiting & reduced oral intake. 9/5/08 Reviewed hospital medical records of 7/9-7/11/2008. FINAL DX: Intussusception Records reveal patient experienced projectile vomiting, severe abdominal pain, irritability, crying. Pt admitted for observation s/p enema reduction of IS.

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