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From the 11/19/2021 release of VAERS data:

Found 4,746 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died

Government Disclaimer on use of this data



Case Details

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VAERS ID: 1098178 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: D.C.  
Vaccinated:2021-01-25
Onset:2021-01-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Decubitus ulcer, Disorientation, General physical health deterioration, Hypophagia, Lethargy, Mental status changes, Wound dehiscence
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Donepezil, famotidine, mirtazapine, senna, quetiapine, tramadol, sinemet, Tylenol
Current Illness: hypertension, parkinson''s disease, dementia, incontinence
Preexisting Conditions: hypertension, parkinson''s disease, dementia
Allergies: sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2nd dose of covid19 vaccine administered on 1/25/21 AM. First dose was about 12/28/2021. Patient had a change in condition noted same day PM, which included worsening mental status with increased confusion such as disorientation and decreased functional status, as well as opening of pressure ulcer on coccyx. Patient became lethargic. Patient condition worsened over the next few days. Patient decreased oral intakes, including medications. Care and comfort measures were in place. Patient expired on 2/4/2021.


VAERS ID: 1098473 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-25
Onset:2021-01-30
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Confusional state, Death, Dysphagia, Intensive care, Mechanical ventilation, Mental impairment, Pancreatitis, Renal failure, Sepsis
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Acute pancreatitis (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 19 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: naproxen amlodipine folic acid omeprazole methotrexate fosomax dorzoltimol latanoprost
Current Illness: taking a steroid for a lung infection.
Preexisting Conditions: Pulmanary issues, rheumatoid arthritis, bronchiectasis, macular degeneration, glaucoma
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My mother had the shot on January 25. On the 30th, she became confused and was having trouble swallowing. I took her to the hospital on the 31st (Sunday). She was admitted with pancreatitis and was unable to drink water. She was then admitted to the ICU. She became septic and her mental status declined. By Tuesday, she was placed on a ventilator. She then had renal failure and died on February 18th.


VAERS ID: 1098680 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-18
Onset:2021-03-06
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol, amlodipine, lipitor, breo ellipta, flexeril, wellbutrin, premarin, prozac, levothyroxine, losartan, singulair, prilosec,
Current Illness: 2nd toe arthroplasty surgery 3/4/2021, laminotomy, medial facetectomy and B foraminotomies L3-S1 on 2/22/21
Preexisting Conditions: Lumbar stenosis, hypertension, hypothryroidism, h/o breast CA, prediabetes, osteoarthritis, s/p hip replacement, anemia, gerd, asthma, cervical spondylosis with myelopathy
Allergies: Tape
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt completed 2 covid vaccine morderna doses Feb 18, 2021. Pt with increasing weakness and short of breath for 3 days PTA on 3/6/2021.


VAERS ID: 1098856 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood test, Cerebral haemorrhage, Computerised tomogram head abnormal, Death, Headache, Incoherent, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lexapro; Mementine; Calcitonin; Iron; Magnesium; Areds; Vitamin D; Serequel; Vitamin C; Donepezil
Current Illness: Dementia
Preexisting Conditions: Dementia
Allergies: Sulfa Compazine
Diagnostic Lab Data: CT Scan and blood work on 3/2/2021 in ER. CT showed brain hemorrhage.
CDC Split Type:

Write-up: Four hours after vaccine shot, she began with a headache then severe vomiting. She became in coherent and when brought to the hospital she had a brain hemorrhage. She passed away on 3/3/2021 at 3:05pm.


VAERS ID: 1098902 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-02
Onset:2021-02-21
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetic, coronary heart disease
Preexisting Conditions: Diabetic, coronary heart disease
Allergies:
Diagnostic Lab Data: Autopsy not done due to known health conditions and no fowl play. Understood that death was likely caused by his Heath issues, but just wanted the death reported in case there are later findings about the vaccines and potential complications.
CDC Split Type:

Write-up: Death


VAERS ID: 1099216 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-15
Onset:2021-03-07
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT''S SISTER REPORTED PATIENT PASSED AWAY 03/07/2021


VAERS ID: 1099326 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2020-03-18
Onset:2021-02-23
   Days after vaccination:342
Submitted: 0000-00-00
Entered: 2021-03-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / -

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Cough, Death, Gastrooesophageal reflux disease
SMQs:, Anaphylactic reaction (broad), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Bepreve; Betoptic; Alphagan; Rocklatan; SystaineZaditor; Systane complete;Spiriva hand haler
Current Illness: None
Preexisting Conditions: COPD; Dystonia
Allergies: only seasonal allergies
Diagnostic Lab Data: Patient dies on March 5, 2021.
CDC Split Type: unKnown

Write-up: A few days after vaccination patient had an unusual dry cough/ and then a pain in his chest, He called our Doctor she said call your cardiologist now, patient called Dr and told him he wanted to go to his office, explained the pain he was experiencing - the doctor told him said he couldn''t see him wanted to do a telemed exam. and proceeded to tell patient to see an gastro entomologist, take Tums, no tomatoes, no coffee and a few other foods and that patient was suffering from Acid Reflux and to call him back net week.


VAERS ID: 1100247 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Discomfort, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No recorded medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unconsciousness; Feeling discomfort within a few minutes after the vaccination; A spontaneous report was received from a healthcare professional concerning a 78-year-old, female patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273) and experienced of feeling discomfort within a few minutes after the vaccination, followed by unconsciousness and death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unspecified date, prior to the onset of the event, patient received their dose of mRNA-1273 (Batch Number: Unknown) for prophylaxis of COVID-19 infection. On an unspecified date, the patient experienced feeling discomfort within a few minutes after the vaccination, followed by unconsciousness and death. Treatment information for event unconsciousness included resuscitate via cardiopulmonary resuscitation with no success. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event unconsciousness was fatal and patient died.; Reporter''s Comments: This is a case of death of a 78-year-old, female patient who experienced within a few minutes of product use who experienced feeling of discomfort and became unconscious and subsequently expired. Based on the current available information, a strong temporal association between the product use and onset of the events, a causal relationship with the events cannot be excluded. However, critical details such as the patient''s medical history and actual cause of death is lacking.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1100650 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: High blood pressure medicine Gabba pentin.
Current Illness: Copd
Preexisting Conditions: Back pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died two days after receiving vaccine. Death certificate said respiratory failure.


VAERS ID: 1101239 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-17
Onset:2021-02-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Crying, Death, Gait disturbance, General physical health deterioration, Walking aid user
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metropolol, Donepezil, antibiotic
Current Illness: UTI
Preexisting Conditions: Dementia, type II diabetes, high cholesterol, high blood pressure, heart disease, kidney disease
Allergies: Sulfa drugs
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had been slowly declining over the past year due to dementia and age. On the date of her second vaccination, Feb. 17, she was getting around with her walker. On Friday, Feb. 19, she was so weak she was no longer able to walk with her walker, and she declined every day thereafter. On Monday, Feb. 22 she began crying and saying "help me". That lasted approximately a week. her health declined every day until Saturday, March 6, when she passed away at 6:15a.


VAERS ID: 1101286 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-03
Onset:2021-03-10
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81mg, Metformin 100mg, Gllipizide 10mg, Simvastatin 40mg, Lisinopril 10mg.
Current Illness: None
Preexisting Conditions: Diabetes and High Blood Pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Large Stroke


VAERS ID: 1101602 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-27
Onset:2021-02-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 1 UN / UN

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Diarrhoea, Malaise, Pyrexia, SARS-CoV-2 test negative, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown. Postmortem COVID-19 test was negative.
Preexisting Conditions: Diabetes mellitus, heart disease, hypertension
Allergies: Unknown
Diagnostic Lab Data: A postmortem nasopharyngeal COVID-19 test, collected on 3/2/21, was negative. No autopsy was performed.
CDC Split Type:

Write-up: Later that day after receiving the shot, patient reportedly became very ill with fever, vomiting, and diarrhea. He was found deceased the next day when friends went to check on him.


VAERS ID: 1101837 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, Malaise
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient Medication List: tacrolimus, mycophenolic acid, prednisone, clonidine, coumadin, vascepa, carbamazepine, vitamin d3, hydroxyzine, nifedipine, carvedilol, rosuvastatin, sodium bicarb, pioglitazone, lantus, humalog, lisinopril.
Current Illness: Dehydration 2 days prior, treatted by Hospital
Preexisting Conditions: Kidney failure and resulting transplant, IDDM, hyperlipidemia, Htn
Allergies: Seasonal allergies only
Diagnostic Lab Data: See medical records for details.
CDC Split Type:

Write-up: The patient became ill two days after the vaccination, and was hospitalized. He was diagnosed with COVID pneumonia on the 15th, and subsequently died.


VAERS ID: 1101959 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-03
Onset:2021-02-06
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamins Prilosec (Other medications but unknown at the moment- will call back)
Current Illness: No
Preexisting Conditions: High Cholesterol
Allergies: No
Diagnostic Lab Data: No. (NO autopsy)
CDC Split Type:

Write-up: He passed on 02/06/2021


VAERS ID: 1102082 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-02-26
Onset:2021-03-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute myocardial infarction, Cachexia, Condition aggravated, Dementia, Dysphagia, Electrolyte imbalance, Odynophagia, Ultrasound scan, X-ray
SMQs:, Myocardial infarction (narrow), Anticholinergic syndrome (broad), Dementia (narrow), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, Losartan Potassium, Women''s multivitamin, probiotic, baby aspirin, Metformin, Memantine, Mirtazapine
Current Illness: Dysphagia
Preexisting Conditions: Dementia, Diabetes type 2, hypertension,
Allergies: Penicillin
Diagnostic Lab Data: Ultrasound 3/3/21, xray 3/2/21
CDC Split Type:

Write-up: Acute Myocardial Infarction due to severe dysphagia, odynophagia, cachexia, fluid and electrolyte abnormalities, due to advanced dementia


VAERS ID: 1102244 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient expired on 02/26/2021 from a Myocardial Infarction


VAERS ID: 1102443 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-01-27
Onset:2021-02-18
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid normal, Brain natriuretic peptide increased, Computerised tomogram thorax, Cough, Death, Fibrin D dimer increased, Lung opacity, Oxygen saturation decreased, Pyrexia, Troponin normal, Urine analysis normal, Vomiting
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Abilify Tablet 5 MG (ARIPiprazole), Donepezil 10 mg HCl Tablet, Finasteride 5 mg Tablet, Levothyroxine Sodium Tablet 75 MCG, Lidoderm Patch 5 % (Lidocaine), Loratadine Tablet 10 MG, MiraLax Powder (PolyethyleneGlycol 3350) 17 gram, Omeprazo
Current Illness: The resident had dementia and was requiring increase assistance. The resident had been experiencing weight loss over the past few months. The resident was medicated for chronic pain.
Preexisting Conditions: The resident was wheelchair bound and dependent on staff for care.
Allergies: Pregabalin
Diagnostic Lab Data: 2/18/2021- CTA-PE of Chest performed at the hospital. Results- no evidence of pulmonary embolism. Scattered centrilobular nodules and groundglass opacities in the right lower lobe, right middle lobe and left lower lobe. Appearance is concerning for endobronchial infectious/inflammatory process such as aspiration pneumonia. The appearance is not compatible with covid pneumonia. 2/18/2021- UA - negative 2/18/2021- D-Dimer 1.55 (High) 2/18/2021- BNP 862 (High) 2/18/2021- Troponin WNL, Lactic Acid WNL,
CDC Split Type:

Write-up: On 2/18/2021 the resident spiked a fever of 101.7 and had decrease oxygen saturation down to 86% with a cough. The resident was transferred to the ER for evaluation. Per Advanced Directives resident was not treated with antibiotics and returned to the Nursing Home on 2/19/2021. The resident had several episodes of emesis and was placed on comfort measures. He dised on 2/25/2021.


VAERS ID: 1102722 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-03
Onset:2021-03-14
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Respiratory distress, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: PARKINSON''S DISEASE
Preexisting Conditions: Parkinson''s Disease, Hyperthyroidism, AFIB, Deprsn, Anxiety, DVT
Allergies: NO KNOWN ALLERGIES
Diagnostic Lab Data: COVID-19 positive - 3/14/2021
CDC Split Type:

Write-up: Patient presented to Hospital ED on 3/14/21 with respiratory distress. Patient was tested for COVID-19 and found to be positive on 3/14/21 in the hospital ED. Patient was a DNR. Hospice was consulted (this writer is employed by Hospice). The patient passed away on 3/15/2021. Per family patient had recently received COVID-19 vaccine. Vaccine information verified in portal.


VAERS ID: 1102736 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-07
Onset:2021-03-14
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Spouse of an existing client signed up for a COVID-19 vaccination and received his first injection of Moderna on 03/07/21 by ARNP. He denied any symptoms of illness, including COVID-19, on the vaccination date. He was educated re: possible side effects and adverse effects and was asked to report any such effects; no interim contact received. This provider''s office called the existing client on 03/15/21 with a routine matter and was advised that this individual had passed away the preceding day. This provider spoke to the existing client, who reported that the cause of death is unknown. The existing client did not believe that her spouse''s death and the vaccination were related. She was asked to notify this provider if any further information is discovered and agreed to do so.


VAERS ID: 1102800 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-05
Onset:2021-03-13
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Agonal respiration, Death, Dyspnoea, Endotracheal intubation, Resuscitation
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LOSARTAN 25 MG DAILY SPIRONALACTONE 25 MG DAIL ELIQUIS 5MG BID ASA 81MG DAILY ATORVASTATIN 20MG DAILY IRON 325MG DAILY FINASTERIDE 5MG DAILY GABAPENTIN 300MG DAILY MELATONIN 3MG DAILY LASIX 40MG BID- PRN VIT B12 INJECTION 1ML MONTHLY BENAD
Current Illness:
Preexisting Conditions: COPD CAD CHF
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received a covid vaccine on 03/05/2021. Daughter reports there were no side effects that night or the following days. The next Saturday, March 13, 2021, the daughter was at her parents house checking up on them. Her father was in the bathroom as she passed in the hall. He came out of the bathroom and proceeded to the living room, she stated dad are you ok? He said he couldn''t breath. Giving his history of COPD and being short of breath sometimes, she didn''t think anything of it. She proceeded to follow him to his chair and was checking his oxygen tank that he had been using with ambulation. It still had some in the tank. She raised her head to tell him he still had some in the tank and saw that he had started "agonal breathing". Daughter is a nurse and knew he needed help. She phone for an ambulance and with the help of her mother got patient to the floor and started CPR. Paramedics arrived on scene, continued CPR and administered meds and also intubated, but were unsuccessful in their efforts.


VAERS ID: 1103055 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None on intake form
Current Illness: None stated
Preexisting Conditions: None stated
Allergies: None stated
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient wife called on 3/11/21 to state that she would like us to cancel her husband second dose appointment for his COVID-19 Moderna vaccine. Wife stated that 24 hours after receiving vaccine patient died. Hospital told patient wife that it could be due to receiving COVID-19 vaccine. Unable to get anymore pertinent information from patient representative.


VAERS ID: 1103192 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-09
Onset:2021-03-14
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Baclofen 10 mg, diazepam 5 mg, Meloxican 15 mg, Omeprazole 20 mg, hydromorphone 4 mg.
Current Illness: Chronic pain and neurologic dysfunction due to multiple traumas
Preexisting Conditions: Pain and neurologic dysfunction
Allergies: No known allergies
Diagnostic Lab Data: No autopsy will be performed per coroner. Dr. documented death certificate as natural causes
CDC Split Type:

Write-up: Patient passed in his sleep 5 days after receiving first dose of Moderna


VAERS ID: 1103347 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Aphasia, Cerebral haemorrhage, Death, Incoherent, Mechanical ventilation
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: There are many. I do not have them with me.
Current Illness: ITP. macular degeneration, congestive heart failure
Preexisting Conditions: see above
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: At 2 PM Friday, March 12, patient was cleaning house and began speaking incoherently. Due to the aphasia, her daughter called 911. The ambulance delivered her to Hospital by 2:20. She presented with a brain hemoragh. Hospital called for medivac which took her to another Hospital. The bleeding continued and the docs ruled out surgery. They were unable to slow the bleed. Patient was put on a ventilor shortly after arriving at hospital. Patient passed at 6:55 PM March 13.


VAERS ID: 1103656 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-10
Onset:2021-02-16
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 AR / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Resuscitation
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix 75mg. CoQ10. Gabapentin 300mg. Olmesartan 20mg. Pantoprazole 40mg. Rosuvastatin 20mg Aspirin 81mg. Doxycycline. Ipatropium
Current Illness:
Preexisting Conditions: High blood pressure High cholesterol Acid reflux History of blood clots History of heart attack twice in 2002
Allergies: Penicillin
Diagnostic Lab Data: None. Autopsy was not ordered by JP
CDC Split Type:

Write-up: Patient was found deceased in garage. Neighbor who is a nurse did CPR until ambulance got there and took over, started IVs and pushed medicine and did CPR as well. Patient was pronounced deceased over th ephone with the JP and Police due to the icy weather conditions on Feb 16th 2021


VAERS ID: 1103708 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-26
Onset:2021-01-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Diarrhoea, Malaise, Musculoskeletal stiffness
SMQs:, Pseudomembranous colitis (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Arthritis (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Loratadine, Atorvastatin, Famotidine, Aspirin, Ranitidine, Rena-vite,
Current Illness: Pulmonary Fibrosis, Diabetes
Preexisting Conditions: Same as above
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Diarrhea, Stiff Neck, Overall feeling not well, Loss of strength


VAERS ID: 1103813 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-28
Onset:2021-03-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001121A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal distension, Acute kidney injury, Chest pain, Death, Dehydration, Dyspnoea, Echocardiogram normal, Electrocardiogram normal, Fatigue, Haemoglobin normal, Influenza virus test negative, International normalised ratio normal, Nausea, Pain, Platelet count normal, Prothrombin time normal, Renal failure, SARS-CoV-2 test negative, Ultrasound kidney normal, Urine analysis normal, Vomiting, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibrance, vit d, femara, losartan, hctz
Current Illness: HTN, Mild COPD, Breast cancer
Preexisting Conditions: as above
Allergies: None
Diagnostic Lab Data: as above. pt/inr normal, no PE, echo and ekg normal. normal wbc, hgb abd platelets. no new medications to cause renal failure. no imp with ivf. covid neg, flu neg, ua normal. renal us normal.
CDC Split Type:

Write-up: Pt was vaccinated on 2/28 and on 3/2 began to experience worsened sob from baseline, development of sternal chest pain, abdominal bloating, nausea and fatigue. She presented to the hospital on 3/9 c/o intractable pain and nausea/vomiting that was worsening. Imaging revealed no change in her cancer from same imaging in jan 2021. PE ruled out. No sepsis. She had acute kidney injury/dehydration. started on ivf. renal imaging normal. echo normal. ekg normal. she rapidly progressed to anuric renal failure and died 3/13/2021. oncology ruled out tumor lysis. she was not felt to be a candidate for dialysis.


VAERS ID: 1103826 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-25
Onset:2021-03-06
   Days after vaccination:40
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure acute, Chest pain, Death
SMQs:, Cardiac failure (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: chest pain, acute heart failue death


VAERS ID: 1103876 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-30
Onset:2021-02-24
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cough, Death, Diarrhoea, Dyspnoea, Nausea
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: shortness of breath, cough, nausea, diarrhea death


VAERS ID: 1103885 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-02-23
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1103943 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-02-25
Onset:2021-03-09
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: silvastatin
Current Illness: slightly elevated cholesterol
Preexisting Conditions: slightly overweight
Allergies: seasonal allergies, asthma
Diagnostic Lab Data: awaiting autopsy results
CDC Split Type:

Write-up: unexplained death


VAERS ID: 1103955 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-03
Onset:2021-03-08
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Secondary malignant neoplasm of bone CAD Colostomy related to diverticulitis abscess Atrial fibrillation Chronic myelomonocytic leukemia not having reached remission PVD Mixed hyperlipidemia CKD stage 3 Panlobular emphysema Metastatic breast cancer
Preexisting Conditions: Panlobular emphysema CKD stage 3
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reactions at the time of vaccine. Was admitted to hospital 5 days later with BLL pneumonia and passed away on 03/10/2021


VAERS ID: 1104177 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-03
Onset:2021-03-08
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: dead on 03/08/2021
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: autopsy is being performed privately
CDC Split Type:

Write-up: first vaccine (Moderna) was injected on 02/03/2021, second vaccine (pfizer) was injected on 03/02/2021, my Mother was dead on 03/08/2021. with no symptoms on 03/07/2021.


VAERS ID: 1104252 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute left ventricular failure, Angioplasty, Coronary arterial stent insertion, Death, Endarterectomy, Peripheral ischaemia, Peripheral swelling, Skin weeping, Stent placement
SMQs:, Cardiac failure (narrow), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: On 2/12/21, patient was hospitalized at Medical Center with "leaking and swollen legs." Patient was transferred to hospital 2/13/21 for a vascular surgeon consult, where patient was diagnosed with lower extremity ischemia and acute diastolic heart failure. A bilateral, common endarterectomy with bovine angioplasty and bilateral iliac stent placement was performed on 2/17/21. Patient was discharged to a skilled nursing facility on 2/26/21. Patient had received first covid vaccination on 1/29/21. He was due to receive his second dose on 2/26/21, however, the appointment was moved to 3/10/21 since patient was hospitalized. Patient received his second dose on 3/10/21. Patient was hospitalized again (reason for hospitalization unknown) where he passed away 3/11/21 at hospital.


VAERS ID: 1104257 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-03-07
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: 1st Dose of COVID Vaccination


VAERS ID: 1104337 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-02-22
Onset:2021-02-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose increased, Death, Foaming at mouth, Oxygen saturation decreased, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ASA Lisinopril metoprolol risperidone potassium
Current Illness: Diabetes, HTN
Preexisting Conditions: Dementia,, CKD. CHF
Allergies: NKDA
Diagnostic Lab Data: BS 500
CDC Split Type:

Write-up: On 3/23 at 0730 resdient non responsive with saliva foaming from mouth. BS 500. All vitals initially Ok then sats dropped to 75. (11 was called immediately upon finding resident. Taken to hospital. Completed course there and later on to rehab. She expired 3/11/2021


VAERS ID: 1104364 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-09
Onset:2021-03-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036A21A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 10 mg daily Hydrochlorothiazide 25 mg daily Lisinopril 40 mg daily
Current Illness: None
Preexisting Conditions: Hypertension Gout
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 24 hours of receiving vaccine


VAERS ID: 1104429 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-10
Onset:2021-03-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chronic obstructive pulmonary disease, Condition aggravated, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: BMI: 12.94 WT: 40.82kg
CDC Split Type:

Write-up: Death Narrative: Patient with medical history significant for malnutrition and end stage COPD. Patient was on 5 to 6 liters/min of oxygen. On 3/10/21, patient received his first COVID-19 vaccination. On 3/12/21, patient was admitted to Hospice for home hospice care due to worsening of COPD. Per medical examiner, patient passed away on 3/13/21.


VAERS ID: 1104699 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Guaifenesin Lorazepam Morphine Ipratropium-Albuterol Venlafaxine Phenazopyridine Amoxicillin Divalproex Sodium Albuterol Omeprazole Furosemide Meloxicam Donepezil Budesonide-Formoterol Memantine
Current Illness: Pneumonia 1/15/21
Preexisting Conditions: COPD Alzheimer''s Disease Chronic Respiratory Failure
Allergies: Quinolone (oral)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had been admitted to hospice care on 11/3/20. He reportedly declined in health and died 2/12/21.


VAERS ID: 1104815 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-15
Onset:2021-01-22
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Seen in ED for positive COVID symptoms - discharged with instructions. Death 1/26/2021


VAERS ID: 1104845 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-11
Onset:2021-03-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Amphetamines positive, Arteriosclerosis, Autopsy, Cardiac disorder, Death, Drug screen positive, Vaccination complication
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Drug abuse and dependence (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Gastroesophageal reflux disease, Chronic back pain
Allergies:
Diagnostic Lab Data: Urine drug screen positive for methamphetamine/amphetamine and cocaine at autopsy. Mild to moderate atherosclerotic cardiovascular disease. No other significant natural disease.
CDC Split Type:

Write-up: Deceased received second Moderna dose on 3/11/2021 at unknown location and unknown time. Complained of ''side effects'' which are unclear at this time. Had a sudden witnessed cardiac event on 3/14/2021 and was rushed to a local emergency department. Diagnosed with ST elevation MI and could not be fully resuscitated.


VAERS ID: 1105115 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-14
Onset:2021-02-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abscess limb, Death, Decreased activity, Groin abscess, Increased upper airway secretion
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Keppra 1000 mg, Lamictal , Vimpat, Quetiapina, Lorazepam, Zyprexa, Motrin, Vitamina K, Acido Folico, Sultato Ferroso, Multivitam?nico 365
Current Illness: None
Preexisting Conditions: Portal hypertension (secondary to portal vein thrombosis), Leukopenia, Thrombocytopenia, Epilepsy, Splenomegaly, Esophageal Varices, Asthma, Pancytopenia and Severe mental retardation.
Allergies: Dilantin and aspirin
Diagnostic Lab Data: None
CDC Split Type: PR-55-21

Write-up: Resident did not express having any symptoms, the only thing that the POC observed abscesses in the arm, groin, thigh and knees after the first vaccination. After the second dose, he was hypoactive. On 2/27 at about 3:30 am he asked him to turn on his side, between 4 am and 5 am POC went to the room I notice it strange, because his head was wrapped in the sheet. When the POC removed the sheet, she observed that her mouth and nose were full of secretions. So he turned it and he himself did not react. He called the emergency who certifies that he had no vital signs. (emergency arrives within 5:45 am to 6:00 am)


VAERS ID: 1105125 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-08
Onset:2021-03-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Apixaban Levothyroxine Sodium Pravastatin Sodium Metoprolol Succinate Lorazapam Folic Acid Feosol Natural Release
Current Illness: Elevated blood pressure
Preexisting Conditions: Hypothyroid ? Paroxysmal atrial fibrillation (HCC) ? S/p TAVR (transcatheter aortic valve replacement), bioprosthetic ? Iron deficiency anemia ? Epistaxis ? Hyperlipidemia ? Hypercoagulable state due to atrial fibrillation (HCC)
Allergies: Amlodipine Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had a hemorrhagic stroke


VAERS ID: 1105146 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-30
Onset:2021-01-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Productive cough, Resuscitation, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Keppra 1000 mg, Flexeril, Vitamins
Current Illness: None
Preexisting Conditions: Epilepsy, Hydrocephalus, and Multiple Sclerosis
Allergies: Not reported
Diagnostic Lab Data: None
CDC Split Type: PR-56-21

Write-up: 1/19 began vomiting and was hospitalized. On 1/30 he was discharged and later received the vaccine. It begins with weakness and a lack of appetite. He started coughing up foul-smelling secretions. He makes the arrangements to take him to the emergency room again, he called 911 to be transported, when they are taking the information from the POC, he is under oxygenation to 44. They take him in the ambulance, he receives CPR, they transport him to the facility where he arrives lifeless.


VAERS ID: 1105261 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-30
Onset:2021-02-22
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Feeding tube user, General physical health deterioration, Hypophagia
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Megace, Lorazepam 2 times a day, Tentral 400mg 2 times a day,, Quetiapine 100mg 2 times a day, Pepcid 20mg, Fluoxetine, Atorvastatin 20 MG, Temazepam 20 mg
Current Illness: None
Preexisting Conditions: ALZHEIMER, CIRCULATION PROBLEMS, POOR APPETITE, HYPERTENSION, ARTHRITIS, DEPRESSION
Allergies: Not reported
Diagnostic Lab Data: None
CDC Split Type: PR-57-21

Write-up: The patient was admitted to hospice because she stopped eating and deteriorated. He was being given food through the tube and then he has no vital signs.


VAERS ID: 1105300 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-18
Onset:2021-02-27
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose abnormal, Cardiovascular disorder, Cholecystitis, Death, Hypertension, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Infectious biliary disorders (narrow), Gallbladder related disorders (narrow), Guillain-Barre syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Quetapil 50 MG, Deforming, Metropol, Simvastatina Sereoquel, Trazodone 50 MG
Current Illness: None
Preexisting Conditions: Hypertension, DIABETES, CHOLESTEROL, Arrhythmia, ALZHEIMER
Allergies: Not reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-58-21

Write-up: He went to the hospital for cardiovascular problems and cholecystitis and was under treatment after the first dose. 2/26/2021 at around 11:00 pm she was complaining of high blood pressure, uncontrolled vital signs, uncontrolled sugar, at 6:00 am she has passed away. They certify respiratory failure.


VAERS ID: 1105408 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-02-01
Onset:2021-03-09
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1105749 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-29
Onset:2021-02-28
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ceftazidime 1500mg IP every day Vancomycin 1500mg IP twice weekly Diflucan 100mg PO every day Epogen SQ 16,000 units weekly Icodextrin 2500mL IP daily Nepro PO daily Potassium Chloride 20mEq PO daily ASA 81mg PO every day Atorvastatin Calc
Current Illness: Peritonitis (MRSA)
Preexisting Conditions: CHF Diabetes Type 2 Insulin dependent ESRD
Allergies: Heparin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died on 2/28/2021


VAERS ID: 1105820 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-12
Onset:2021-02-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory distress syndrome, Acute respiratory failure, Agonal respiration, Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Base excess negative, Basophil count decreased, Basophil percentage, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture, Blood electrolytes normal, Blood glucose increased, Blood lactic acid increased, Blood pH increased, Blood potassium normal, Blood pressure decreased, Blood sodium decreased, Blood urea increased, Bradycardia, C-reactive protein increased, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Continuous positive airway pressure, Cyanosis, Death, Differential white blood cell count abnormal, Dyspnoea, Echocardiogram, Electrocardiogram QT prolonged, Electrocardiogram T wave peaked, Electrocardiogram abnormal, Eosinophil count normal, Eosinophil percentage, Fibrin D dimer increased, Full blood count abnormal, General physical health deterioration, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Haemoptysis, Leukocytosis, Lung infiltration, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume, Mean platelet volume normal, Mechanical ventilation, Metabolic acidosis, Monocyte count, Monocyte percentage, Multiple organ dysfunction syndrome, Myocardial ischaemia, Neutrophil count increased, Neutrophil percentage increased, Oxygen saturation decreased, PCO2 decreased, PO2 decreased, Platelet count decreased, Pneumonia, Procalcitonin increased, Protein total normal, Pulse absent, Red cell distribution width normal, Respiratory alkalosis, Respiratory symptom, SARS-CoV-2 test, SARS-CoV-2 test negative, Sepsis, Septic shock, Suspected COVID-19, Tachypnoea, Troponin T increased, Troponin increased, Venipuncture, White blood cell count
SMQs:, Torsade de pointes/QT prolongation (narrow), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Rivaroxaban 15 and 20 MG, Tylenol, Meclizine 25 MG; Aspirin 18 MG daily, Pravastatin 20 MG daily, Multivitamins, BP formulation, Norvasc 5mg tablet daily . atenolol 25MG tablet daily
Current Illness: none
Preexisting Conditions: Abdominal Aortic Anuerysm, Atypical chest pain, Benign essential Hypertension, Pure hypercholesterolemia
Allergies: none
Diagnostic Lab Data: Diagnostics: Results for orders placed or performed during the hospital encounter of 02/14/21 CBC WITH DIFFERENTIAL Result Value Ref Range White Blood Cells 10.8 3.8 - 10.8 K/uL Red Blood Cells 3.94 (L) 4.33 - 5.75 M/uL Hemoglobin 13.0 (L) 13.4 - 17.6 g/dL Hematocrit 38.0 (L) 38.2 - 50.2 % MCV 96.4 (H) 82 - 96 fL MCH 33.0 (H) 28.0 - 32.8 pg MCHC 34.2 32.4 - 35.7 g/dL RDW 13.2 11.2 - 15.6 % Platelet Count 131 (L) 140 - 390 K/uL MPV 9.4 6.7 - 10.6 fL Neutrophil % 91.2 % Lymphocyte % 1.7 % Monocyte % 6.8 % Eosinophil % 0.0 % Basophil % 0.3 % Absolute Neutrophils 9.8 (H) 1.8 - 7.1 K/uL Absolute Lymphocytes 0.2 (L) 0.9 - 3.5 K/uL Absolute Monocytes 0.7 0.2 - 0.9 K/uL Absolute Eosinophils 0.0 0.0 - 0.5 K/uL Absolute Basophils 0.0 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range Sodium 135 133 - 144 mEq/L Potassium 4.8 3.5 - 5.0 mEq/L Chloride 103 95 - 107 mEq/L Carbon Dioxide 22 22 - 32 mEq/L Anion Gap 10 6 - 15 mEq/L BUN 38 (H) 8 - 24 mg/dL Creatinine 1.41 (H) 0.50 - 1.30 mg/dL Glomerular Filt Rate 44 (L) $g60 mL/min Glucose 164 (H) 70 - 100 mg/dL Albumin 3.4 (L) 3.5 - 5.2 g/dL Calcium 8.5 (L) 8.6 - 10.4 mg/dL AST 39 11 - 41 IU/L ALT 14 11 - 66 IU/L Alkaline Phosphatase 51 35 - 121 IU/L Bilirubin, Total 0.9 <1.5 mg/dL Total Protein 6.6 6.2 - 8.5 g/dL Globulin 3.2 1.8 - 3.7 g/dL A:G Ratio 1.1 (L) 1.2 - 2.7 TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 176 (HH) <12 ng/L PROCALCITONIN Result Value Ref Range Procalcitonin 0.36 (H) <0.25 ng/mL COVID (SARS-COV-2) BY RAPID ANTIGEN Result Value Ref Range COVID-19 Antigen Not detected NOTD TROPONIN T, HIGH SENSITIVITY Result Value Ref Range Troponin, High Sensitivity 233 (HH) <12 ng/L LACTIC ACID Result Value Ref Range Lactate 2.5 (H) 0.4 - 2.0 mmol/L CRP C REACTIVE PROTEIN QUANT Result Value Ref Range C Reactive Protein, Quantitative 7.34 (H) <0.80 mg/dL COVID AG DIRECT OPTICAL BILL Result Value Ref Range CPT 87811 Covid Antigen Direct Bill Billed for services performed D-DIMER Result Value Ref Range D-dimer 0.53 (H) <0.50 ug/mL FEU ARTERIAL BLOOD GAS Result Value Ref Range Patient Oxygen 100% pH, Arterial 7.46 (H) 7.35 - 7.45 pCO2, Arterial 29 (L) 30 - 45 mmHg pO2, Arterial 54 (L) 75 - 95 mmHg Base Deficit 2 0 - 2 Oxygen Saturation, Arterial 87 (L) 95 - 98 % Bicarbonate, Arterial 20 (L) 22 - 26 mmol/L Specimen type Arterial TCO2, Arterial 21 20 - 30 mEq/L Allens Test ALLENS TEST OK EKG (HOSPITAL) Result Value Ref Range Systolic BP 107 mmHg Diastolic BP 56 mmHg Ventricular Rate 82 BPM Atrial Rate 82 BPM QRS Duration 100 ms Q-T Interval 394 ms QTC Calculation(Bezet) 460 ms Calculated R Axis 17 degrees Calculated T Axis 45 degrees Diagnosis Accelerated Junctional rhythm Nonspecific ST and T wave abnormality Prolonged QT interval or tu fusion, consider myocardial disease, electrolyte imbalance, or drug effects Abnormal ECG When compared with ECG of 10-NOV-2020 10:24, Junctional rhythm has replaced Sinus rhythm Vent. rate has increased BY 30 BPM ST now depressed in Anterior leads CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Drawn from Left Antecubital area. Venipuncture Culture Pending Report Status Pending CULTURE, BLOOD. Specimen: BLOOD Result Value Ref Range Specimen Description BLOOD 10 mL each bottle Venipuncture Drawn from Left Antecubital area. Culture Pending Report Status Pending Medical Decision Making: Patient is an 89-year-old male who presents emergency department for evaluation of shortness of breath and cough. Differential diagnosis includes, but is not limited to, acute coronary syndrome, pneumonia, pulmonary embolism, reaction from recent COVID-19 vaccine, COVID-19 infection, other viral upper respiratory infection, pleural effusion, or CHF. The patient denies any discrete chest pain at this time, though he has had some chest pain with exertion for the past 6 months. He has had shortness of breath along with his cough, increasing my suspicion for possible infectious process. Upon his arrival, the patient is known to be tachypneic, with normal oxygen saturation rates. He is not tachycardic or febrile, therefore does not meet SIRS criteria at this time. Plan at this time to obtain laboratory evaluations, chest x-ray, and EKG. Low threshold to broaden evaluations to include infectious workup. Please reference the remaining ED Course for further assessment, plan, and disposition documentation. ED Course as of Feb 14 1916 Sun Feb 14, 2021 1230 EKG reveals sinus rhythm at a rate of 82 beats per minute. QRS duration 100 milliseconds. QTC slightly prolonged at 460 milliseconds. There is somewhat concerning peaked T-waves in leads V2 and V3 along with with possible ST elevation in lead V1 this does represent a change from the patient''s previous study in November, 2020. EKG (Hospital) 1315 No leukocytosis. Hemoglobin and hematocrit within normal limits for the patient. No thrombocytopenia. Slight elevation in absolute neutrophil count. CBC (Complete Blood Count) With Differential(!) 1330 Elevated at 176. As the patient has been having pain for the past 2 days, I am uncertain if this is catching the increase in his troponin, or the downtrend. He continues to deny chest pain and has reported that his shortness of breath has resolved. TROPONIN T, HIGH SENSITIVITY(!!) 1419 Electrolytes within normal limits. Creatinine elevated at 1.41, though this is not significantly elevated in comparison to study obtained approximately 3 weeks ago at 1.2. Liver function tests within normal limits. No anion gap. Comprehensive Metabolic Panel(!) 1420 By my interpretation, multifocal bilateral infiltrates, most consistent with COVID-19. Also possible right middle lobe infiltrate, concerning for possible superimposed bacterial pneumonia. This is interesting as the patient did just receive his 2nd COVID-19 vaccine. Plan at this time to broaden infectious work up and order for the patient to receive empiric antibiotics. XR Chest 1V Portable 1437 Elevated at 2.5. I will provide the patient with another fluid bolus as his IVC does appear flat upon ultrasound. Lactic Acid(!) 1503 Continues elevated 233. Will consult cardiology. TROPONIN T, HIGH SENSITIVITY(!!) 1506 IMPRESSION: 1. Significant and concerning patchy airspace opacities of the right upper, right lower and left mid lung, concerning for a pneumonic process. Less likely, viral upper is for infection, including Covid 19, could be present. 2. No other etiology seen for symptoms S: 2/14/2021 14:45 CST Electronically Authenticated D: 2/14/2021 14:42 CST XR Chest 1V Portable 1506 I did have a discussion with the patient''s daughter regarding which she believes her father''s code status is. She agrees that he is likely DNR DNI, but does think that he would like to have the cardiac catheterization completed. I will confirm this with the patient. 1617 Patient noted to become hypoxic to 76%. Borderline hypotensive at 91/55. No associated tachycardia. Slightly tachypneic at 26 br/min. Oxygen increased to 15 L/min and RT paged for BiPAP. After a discussion with the patient, he endorses that he understands what DNR/DNI status means, as his wife recently passed away approximately five months ago. He does share that he wishes to be DNR/DNI, which he believes he has paperwork reflecting. I believe at this time that he is of sound mind to make this decision as well, should we not have paperwork available to us reinforce this. He does request that I contact his daughter. 1621 Bedside cardiac ultrasound does not reveal pericardial effusion. IVC appears flat. Will order for the patient receive a 2nd 500 cubic centimeters bolus. RT is present at the bedside Redding to place NIPPV. 1704 D-dimer does age adjust within normal limit. D-DIMER(!) 1705 Patient with acute primary respiratory alkalosis with secondary metabolic acidosis. Continues to be hypoxic on 100% FiO2 with saturation rates at 89%. At this point in time, I favor the patient''s NSTEMI is secondary to demand ischemia given his ongoing hypoxia. However, given his previous reported history of exertional chest discomfort and dyspnea on exertion, I will at least discuss the patient with another Hospital. ARTERIAL BLOOD GAS(!) 1805 Patient did have a significant desaturation event that resulted after he disconnected himself from NIPPV. Upon my arrival into the room, he was noted to be setting 8% with good waveform. He was cyanotic with agonal respirations. He was noted to have a pulse that corresponded with the monitor at a tachycardic rate. He was rapidly placed in a supine position and of bagged with a non-rebreather to increase his oxygen saturation rates. His oxygen saturation rate did increase, but has not completely recovered. We did bag him for several minutes and his oxygen level is now in the low 80s. He is currently on non-rebreather at 15 liters/minute. He is not following commands. His daughter is present and I did advise her of this recent update. I did speak to another Hospital and inform them that the patient would not be transferred at this time. Patient''s blood pressure is noted to be 124/73 mmHg, therefore I will order him some morphine for air hunger. I did brief the patient''s daughter on his current status and we will have her be present in the room with him. 1851 Patient continued to deteriorate, ultimately coughing up bloody secretions. He was suctioned, but continued to be tachypneic and have increased work of breathing. He became bradycardic with heart rates in the 30s. After a discussion with the patient''s daughter, the decision was made to silence alarms. Patient was accompanied by his daughter, ultimately noted to lose pulses and time of death was called at 1830, confirmed by loss of palpable pulses and lose of auscultated pulses. Time was spent discussing the patient with his daughter. We did expedite his PCR COVID swab so as to ultimately know his COVID-19 status. We did offer to contact additionally family members on the behalf of the patient''s family.
CDC Split Type:

Write-up: Patient seen and evaluated by PA-C. with myself. We agreed on the clinical findings and implemented our plan together. Please see PA''s note for details. All relevant procedures supervised. Patient arrived to the emergency department due to respiratory symptoms, hypoxic, reported that Wednesday he received his 2nd dose of COVID vaccine. His initial workup was concern for NSTEMI with elevated troponin and peaked T-waves, his chest x-ray concerning for COVID/pneumonia. Patient initially tolerated oxygen by nasal cannula and sepsis protocol was started including IV fluid resuscitation that was done cautiously due to the concern of COVID with respiratory failure. The biotics were given. PA-C readdressed code status with patient who confirmed that his DNR DNI, she so contacted his daughter. Patient had multiorgan failure including acute kidney injury, and pneumonia with respiratory failure +/- respiratory failure. Due to the concern of NSTEMI patient was initially going to be transfer to was hospital and transfer was started. Patient respiratory status started deteriorating and his blood pressure dropped slightly but improved after 500 cubic centimeters of IV fluid and he was also placed on a NIPPV. Around 6:00 p.m. patient has significantly desaturation and he discontinued himself NIPPV. Due to inability to intubate patient, he was ventilated with BVM, patient is slowly improved saturation levels and was opening his eyes, he was placed on a non-rebreather. At this point there is high concern of ARDS and due to inability to intubate or give for the respiratory support His daughter was at bedside and updated of current medical status and poor prognosis. Patient continued deteriorating and at this point he had agonal breathing. His daughter was at bedside and she was made aware of the futile prognosis of patient due to his respiratory failure. Patient rapidly became bradycardic and went into cardiac arrest. No CPR was done due to the DNI DNR status of the patient. Critical Care Procedure Note Authorized and Performed by: MD Total critical care time: Approximately 30 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient''s response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see MDM section and the rest of the note for further information on patient assessment and treatment. PE: VITAL SIGNS: BP: 126/75 Pulse: (!) 122 Resp: (!) 40 SpO2: (!) 82 % Temp: 98.1 ?F (36.7 ?C) Height: 5'' 8" (172.7 cm) Weight: 152 lb (68.9 kg) General: Alert, nontoxic, in no acute distress. Lungs: Clear to auscultation bilaterally. CLINICAL IMPRESSION: 1. Sepsis with acute hypoxic respiratory failure and septic shock, due to unspecified organism (HCC) 2. Suspected COVID-19 virus infection 3. NSTEMI (non-ST elevated myocardial infarction) (HCC) 4. Multifocal pneumonia 5. ARDS (adult respiratory distress syndrome) (HCC) 6. Acute kidney injury (HCC) Further care and disposition otherwise as outlined by PA. ED on 2/14/2021 Revision & Routing History Detailed Report Note filed date Mon Feb 15, 2021 8:46 AM


VAERS ID: 1106175 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Kentucky  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: a friend died from the vaccine; A spontaneous report was received from a non health care professional, concerning her friend, who was administered Moderna''s COVID-19 vaccine (mRNA-1273) and died from the vaccine. The patient''s medical history,concomitant history, and lab data was not provided by the reporter. On an unknown date, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. The patient experienced death after receiving the moderna mRNA1273 vaccine. No further details were provided. The action taken with the second dose of mRNA-1273 in response to the event was not applicable. The outcome of the events, died from the vaccine, were considered as fatal.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1106554 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2020-12-28
Onset:2020-12-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: See chronic
Preexisting Conditions: Primary Pulmonary HTN Diabetes Chronic Renal Failure - Dialysis
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: She received vaccine on 12.28.21. On 12.30.21 she went to the ER and was subsequently sent to Hospital. Not sure what the findings were, but she was discharged after several hours. I spoke with her on the phone on 1.1.21,, She wasn''t feeling well. I asked her what was going on because she had been doing really well for a few months. She stated "Every since I took the vaccine, I have felt really bad." She died on 1.5.21. Timeline: 12.28.20 Vaccine 12.30.20 ER 1.1.21 Continues to feel bad and reports feeling worse and worse since vaccine. 1.5.21 Died at home.


VAERS ID: 1106581 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-03-10
Onset:2021-03-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: released from hospital one week prior , due to low potassium levels
Preexisting Conditions: unknown
Allergies: No known drug allergies
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient was discovered deceased in her apartment at 3pm on March 12, 2021.


VAERS ID: 1106667 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-12
Onset:2021-03-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Death, Eye movement disorder, Feeling abnormal, Resuscitation
SMQs:, Dementia (broad), Guillain-Barre syndrome (broad), Ocular motility disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine 5 mg daily, carvedilol 12.5 mg twice daily, furosemide 80 mg twice daily, sevelamer 800 mg 2 with meals tid, terazosin 2 mg daily, pantoprazole 20 mg daily if needed for heartburn, cinacalcet 30 mg daily
Current Illness: DM 2 with ESRD, hyperlipidemia, vascular disease, autonomic neuropathy, retinopathy, CAD w hx of CABG and coronary artery stent, chondrocalcinosis, gout. also hx of covid disease 6/3/2020. anemia renal disease, hyperparathyroidism of renal failure. hx smoking. hx stroke and TIAs; hx of subdural hematoma .
Preexisting Conditions: see above.
Allergies: penicillin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Information here obtained from daughter: on Thursday patient had an uneventful fistulagram with angioplasty. Patient got vaccine at end of usual Friday am dialysis treatment. He was observed for about 30" and no untoward event noted, vitals usual. At home on Saturday morning, seemed not quite himself by wife as reported by daughter, from whom i got his information. He gets up late as hemodialysis starts at 515 am. No reported problems on Friday. On Saturday morning, he seemed not himself but sat down and ate breakfast around 9 am. On getting up from table he got suddenly weak, his head rolled back and his eyes rolled up. 911 called and he was given resuscitation efforts of unknown duration which were unsuccessful. He was pronounced dead at 11 am and the mortuary was called. No premortem labs, et al.


VAERS ID: 1106684 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-03-08
Onset:2021-03-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041MZ017 / 2 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Promethazine, Fentanyl patch
Current Illness: R ankle ulcer, R heel pressure injury, hyperkalemia, CHF
Preexisting Conditions: PVD with chronic Right ankle ulcer, PVD with R heel pressure injury, dysphagia following CVA, oropharyngeal dysphagia, AFib, HTN, CAD, Acute on Chronic diastolic heart failure, RT hemaplegia following CVA, Aphasia following CVA, hemaplegia following CVA, Acute kidney failure, hyperkalemia, hypernatremia, adult failure to thrive, blood loss anemia, gout, presence of AICD, history of cardiac arrest, G-tube feeding (G-tube feeding discontinued on 2/14/21, G-tube dislodged 3/8/21)
Allergies: Cephalexin, Ciprofloxacin, Clindamycin, Lisinopril, Losartan, Shellfish, Shilvadene, Toradol, Vitamin E, Latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident on palliative/comfort care services since readmission to facility on 2/9/2021. Received first dose of Moderna COVID-19 vaccine on 1/7/2021. Received second dose of Moderna COVID-19 vaccine on 3/8/21. G-tube feeding discontinued on 2/14/21. Resident expired 3/10/2021.


VAERS ID: 1106719 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-03-09
Onset:2021-03-14
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: kidney chronic disease , diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Her daughter informed pharmacy staff that pt passed away on sunday 3/14/21


VAERS ID: 1106733 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-03-08
Onset:2021-03-14
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041MZ0A / 2 RA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Failure to thrive, Hypokalaemia
SMQs:, Neonatal disorders (broad), Hypokalaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Potassium chloride, timolol maleate 0.5%, latanoprost 0.0005%
Current Illness: R upper lobe PNA
Preexisting Conditions: PNA, Afib with rapid response, Senile Dementia without behavioral disturbances, Hypertension, History of fall, Glaucoma, Mild protein-calorie malnutrition, lumbar degenerative disc disease, Hyperlipidemia, Hx of esophageal polyps, Dysphagia and Hiatal Hernia
Allergies: Aspirin
Diagnostic Lab Data:
CDC Split Type:

Write-up: First dose of Moderna COVID-19 vaccine given 1/7/21. Second dose of Moderna COVID-19 vaccine given 3/8/21. No adverse effects noted after vaccination. Resident was on hospice care since 2/27/2021 with poor food and fluid intake prior. Admitted to hospice with hypokalemia, failure to thrive.


VAERS ID: 1106834 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-03-05
Onset:2021-03-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: "ASA" was noted on pre-screen; patient apparently also on oxygen per friend and POD staff due to COPD
Current Illness: COPD; recently began oxygen therapy
Preexisting Conditions: COPD; unknown others
Allergies: None reported on prescreen
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient apparently expired 3/09/2021, no other information known, unknown if linked.


VAERS ID: 1108264 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-02-23
   Days after vaccination:47
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: NO CURRENT/RECENT LABS AVAILABLE-LAST LABS DONE AT MEDICAL CENTER WERE WNL ON 12/07/2011
CDC Split Type:

Write-up: DEATH Narrative: No information available in the record other than date of vaccine on 1/7/2021 with no adverse effects or complications noted during observation period. Patient was not known to have had COVID infection prior to death. Had last received medical care at facility in 2012 except received audiology care up to 12/2/2020. No recent hospitalizations known. No death note or autopsy noted. Only indication of death is the updated banner/date of death in demographics. Death most likely due to advanced age (84 y/o) in addition to comorbidities.


VAERS ID: 1108265 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-03-14
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Basophil percentage, Blood chloride decreased, Blood creatinine increased, Blood gases abnormal, Blood glucose increased, Blood lactic acid increased, Blood potassium normal, Blood sodium decreased, Blood urea increased, Carbon dioxide decreased, Cardiac arrest, Cardiac failure chronic, Cardiogenic shock, Death, Dyspnoea, Endotracheal intubation, Eosinophil percentage decreased, Glomerular filtration rate decreased, Haematocrit normal, Haemoglobin normal, Immature granulocyte percentage increased, Intensive care, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume increased, Metabolic disorder, Monocyte percentage decreased, Neutrophil count increased, Neutrophil percentage increased, Nucleated red cells, Oxygen saturation decreased, Platelet count decreased, Platelet disorder, Red blood cell count normal, Red cell distribution width increased, Septic shock, Ventricular fibrillation, Weight increased, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Toxic-septic shock conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Report Released Date/Time: Mar 14, 2021@11:46 Provider: Specimen: VENOUS BLOOD. BG 0314 6 Specimen Collection Date: Mar 14, 2021@11:39 Test name Result units Ref. range Site Code PH 7.24 L 7.31 - 7.41 [689] PCO2 40.3 L mmHg 41 - 51 [689] PO2 41.9 mmHg 35 -42 [689] BICARBONATE 16.8 L mmol/L 22 - 26 [689] O2,SAT 67.7 L % 68 - 77 [689] TEMPERATURE 37.0 Centigrade 36.7 - 37.3 [689] Report Released Date/Time: Mar 14, 2021@05:13 Provider: Specimen: PLASMA. CH 0314 10 Specimen Collection Date: Mar 14, 2021@04:46 Test name Result units Ref. range Site Code LACTIC ACID 10.4 H* mmol/L 0.5 - 1.8 [689] Report Released Date/Time: Mar 14, 20210@04:57 Provider: Specimen: BLOOD. HE 0314 6 Specimen Collection Date: Mar 14, 2021@04:46 Test name Result units Ref. range Site Code WBC 27.6 H K/cmm 4.5 - 11.0 [689] RBC 4.37 M/cmm 4.23 - 5.66 [689] HCB 15.0 g/dL 12.8 - 17 [689] HCT 44.1 % 39-2 - 50.4 [689] MCV 100.9 H fL 82 - 99 [689] MCH 34.3 H pg 26.2 - 32.6 [689] MCHC 34.0 g/dL 30.1 - 35.1 [689] RDW 17.8 H % 12 - 16 [689] PLT 67 L K/cmm 140 - 360 [689] IMMATURE PLT FRACTION 14.3 H % 1-7 [689] Eval: In patients with thrombocytopenia an increased immature platelet fraction Eval: is suggestive of increased peripheral destruction, consumption, Eval: inflammatory process, or a recovering marrow. Thrombocytopenia with a Eval: normal or suppressed IPF is suggestive of a platelet production disorder. MPV 12.7 H fL 9.2 -12.4 [689] NEUT % 92.0 H % 43.7 - 75.8 [689] LYMPH % 1.3 L % 14.0 - 42.3 [689] MONO % 3.5 L % 5.1 - 13.7 [689] EOSIN % 0.1 L % 0.4 - 6.8 [689] BASO % 0.2 % 0.1 - 2.0 [689] IMMATURE GRAN % 2.9 H % 0.0 - 0.7 [689] ABSOLUTE NEUTROPHIL COUNT 25.42 H K/cmm 2.2 - 7.6 [689] ABSOLUTE LYMPHOCYTE COUNT 0.37 L K/cmm 1.0 - 3.2 [689] NRBC/100WBC 0.1 H %/WBC 0.0 - 0.0 [689] Comment: Platelet count confirmed by manual smear review. 3/13/21 Manual diff performed within past 72 hours. 3/13/21 Smear available for review. Diff consistent with recently verified diff Report Released Date/Time: Mar 14, 2021@05:53 Provider: Specimen: SERUM. CH 0314 9 Specimen Collection Date: Mar 14, 2021@04:46 Test name Result units Ref. range Site Code SODIUM 131 L mmol/L 135 - 145 [689] POTASSIUM 4.5 mmol/L 3.5 - 5.0 [689] CHLORIDE 91 L mmol/L 100 - 110 [689] CO2 14 L mEq/L 20 - 30 [689] UREA NITROGEN, BLOOD 60 H mg/dL 7 - 25 [689] CREATININE,SERUM 3.3 H mg/dL 0.5 - 1.5 [689] eGFR(IDMS) 18 L* mL/min Ref: $g=60 [689] Eval: As of April 16, 2010 a new formula was Eval: implemented for eFGR which is based on a Eval: creatinine that is now matched to the national Eval: standard (IDMS). New values should be considered Eval: more accurate. GLUCOSE,RANDOM 140 H mg/dL 65 - 100 [689] Eval: Results must be interpreted on a case-by-case basis. Values $g200 may Eval: require further
CDC Split Type:

Write-up: Death Narrative: 83 y.o. male with pmh of heart failure admitted on 3/9 for shortness of breath and weight gain. Had Vfib arrest on 3/12 and was intubated/xfer to ICU. Continued to require increasing levels of pressors. He suffered VF arrest in the setting of metabolic, septic and cardiogenic shock. He had end stage heart failure and required 4 pressors. Was made CMO and passed away. Noted to have not received 2nd does of Moderna likely due to hospitalization at the time that the second dose would have been due. Patients history of adverse drug reactions included: lisinopril, dabigatran, and penicillin.


VAERS ID: 1107188 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Missouri  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: death after second dose; A spontaneous report was received from a consumer concerning a female patient of unknown age, who experienced severe symptoms post first dose of Moderna''s Covid-19 vaccine (mRNA-1273) and death shortly after her second dose. The patient''s medical history was not provided. Concomitant medication was not provided by the reporter. No lab data was not provided On unspecified date, the patient received her second of two planned doses of mRNA-1273 (Batch number not provided) intramuscularly for prophylaxis of COVID-19 infection. It was reported that shortly after receiving the second dose of mRNA-1273, the patient died. Treatment information was not provided/unknown. Action taken with the drug in response to the events is not applicable. The patient died on an unknown date. Plans for an autopsy were not reported; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: death


VAERS ID: 1107648 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-01
Onset:2021-03-08
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Military       Purchased by: ?
Symptoms: Death, Leukaemia, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed leukemia and kidney failure. Died in 6 days.


VAERS ID: 1107656 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-03
Onset:2021-03-15
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Abilify 10mg daily Bumex 1mg daily B12 injection monthly Wellbutrin xl 300mg daily Cardizem 30mg three times daily levothyroxine 200mcg daily metoprolol 50mg twice a day multivitamin xarelto 20mg daily Butrans 15mcg/hr patch weekly midodrin
Current Illness: Unknown
Preexisting Conditions: congestive heart failure with reduced EF atrial fibrillation sleep apnea acute kidney injury anemia chronic pain depression
Allergies: no known allergies
Diagnostic Lab Data: determined to be natural causes, thought to be due to heart failure
CDC Split Type:

Write-up: Patient was found dead on 3/15/2021


VAERS ID: 1107735 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-19
Onset:2021-03-07
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebral thrombosis, Computerised tomogram, Death, Electrocardiogram
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Thyrogin, 2 blood pressure medications (sorry, don''t have names), D3, Multivitamins, Lutein
Current Illness: Annual exam had resulted in a clean bill of health the Friday prior to his death.
Preexisting Conditions: High blood pressure, thyroid.
Allergies: none
Diagnostic Lab Data: EKG and CAT scan, perhaps others.
CDC Split Type:

Write-up: Death on March 8 due to a large blood clot at the base of his brain. This was 16 days after innoculation.


VAERS ID: 1107898 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-27
Onset:2021-03-04
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood potassium normal, Blood sodium increased, Blood urea increased, Carbon dioxide increased, Death, Dysphagia, Glomerular filtration rate decreased, Haematocrit normal, Haemoglobin decreased, Hypernatraemia, Lethargy, Liver function test normal, Pallor, Platelet count normal, Protein total decreased, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: senna
Current Illness:
Preexisting Conditions: dementia, glaucoma, constipation
Allergies: none
Diagnostic Lab Data: 3/13/21 - sodium 180 mmol/L; potassium 4.2 mmol/L; Chloride 138 mmol/L; CO2 32 mmol/L, BUN 64 mg/dL, Creatinine 1.18 mg/dL, eGFR 41mL/min/1.73m2 Total protein 5.6 g/dL, remainder of liver function tests and calcium level was normal. CBC showed wbc 7.82 K/uL, Hgb 10.9 g/dL, Hct 38.9%, Plt 151 K/uL
CDC Split Type:

Write-up: 5 days post-vaccination (1st dose of Moderna), patient started developing lethargy, and difficulty swallowing. 7 days post-vaccination patient looked "ashen". 12 days after vaccination patient was improving, but 14 days after vaccination patient was found to have (on lab work) critical hypernatremia (sodium level of 180 mmol/L), patient was re-referred back to hospice, and 17 days post-vaccination patient died.


VAERS ID: 1107923 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-28
Onset:2021-02-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown to facility
Current Illness: numerous, unknown to facility
Preexisting Conditions: numerous, unknown to facility
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient died 2/6/21


VAERS ID: 1108261 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-08
Onset:2021-03-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia, Cardiac failure congestive, Death, Diabetes mellitus, Fall
SMQs:, Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received 1st dose of Moderna COVID-19 vaccine on 03/08/2021. Patient died 03/09/2021. Medical examiner received report that patient was alert before a fall on the night of 03/08/2021. Death certificate will report death likely due to arrhythmia due to underlying CHF. Contributing factors include diabetes.


VAERS ID: 1108262 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-15
Onset:2021-02-06
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away unrelated to covid vaccine Narrative: The patient had hypertension, diabetes, hyperlipidemia and sleep apnea. Patient received first dose of Moderna vaccine 1/15/2021 and no adverse reaction was recorded. Clinical staff called to review patient''s intent for second dose, patient is not interested and has elected to not receive second dose following clinical discussion of the risks and benefits of the COVID-19 vaccination. Patient was called on 2/17/2021 and his son stated patient passed away on 2/6/2021.Cause of death not documented. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1108365 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-08
Onset:2021-03-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Bowel movement irregularity, Death, Decreased appetite, Defaecation disorder, Dyspnoea, Nausea, Pain
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: yes but unknown
Current Illness: No
Preexisting Conditions: Polythemavera (blood disease), Arthritis
Allergies: Unknown
Diagnostic Lab Data: No/Unknown
CDC Split Type:

Write-up: She had breathing problems, bowel movement problems, sharp pain -site unknown No appetite and nausea. Went to the Doctor on wednesday and they gave her a prescription for nausea (promethazine) 12.5mg She Passed away 03/12/2021 at 8:54pm waiting to be picked up by a friend that was going to take her to the emergency room/hospital.


VAERS ID: 1108470 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-15
Onset:2021-02-12
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute left ventricular failure, Deep vein thrombosis, Pleural effusion, Pulmonary embolism
SMQs:, Cardiac failure (narrow), Systemic lupus erythematosus (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pulmonary Embolism Narrative: Patient was hospitalized with acute pulmonary embolis on 2/12/2021. Was started on Eloquis and discharged on 2/15/2021, with primary diagnosis of acute PE and BLE DVT. Secondary diagnosis of acute systolic heart failure with bilateral pleural effusions. On 2/17 we got notification that patient was placed on hospital.


VAERS ID: 1108471 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-02-20
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Pt received 1st moderna covid vaccine 2/12/2021 and passed away of unknown causes 2/12/2021 Pt 76 year old with AAA,HTN,CKD,COPD


VAERS ID: 1108472 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-06
Onset:2021-03-13
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Dizziness, Pulseless electrical activity, Resuscitation, Syncope, Ventricular tachycardia
SMQs:, Torsade de pointes/QT prolongation (narrow), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest Narrative: Per medics, Patient was gardening when he stated he felt dizzy and collapsed. Wife started CPR until medics arrived. Patient arrived at the hospital after 20min of pulseless V tach and 10 min of PEA.


VAERS ID: 1108475 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-01-23
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received COVID vaccine # 1 on 1/6/2021, on 1/23/21 his wife reported to the facility that he passed away. Notes in database do not mention cause of death or where death occurred. There are no scanned records in database with any detail either.


VAERS ID: 1108476 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-06
Onset:2021-02-10
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute myocardial infarction, Cardiac failure acute, Cardiac failure congestive, Condition aggravated, Cough, Death, Malaise, Pneumonia
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Dose #1 of vaccine was administered 2/6/21, per daughter''s report patient became ill 3 days later (cough) and was taken to local hospital and was discharged with diagnosis of CAP, NSTEMI and acute on chronic CHF exacerbation. Discharged home on hospice where he passed away at home on 2/20/21.


VAERS ID: 1108477 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-01-29
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died unrelated to covid vaccine Narrative: The patient had advanced Alzheimer''s disease and severe dementia. Patient received the first dose of Moderna vaccine on 1/7/2021 and no adverse reaction was reported. Placed in hospice care and passed away on 1/29/2021. Cause of death not documented. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1108588 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-04
Onset:2021-03-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / -

Administered by: Private       Purchased by: ?
Symptoms: Blood cholesterol normal, Blood glucose normal, Blood lactate dehydrogenase decreased, Blood pressure decreased, Cardiac arrest, Condition aggravated, Death, Feeling cold, Heart rate normal, Hypercholesterolaemia, Hypertension, Nausea, Pain in extremity, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Cardiomyopathy (broad), Lipodystrophy (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: anastrozole (1mg);cyanocobalamin (1,000 mcg);LORazepam (.5 mg); metropolol tartrate (50 mg); pravastatin (20 mg); turmeric root extract (500 mg); multivitaim (C, E, copper, zinc, lutein)
Current Illness:
Preexisting Conditions: mitral valve prolapse (longstanding)hypertension/hypercholesterolemia/mixed hyperlipidem; last tests = normal levels; malignant neoplasm of left breast (estrogen receptive positive), removed and several years cancer-free.
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: After vaccine (2nd dose) on 3/04, patient resumed normal activities, running errands, etc. In the evening of 3/05, patient complained of extremely sore arms (not alleviated by painkillers) and nausea. Additionally, patient felt extremely cold. She went to bed early, at 7:00 pm, and was found dead the next morning 3/06 at 7:30 am. She had vomited. The coroner (not a medical examiner) declared cause of death as 1) cardiac arrest 2) hypertension and 3)hypercholesterolemia, based solely on medical records. There was no autopsy. Due to or despite medications, patient''s blood pressure readings were typically low (last one 118/70), pulse normal (89), BMI 25.29, cholesterol levels normal (166/LDL 82), blood sugar 95.


VAERS ID: 1108595 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-10
Onset:2021-02-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chronic obstructive pulmonary disease, Condition aggravated, General physical health deterioration, Hypotension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Alzheimers dementia, COPD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: senescence, hypotensive reaction to COVID-19 vaccination, COPD


VAERS ID: 1108609 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-13
Onset:2021-03-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: See additional information
Current Illness:
Preexisting Conditions: See additional information
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive the morning of March 14, 2021. She was pronounced dead at 5:33 AM. The medical examiner quoted natural cause of death.


VAERS ID: 1108623 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Decreased appetite, Dyspepsia, Fatigue, Myocardial infarction, Nausea, Pain, Pyrexia
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Centrum Silver for Men, Calcium-Vit D 185mg, Aspirin 81mg, Escitalopram oxalate 10 mg, Hydrochlorothiazide 12.5 mg, Losartan Potassium 100 mg, Tamsulosin HCl 0.4 mg
Current Illness: hayfever
Preexisting Conditions: High blood pressure Obesity
Allergies: Penicillin Clindamycin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fatigue, Body aches, loss of appetite, 100 degree fever for a short time. indigestion, nausea for about 3 days Fatal Heart attack 2/28/2021


VAERS ID: 1108766 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-17
Onset:2021-03-12
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Family reported today 3/17/2021 that patient passed away 3/12/2021, they did not indicate that it had anything to do with the vaccination or give medical history.


VAERS ID: 1108959 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-18
Onset:2021-02-21
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Angiogram cerebral, Cerebral artery occlusion, Computerised tomogram head, Death, Endotracheal intubation, Haemorrhagic transformation stroke, Magnetic resonance imaging head, Neurological decompensation, Respiratory distress, Syncope, Thrombectomy
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol XL, Rivaroxaban
Current Illness: Atrial fibrillation Alcoholism
Preexisting Conditions: Atrial fibrillation Alcoholism
Allergies: NKDA
Diagnostic Lab Data: CTA Brain, Cerebral angiogram, MRI Brain
CDC Split Type:

Write-up: Stroke resulting in death. Admitted to hospital 2/21/21 as transfer from first Hospital after found collapsed in his hotel room. Left M1 occlusion, thrombectomy performed, then had hemorrhagic trnasformation. Developed worsening respiratory status after extubation, was reintubated. Given poor neurologic status, was extubated and started on palliative morphine drip. Pt died 0100 3/1/21.


VAERS ID: 1109087 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-05
Onset:2021-03-10
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Multi-organ disorder
SMQs:, Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: diabetes, heart disease, kidney failure, possible cancer
Preexisting Conditions: same as above
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt expired in Community Hospital ED on 3-10-21. This was 5 days after receiving his second Moderna covid vaccination. Hospital nurse says ED report says multiple system problems.


VAERS ID: 1109346 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-17
Onset:2021-02-23
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: When patient didn''t show up for her second COVID-19 vaccine today 3/17/21, we couldn''t reach her so we contacted her Dr. office. They informed us that patient visited the emergency department on 2/22/21 and passed away while in the hospital on 2/23/21.


VAERS ID: 1109418 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-12
Onset:2021-03-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Respiratory arrest, Sudden death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: rosuvastatin 20, propranol 120mg ER, gabapentin, primidone 250 BID
Current Illness: essential tremor, s/p successful DBS neurosurgery 3/9/21
Preexisting Conditions: Dyslipidemia Essential tremor developmental delay
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: sudden death, while sleeping 2 days after injection Vaccine 3/12/21 last seen conversant and comfortable at 3a 3/14/21 Found nonresponsive and not breathing at 8:30a 3/14/21


VAERS ID: 1109427 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Confusional state, Continuous positive airway pressure, Death, Dyspnoea, Fatigue, Heart rate decreased, Lethargy, Memory impairment, Nightmare
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide,K-Tab/Potassium, Eliquis, Amlodipine Besylate, Lisinopril, Gabapentin,Lipator
Current Illness: No illnesses
Preexisting Conditions: Atrial Fibrillation High Blood Pressure Diabetes Sleep Apnea
Allergies: Iodine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Moderna Covid-19 Vaccine EUA After receiving the first vaccine, started making gasping noises at night, lethargy, fit bit would not register sleep at night, some breathing issues during waking hours. HR observed to decrease to under 40 over the last week of his life. 5 days after 2nd vaccine had extreme fatigue, nightmares, forgot to take regular meds in the morning, 6 days after he woke up very confused and had nightmares and 7 days after vaccination woke up late, exhausted, with shortness of breath all day and refused to go to ER. Went to bed early and died in the night with his CPAP machine on.


VAERS ID: 1109535 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-26
Onset:2021-03-10
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Don?t know the prescriptions being taken
Current Illness: Not aware of any
Preexisting Conditions: Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My Father had a hemorrhagic stroke. He passed away 13 days after receiving the second Modern?s vaccine.


VAERS ID: 1110160 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-27
Onset:2021-03-10
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol, Amlodopine, Aspirin, Atorvastatin, Benazepil, Budesonide-Formoterol, Carvedilol, Cyanocobalamin, Furosemide, Lidocaine, Metoprolol, Nitroglycerin, Omeprazole, Pantoprazole, Tamsulosin, Terbinafine, Tizanidine, Tylenol, Venlafaxin
Current Illness:
Preexisting Conditions: Cardiovascular and Mediastinum Coronary artery disease involving native coronary artery of native heart without angina pectoris Enlarged aorta (HC) HTN (hypertension), benign Nervous and Auditory Cervical radiculopathy Musculoskeletal and Integument Adhesive capsulitis of right shoulder Cervical disc disorder Closed fracture of shaft of humerus Degeneration of lumbar intervertebral disc Fracture of phalanx of thumb Spondylolisthesis Avascular necrosis (HC) Other History of selective injection of anesthetic agent around lumbar nerve root Shoulder joint pain Weight gain Iron deficiency anemia secondary to inadequate dietary iron intake Mixed hyperlipidemia Spinal stenosis of lumbosacral region
Allergies: Iodine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Phone call from patient'' s 2 daughters on 3/10/2021. Patient was found dead in bed with a remote in his hand. He had not been sick. He had received Moderna SARS vaccine 2/27/2021= 11 days earlier, but did not have any adverse reactions. He had recovered from lumbar spine surgery several months earlier. He was pronounced dead by the fire chief.


VAERS ID: 1110232 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-01
Onset:2021-03-04
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036A21A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Chills, Death, Diarrhoea, Dizziness, Dyspnoea, Hyperhidrosis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine,indapamide,glipizide,metropololtartate,almodipine,lisinopril,b12,d3
Current Illness: Hipertension,diabetic,kidney problem,abdominal aneurism,thyroidproblem
Preexisting Conditions: Thyroid problem, kidney problem , diabetic , hypertension, abdominal aneurism
Allergies: Hair dye
Diagnostic Lab Data: Death
CDC Split Type:

Write-up: DizzineS, sweating,weak, chilling, diarrhea, shortness of breath, death


VAERS ID: 1110311 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-09
Onset:2021-03-04
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away within 60 days of receiving a COVID vaccine


VAERS ID: 1110388 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-01
Onset:2021-02-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Auscultation, Bacterial infection, Bloody discharge, Cardiac failure, Colostomy infection, Culture stool positive, Death, Full blood count abnormal, Gastrostomy tube removal
SMQs:, Cardiac failure (narrow), Haematopoietic leukopenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Cardiomyopathy (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 40
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Isorbi 30mg, Metroprolo 25mg, Plavis 75 mg, rosubastatin 20mg
Current Illness: A few days previous to the vaccination the resident was evacuating blood and was suppurating through the PEC tube.
Preexisting Conditions: CVA, Right side paralysis, did not speak, cardiovascular conditions, diabetes and depression.
Allergies: Not reported
Diagnostic Lab Data: CBC and stool culture,
CDC Split Type: PR-59-21

Write-up: On 2/1/2021 they performed CBC, the result was aseptic bacteria so it came out and she was taken to the hospital. They removed the tube in the hospital, (she remained in the hospital) First she was hospitalized and then she was transferred to the Medical Center Hospital to auscultate bleeding in the stool and to be evaluated by the Gastroenterologist. This specialist performs the necessary studies, they do not give a diagnosis and in the process she dies. The hospital indicated that she had a blood drain and heart failure.


VAERS ID: 1110437 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-30
Onset:2021-02-09
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Absence of immediate treatment response, Biliary colic, Cholelithiasis, Fatigue, Lung disorder, Renal impairment
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Lack of efficacy/effect (narrow), Retroperitoneal fibrosis (broad), Gallbladder related disorders (narrow), Biliary tract disorders (narrow), Gallstone related disorders (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Corect 25mg, Ferrous Sulfate 325 mg, Synocril, Norvasc 10 mg, Plavix 75mg, Lipitor 10 mg, Ativan 1mg, Insulin 70/10 10 units. Vitamin C and Tussin.
Current Illness: None reported
Preexisting Conditions: Cardiovascular conditions, Diabetes, Chronic liver condition, Hypertension, Depression.
Allergies: Not reported
Diagnostic Lab Data: Not reported
CDC Split Type:

Write-up: Since the vaccine was administered on 1/30/2021 the resident was complaining of tiredness. On 2/9/2021 she complains more than usual with fatigue, a lot of fatigue so they make the decision to transfer her to the hospital. In the hospital she was informed that the pain was from a gallbladder stone, also that she has a lung condition and a compromised kidney. A Dr. from Hospital tells POC that the patient was not responding to treatments and was compromised thus prolonging the hospital stay.


VAERS ID: 1110439 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-03-10
Onset:2021-03-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: DM, HTN
Allergies: aspirin, honey
Diagnostic Lab Data: N?A
CDC Split Type:

Write-up: Tolerated Well without complications


VAERS ID: 1110462 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-21
Onset:2021-01-28
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away within 60 days of receiving a COVID vaccine


VAERS ID: 1110537 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-03-12
Onset:2021-03-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Brain herniation, Cerebral haemorrhage, Cerebral mass effect, Computerised tomogram head abnormal, Endotracheal intubation, Neurological symptom
SMQs:, Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: ACETAMINOPHEN, AMIODARONE, ELIQUIS, LEVOTHYROXINE, LOSATAN, PRIMADONE, TRIMETHOPRIM, NORCOAR, VALIUM
Current Illness: FX FEMUR
Preexisting Conditions: A-FIB, ARTHRITIS, COLON CA COPD, SAD, GERD, HYPERSHOLESTEREMIA, HYPERTENSION, NEUROPATHY
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was found to be having stroke like symptoms 3/15 in the morning at nursing home. he was evaluated and was transported by ambulance from one hospital to another hospital as the CT scanner was down. patient had an injury on march 1 with a cabinet falling on him breaking his femur and family not sure if at that time he had hit his head. Patient was intubated in the ER CT scan showed a massive cerebral bleed with midline shift and transtentorial herniation


VAERS ID: 1110581 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-13
Onset:2021-02-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, Blood electrolytes, Cardiac failure congestive, Chills, Coagulation test, Death, Dyspnoea, Echocardiogram, Haematocrit, Haemoglobin, Heart rate increased, Nausea, Pain, Polyuria, Vascular imaging
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Tubulointerstitial diseases (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Atenolol, Vit D3, Vit B12, Lasix, Calcitrol
Current Illness: none
Preexisting Conditions: CKD, HTN,
Allergies: none
Diagnostic Lab Data: Clotting times, H/H,CMP, electrolytes, daily while hospitalized. Scan for PE, Echo
CDC Split Type:

Write-up: Withing 24 hours of vaccine admin developed nausea, chills, aches, dyspnea, elevated heart rate. Saw PCP on 2/15 and was sent to ER and then admitted to hospital for 5 days-continued extreme nausea and atrial fibrillation after diuresis for CHF. HR 120s had to be put on multiple meds to bring ratedown. Discharged on 2/19. Cont worsening nauaea/chills/aches. Passed away on 2/23


VAERS ID: 1110641 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-02-23
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away within 60 days of receiving a COVID vaccine


VAERS ID: 1110696 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-22
Onset:2021-02-13
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away within 60 days of receiving a COVID vaccine


VAERS ID: 1110978 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-12
Onset:2021-02-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Death, SARS-CoV-2 RNA undetectable
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Unknown information regarding side effects from first Moderna Covid vaccine. Second Covid vaccine on 2/12/2021 and there were no issues. Patient died on 31/10/2021. Postmortem Covid test is negative for SARS-CoV2 RNA.


VAERS ID: 1111042 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-10
Onset:2021-03-15
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pain in extremity, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastin, Lantus, Bacid, Ferrous Sulfate, Flomax, Gabapentin, Lasix, Metoprolol, Norvasc, Duloxatine
Current Illness: None, admitted to this facility on 2/4/21. Recently declining condition, decreased appetite.
Preexisting Conditions: DM, Unspecified behavioral syndromes associated w/ physiological disturbances and physical factors, CAD, HTN, Chronic pain syndrome, physical deconditioning, anemia, CKD, hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: RHC 3/15/21. No significant reaction from vaccine. Had sore arm.


VAERS ID: 1111389 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-24
Onset:2021-03-05
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Condition aggravated, Cough, Death, SARS-CoV-2 antibody test negative, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Proair, Xanax, Cardizem, Lasix, Insulin, Magnesium
Current Illness: PMH of Hypertension, H/o of HFpEF, PAF not on anticoagulation due to GI bleeding, Severe Pulmonary hypertension, T2DM, H/o of GI bleeding, ESRD on HD, Chronic hypoxic respiratory failure on home oxygen.
Preexisting Conditions: PMH of Hypertension, H/o of HFpEF, PAF not on anticoagulation due to GI bleeding, Severe Pulmonary hypertension, T2DM, H/o of GI bleeding, ESRD on HD, Chronic hypoxic respiratory failure on home oxygen.
Allergies: none
Diagnostic Lab Data: Covid PCR positive on 3/7. Covid IgG serology negative on 3/7.
CDC Split Type:

Write-up: Cough started on 3/5. Hospitalization on 3/7, Expired 3/16. Doctor''s Death Diagnosis: acute on chronic respiratory failure.


VAERS ID: 1111483 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-03-01
Onset:2021-03-13
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died at Home


VAERS ID: 1111574 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-08
Onset:2021-03-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Passed away 4 days after second dose, complained of not being able to breathe in the middle of the night, and passed minutes later.


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