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From the 9/10/2021 release of VAERS data:

Found 14,925 cases where Vaccine is COVID19 and Patient Died



Case Details

This is page 11 out of 150

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VAERS ID: 1040633 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-30
Onset:2021-02-06
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M2OA / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Computerised tomogram, 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: 2021-02-06
   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: Levothyroxine 100mcg, one tablet daily
Current Illness:
Preexisting Conditions: Hypothyroidism, recent hypertension
Allergies:
Diagnostic Lab Data: CAT scan (2/6/2021)
CDC Split Type:

Write-up: Death due to hemorrhagic stroke.


VAERS ID: 1040802 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Death, Diarrhoea, Injection site pain, Vomiting
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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:
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: Toileting and had expired while doing so; Severe abdominal pain; Diarrhea; Vomiting; Mild injection site pain; A spontaneous report was received from a healthcare professional concerning an 88-year-old , female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced the events, toileting and had expired while doing so (death), mild injection site pain, severe abdominal pain, diarrhea, and vomiting. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 20 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Lot number: 029L20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. On 20 Jan 2021, the patient felt mild pain at the injection site after receiving the vaccine. On 21 Jan 2021, the patient reported severe abdominal pain, diarrhea and vomiting. These symptoms were intermittent for a week and no other adverse events were noted. On 27 Jan 2021, the patient passed away while toileting. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 27 Jan 2021. The cause of death was unknown. An autopsy was not performed.; Reporter''s Comments: The gastrointestinal events were consistent with increased risk associate with elderly age of patient. The cause of death was unknown. Autopsy was not performed. Very limited information regarding the events is available at this time. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1040877 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-02-18
Onset:2021-02-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: wellbutrin, crestor, albuterol, deltasone, cozaar, spiriva, coreg
Current Illness: chest pain, COPD, Bipolar, dyslipidemia, stage 3 chronic kidney disease
Preexisting Conditions: as above
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown if related to vaccine. patient received 2nd vaccine at 0830, observed 15 minutes, discharged, arrested at 0915 upon entering her home. vaccine was administered by DOH at their community location. patient was pronounced lifeless in the ED.


VAERS ID: 1040927 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-16
Onset:2021-01-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Dizziness, Fall, Feeling abnormal, Resuscitation, SARS-CoV-2 test negative
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Accidents and injuries (narrow), Vestibular disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nisidipine 90 MG once day, Ramipril 20 MG once a day, Synthroid 137 MCG once a day, Aricept 10 MG once a day
Current Illness:
Preexisting Conditions: Hypertension, Hypothyroidism, early dementia, Vertigo
Allergies:
Diagnostic Lab Data: COVUD test on the 7th and 8th (once deceased by hospital) both were negative
CDC Split Type:

Write-up: Patient previously had dizzy spills, but about a week after receiving the vaccine her dizzy spills began to get worse. The whole prior she kept saying I am just not right. On the 2/7/21 she a COVID test done, a nurse came to her house and preformed. On the morning of the 8th patient was on the phone with someone else and patient asked this person to call me and go check on her. Within 5 minutes I was over at her house, and I found her on the floor, she on her belly facedown. It looked like she was on the toilet, and it looked like she fall getting her off, she was still wet, she still felt warm. I called the ambulance and immediately began CPR. When EMS arrived they took over the CPR and transported her to the Hospital. The EMS was there for about 40 minutes and used an machine to preform the compressions. She was pronounced deceased at the hospital. No autopsy was done.


VAERS ID: 1041064 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-02-04
Onset:2021-02-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / N/A LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: CLIENT EXPIRED 1 WEEK FOLLOWING THE VACCINE.


VAERS ID: 1041185 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-04
Onset:2021-01-18
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Levadopa; colace; lorazepam and morphine
Current Illness: COVID + 12/10/2020 recovered. Placed on Hospice care 10/2020
Preexisting Conditions: Dementia; HTN; Parkinson''s; Bladder Cancer
Allergies: No Known Allergies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death within 30 days


VAERS ID: 1041191 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-24
Onset:2021-01-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dysarthria, Fall, Heart rate abnormal, Wheelchair user
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Decedent had unwitnessed fall out of wheelchair 1/25/21 around 9:43am, denied head strike, pain, discomfort. Around 10:02pm, 1/25/21, decedent noted to have slurred speech and fluctuating HR, transported to Hospital and made cmo.


VAERS ID: 1041200 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, COVID-19, Death, Fall, Muscular weakness, Nervousness, SARS-CoV-2 test positive, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 9
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Was tested for COVID-19 on January 30th, 2021.
CDC Split Type:

Write-up: Patient described feeling nervous, anxious the next morning (Wednesday) after the vaccine. He later fell in the bathroom after using the restroom, his legs gave out (his words) and consequently was on the ground for 23 hours before being transported to the hospital. That was Thursday afternoon. He was diagnosed with COVID-19 on Saturday night and died the following Friday morning.


VAERS ID: 1041230 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-01-22
Onset:2021-01-26
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Chest pain, Coronary artery disease, Death, Dyspnoea, Electrocardiogram ST segment elevation
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: unknown
Current Illness: n/a
Preexisting Conditions: Hyperlipidemia, GERD, Monoclonal B-cell Lymphocytosis, Asthma, DJD of spine, osteoarthritis, hypertension
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received first dose of covid vaccine on 1/22/2021. Patient had no immediate reaction. Patient presented to the Emergency Department on 1/26/2021 c/o shortness of breath and chest pain. ECG showed a ST elevation myocardial infarction. Patient was treated and transferred to a cath lab where he died. Patient had significant coronary artery disease.


VAERS ID: 1041276 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-12
Onset:2021-02-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dehydration, Foaming at mouth, Hypercalcaemia, Respiratory tract congestion
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Generalised convulsive seizures following immunisation (broad), Dehydration (narrow)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Namenda, Mirtazapine, Multi-vitamin, Loratidine, Effexor XR
Current Illness: Hypertension, dementia, arthritis
Preexisting Conditions: Hypertension. Recent decline in weight and appetite, 8 pound weight loss in 30 days.
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: on 2/13 at 7:30am resident was observed congested, foaming at the mouth. transferred to the hospital, verbal report from hospital nurse stated the resident was admitted for hypercalcemia and dehydration. The resident expired on 2/14/21 at 9:30am. Died on 2/14/2021


VAERS ID: 1041333 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-05
Onset:2021-02-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bedridden, Dysphagia, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), 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), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lorazepam, Seroquel, Trileptal, Senna Plus, Acetaminophen, Aspirin, Buspar, Sinemet, Cyanocobalamin, Depakote, Aricept, Pepcid, Hydrochlorothiazide, Provera, Melatonin, Namenda, Dolophine, Milk of Magnesia, Morphine, Omeprazole, Sorbitol, F
Current Illness: End stage Dementia, End stage Parkinson''s Disease, on Hospice care. Dependent in all cares, non-verbal.
Preexisting Conditions: End stage Dementia, End stage Parkinson''s Disease, on Hospice care
Allergies: Penicillin, Vicodin
Diagnostic Lab Data:
CDC Split Type:

Write-up: He developed a fever on 1/8, become unable to swallow and bedbound. He was already end of life and Hospice care at the time of the vaccine.


VAERS ID: 1041656 (history)  
Form: Version 2.0  
Age: 103.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-02-06
Onset:2021-02-12
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 2 AR / SYR

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

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: Water pills other medication unknown
Current Illness: no
Preexisting Conditions: congestive heart failure
Allergies: unknown
Diagnostic Lab Data: no
CDC Split Type:

Write-up: she died 2/12/2021 at close to 2pm


VAERS ID: 1041719 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arthralgia, Death, Fall, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Hypersensitivity (broad), Arthritis (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Depakote, lasix, memantine, metoprolol, senna s, vit D3, miralax, xarelto, remeron
Current Illness: Resident slid out of recliner at 430pm on the date of vaccine and death. Denied pain and ROM was without issues. At 630pm she complained of right hip pain. Mobile xray was ordered. Resident passed in her bed after sleeping for 30 mins. Xray did not make it on time, therefore, unsure of fracture.
Preexisting Conditions: Dementia, PVD, Vit D deficiency, anxiety, HTN, Afib, postrial kyphosis, CHF, UTIs, Debility, sundowning, skin neoplasm left side of nose
Allergies: Fosomax
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received moderna vaccine #2 at 1:30pm. No s/s of adverse reactions. Ate dinner at 4pm. She was in her room at 430pm and she slid out of her chair and was laying on her Right side. She reported she slid out of her chair because she needed to go urinate per staff. She denied pain. At 630p complained of right hip pain. mobile xray was ordered. At 825pm resident was sleeping x 30 mins in her bed when she was found to have no pulse or respirations. She ceased to breathe. Mobile xray did not make it on time.


VAERS ID: 1041740 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-06
Onset:2021-02-13
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 RA / IM

Administered by: Private       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: Escitalopram, gabapentin, trazodone, atorvastatin, hydrocodone/acetaminophen, ondansetron, lidocaine 5% patch, aspirin 81mg, pantoprazole, finasteride, calcium citrate, cholecalciferol, potassium, furosemide.
Current Illness:
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died on 2-13-21


VAERS ID: 1041784 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-23
Onset:2021-01-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 AR / SYR

Administered by: Military       Purchased by: ?
Symptoms: Cerebrovascular accident, Confusional state, Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), 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: 2021-01-27
   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: Multivitamin, Thiamine, Amlodipine, Cholecalciferol, Donepezil, Folic Acid, Atorvastatin
Current Illness:
Preexisting Conditions: A stroke a year and half before, AVM, Arthritis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On the 25th he was home alone, he called 911 and let them know he thought he was having a stroke. EMS arrived and transported him to Hospital. It was massive stroke, he was not able to comprehend anything, he was put into Hospice the following day and passed away on the 27th. There was no autopsy preformed.


VAERS ID: 1041789 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-15
Onset:2021-01-17
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arteriosclerosis, Arteriosclerosis coronary artery, Chills, Chronic obstructive pulmonary disease, Death, Lung neoplasm malignant
SMQs:, Other ischaemic heart disease (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: Advair, Albuterol, ASA, Alendronate
Current Illness: no
Preexisting Conditions: Advanced COPD on Oxygen therapy, Stage 1, lung Ca, Adenocarcinoma
Allergies: unknown
Diagnostic Lab Data: no
CDC Split Type:

Write-up: As per patient daughter - patient had some minor chills on the day of the vaccination - Friday 1/15/21; felt well next day -Saturday, than she was found slumped and lifeless on the couch on Sunday 1/17. Cause of death on death certificate was reportedly put as COPD, Lung Ca and ASHD.


VAERS ID: 1041832 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Loss of consciousness, Pulse absent, Respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: pending autopsy
CDC Split Type:

Write-up: Patient was found unconscious without a pulse. Patient remained in asystole without pulse or respirations despite CPR.


VAERS ID: 1041839 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-02-14
Onset:2021-02-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

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

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Protonix 40 mg PO QD Vit D3 50,000 Units PO weekly MVI 1 tab PO QD Calcium Carbonate 600 mg1 PO QD Lantus 28 Units SQ in morning, 24 Units at dinner Iron 65 mg PO QD Monurol 3 gm PO, 3 pkts weekly Colesevelam 3.75 gm oral 1 pkt BID Plavix 7
Current Illness: HTN HLD CAD Type 2 Dm GERD hypothyroidism
Preexisting Conditions: HTN HLD CAD Type 2 Dm GERD hypothyroidism
Allergies: Sulfur
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Death- ~ 7 hours after vaccine


VAERS ID: 1041990 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-28
Onset:2021-01-15
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E10140 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acidosis, Body temperature decreased, COVID-19 pneumonia, Chest X-ray abnormal, Death, Hypotension, Intensive care, International normalised ratio increased, Mental status changes, Metabolic function test abnormal, Sepsis, Septic shock, Urinary tract infection
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Covid IN NOVEMBER
Preexisting Conditions: CKD , CAD WITH STATUS POST CABG , HTN HYPOTHYROIDISM, DEMENTIA AND RECURRENT UTI
Allergies: nkda
Diagnostic Lab Data: CXRAY - COVID PNA bmp - SEVERE ACIDOSIS TEMPERTURE 94 BEAR WARMER HYPOTENSION LEVOPHED AND 3L OF ns O2 AT 3L inr 2.09 WITHOUT COUMIDIN
CDC Split Type:

Write-up: PATIENT WAS ADMITTED TO ER FOR ALTERED MENTAL STATUS / UTI SEPSIS WITH SEPTIC SHOCK / COVID AND COVID PNA PATIENT WAS ADMITTED TO ICU AND DIED . POA WISH TO WITHDRAWL EXTRME MEASURES


VAERS ID: 1042012 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-01
Onset:2021-02-14
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 RA / IM

Administered by: Private       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: 2021-02-14
   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: Cabergoline, Avalide, Valtrex, Zyrtec
Current Illness: None known
Preexisting Conditions: Prolactinoma/Pituitary adenoma (2018), HTN, Meniscal tear (knee), h/o myomectomy, h/o C-section
Allergies: None known
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient died suddenly 2/14/2021


VAERS ID: 1042145 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-29
Onset:2021-02-06
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute kidney injury, Acute respiratory distress syndrome, Asthenia, Bilevel positive airway pressure, Blood creatinine increased, Blood glucose decreased, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Cytokine release syndrome, Death, Decreased appetite, Fatigue, Hypoglycaemia, Hyponatraemia, Hypoxia, Infusion, Lung opacity, Pyrexia, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (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), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None reported
Preexisting Conditions: PE, Asthma, Obesity, Diabetes, COPD
Allergies: None
Diagnostic Lab Data: COVID-19 (2/7/21) and Blood Glucose (2/6/21)
CDC Split Type:

Write-up: Patient reported feeling weak, fatigue, fever (102), and loss of appetite. Patient subsequently went to the ER 2/6/2021 and tested positive for COVID-19 on 2/7/21 (collection date). See following discharge summary from ED: 82 y.o. female who initially presented to the ED with complaint of generalized weakness, fatigue, fever, and loss of appetite x at least 4 days since receiving Covid 19 vaccine. Her workup in the emergency room was significant for hypoxia with 02 saturation 88% on 2LPM (home nocturnal 02 requirement) with improvement to mid-90s on 4LPM. Blood sugar was 47, Cr 1.61. CXR showed extensive R lung and moderate left lung opacities. She was started on empiric ceftriaxone and azithromycin and admitted to the hospitalist service for further workup and mgmt. During her stay in the hospital, pt did test positive for Covid 19. She developed rapidly progressive respiratory failure, felt to be secondary to ARDS. There was also question of contributing pulmonary edema, however this was refractory to lasix and thus ARDS was felt to be the most significant factor. She had requested DNR/DNI status, thus as her 02 requirement escalated she was transitioned to 15LPM NRB and then to BiPAP support. Unfortunately, she continued to suffer greatly with the BiPAP in place, and therefore made the decision to transition herself to comfort measures only after visitation from her family. Her other medical issues were supported as appropriate during her stay, with dextrose infusion for hypoglycemia and AKI, also hyponatremia felt to be due to IVVF. Unfortunately, am unable to find any documentation regarding how pt was feeling when she received the vaccine compared to her baseline state of health. thus am unable to say whether the severity of her illness represents vaccine? enhanced disease or the much more common cytokine release syndrome leading to ARDS. Regardless, she developed ARDS as result of her Covid 19 illness. Time of death: 1408 on 2/9/21. Cause of death: ARDS due to Covid 19 pneumonia.


VAERS ID: 1042351 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-11
Onset:2021-02-16
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: synthroid
Current Illness: mild liver disease
Preexisting Conditions:
Allergies: none
Diagnostic Lab Data: none not sure if this is a vaccine reaction but thought I should report it just in case you wanted to investigate farther like an autopsy.
CDC Split Type:

Write-up: death


VAERS ID: 1042412 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-05
Onset:2021-02-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 9269 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Headache, Muscular weakness, Musculoskeletal stiffness, Pain, Presyncope, Pyrexia, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Avapro, Synthroid, Vit.D, Multivitamin, Calcium, AREDS2,Biotin
Current Illness: None
Preexisting Conditions: Mild Hypertension Macular Degeneration
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Days 3, 4, 5, 6: Inability to move head in any direction (up/down or L/R) without SEVERE pain. Neck unable to support head unless directly above shoulders. Leaning forward slightly to sit or stand up caused unbearable pain. Unable to lift head from pillow to roll over. Could only swallow food, if neck muscles held tightly with hand to prevent movement. Severe pain caused Vasovagal syndrome fainting. Asymptomatic fever 99.7-100.5 for Days 3, 4, 5. No chills, weakness or aching. Day 7: In A.M., slightly increased head movement possible for first time without pain. By P.M. even better, but still only very limited movement of a few inches possible. Improved daily thereafter. Day 15 (today): Mild stiff neck persists.


VAERS ID: 1060522 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-17
Onset:2021-02-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9267 / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Feeling abnormal, Injection site pain, Malaise
SMQs:, Dementia (broad), Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   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: 86 year old MALE with PMH of Afib s/p AICD/PPM, HFrEF (EF< 20% 10/2019), DM2, HTN, HLD, BPH, Depression. Was stable and feeling well when he was administered Covid-19 vaccine on 02/17/2021- Pfizer COVID-19 Vaccine 0.3 ml IM. MVX (Manuf); PFR; Lot#; EL9267; Exp Date:05/31/2021 Administration Anatomic site: Right Deltoid; Pt was monitored for 30 minutes after administration and had no adverse effects. He was called later in the day and reports he feels well and has had no adverse reactions, he endorsed his arm is a little sore at injection site. ON 02/19/2021- his dghter found him on the floor, next to his bed, dead. She reported on 2/19/2021- that she was out with him to dinner on 2/18/2021, and he stated he did not feel well, that his insides did not feel right. He proceeded to have dinner and 2 drinks. HE was doing ok, when she took him home.


VAERS ID: 1060523 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-31
Onset:2021-01-25
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: contracted covid after first dose Narrative: First covid vaccine dose 12/31/2020, tested positive for covid 1/7/2021, died from complications 1/25/2021


VAERS ID: 1042967 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-13
Onset:2021-02-18
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Loss of consciousness, Medical induction of coma
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), 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), 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: 2021-02-19
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: Sinus infection
Preexisting Conditions: Hypertension, Diabetes
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient called son around 6:30am on 2/18/21. When son tried to contact patient around 8:30am, he was not able to get a hold of patient. Son sent someone over to check on patient. They found patient on the floor. He was coherent at first but then lost consciousness. It believed he experienced a stroke sometime around 8:30-9:00am of 2/18/21. Patient was taken to hospital and then transferred to another hospital. He was put in a medically induced coma. He passed between 4:00 and 4:30 pm on 02/19/21.


VAERS ID: 1043123 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-01-28
Onset:2021-02-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Public       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
Current Illness: Positive COVID-19 PCR collected postmortem
Preexisting Conditions: Hypertension, COPD, T2DM, Obesity
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1043302 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH PFIZER EL9269 / 1 - / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Clostridium difficile infection, Death, Eye movement disorder, Intensive care, Mechanical ventilation, Pulse absent, Renal failure, Respiratory arrest, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Pseudomembranous colitis (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 5
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:
Current Illness:
Preexisting Conditions: Kidney failure - dialysis treatment 3x per week Recently recovered from stage 3 colon cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My dad received the Pfizer vaccination on 2/5/21. He was admitted into the hospital the next day for C-Diff bacterial infection. He had been on dialysis treatments for kidney failure treatment since 2017 and had recently been diagnosed with stage 3 colon cancer in June 2020. He had completed his final treatment of chemotherapy on 2/4/21 and several weeks prior had been determined cancer free. On Tuesday 2/9/21 he was released from the hospital and went home. Early Thursday morning 2/11/21 @ approximately 1:30 am CST his eyes rolled back in head and he stopped breathing and was non responsive. My mother called 911 and attempted CPR. Paramedics arrived and were able to successfully get a pulse then transferred him to the hospital. He was put on a ventilator @ the hospital and then transferred to a different hospital a few hours later. He lost pulse/heartbeat several times @ the 2nd hospital he was transferred to. We were not allowed to travel with him or see him b/c of all of the COVID restrictions. We were communicating with the ICU doctor by phone who ultimately communicated to us that there was nothing further that could be done to save his life. He subsequently passed away @ approximately 8:55 am CST on 2/11/21.


VAERS ID: 1043482 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M2OA / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Drainage, Erythema, Haemangioma of skin, Purulent discharge, Rash, Rash macular, Scab
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lisinopril,
Current Illness: none
Preexisting Conditions: HTN and cardiac disease
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Noted red blotchy areas 2 days post vaccination on bilateral inner thighs. Patient states he has yellow drainage if he expresses the areas. Has a photo of the rash. They are circular individual areas about 1 cm circumference. Each individual area is bright red with a open pinpoint area in the center. Some have a crusty area. He denies itching, burning. Denies rash in any additional areas post vaccination. Referred to see physician.


VAERS ID: 1043690 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Idaho  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Sudden death, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   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: Aspirin 325 mg 1 tab po daily Lisinopril 5 mg 1 tab po daily Metoprolol succinate 50 mg 1 tab po bid Sotalol 120 mg 1.5 tab po bid Alfuzosin 10 mg 1 tab po daily Myrbetriq 50 mg 1 tab po daily Diltiazem 240 mg 1 tab po daily Rosuvastatin 40
Current Illness:
Preexisting Conditions: HLD, GERD, OSA, rosacea, pulmonary HTN, HTN, CAD, hx of prostate cancer, sinus node dysfunction, aortic stenosis, diastolic dysfunction, cardiac pacemaker
Allergies: Amiodarone - pulmonary toxicity Lipitor - rash Penicillins - mild hives Adhesive tape/silicones - rash
Diagnostic Lab Data:
CDC Split Type:

Write-up: Ventricular fibrillation/sudden death


VAERS ID: 1043880 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Death, Insomnia, Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   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: atorvastatin, Vit D3, Vit B12, Plavix, duloxetine, Gabapentin, glipizide, levothyroxine, tolterodine, verapamil, atropine, Flonase, Symbicort, Invega, loperamide, Tylenol, albuterol sulfate
Current Illness: urinary tract infection
Preexisting Conditions: diabetes mellitus with polyneuropathy, schizoaffective disorder, chronic obstructive pulmonary disease, essential hypertension, bipolar disorder, hypothyroidism, history of cerebral infarction, diabetic retinopathy, overactive bladder, Vitamin D deficiency, encephalopathy, chronic kidney disease, seizures
Allergies: iodine, shellfish
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received second Moderna COVID-19 vaccination administered in left arm at her assisted living facility by Pharmacist at 1153 on 2/19/2021. Pt was monitored for vaccine reaction with no known adverse reaction. Approximately 18 hours post-vaccine, she was found deceased in her sleep at 0540 on 2/20/21. Per circumstances/pt history, it is presumed that the patient aspirated while sleeping, perhaps secondary to a seizure. Coroner was notified and declined as coroner''s case. VAERS notification being made due to pt death within 24 hours of receiving a vaccine.


VAERS ID: 1044247 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-21
Onset:2021-01-26
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Pharmacy       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: 2021-02-06
   Days after onset: 11
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: Moderna COVID 19 Vaccine: Patient started with symptoms of covid 5 days after first vaccine. She was hospitalized and passed due to COVID 19 on 2/6/21. Patients family informed us when she was due for the second dose.


VAERS ID: 1044352 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-08
Onset:2021-02-14
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 AR / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal discomfort, Cardiac failure, Death
SMQs:, Cardiac failure (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Synthroid; Cosentix; Multivitamin; Vitamin C; Omeprazole; Loratadine
Current Illness: None
Preexisting Conditions: Psoriatic Arthritis; Hypothyroidism
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stomach upset, sudden heart failure, death


VAERS ID: 1044420 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-01-09
Onset:2021-01-31
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, Blood creatinine normal, Blood fibrinogen increased, Blood lactic acid, Blood sodium decreased, C-reactive protein increased, Cardiac arrest, Death, Diarrhoea, Fibrin D dimer increased, Multiple organ dysfunction syndrome, Myocarditis, Oropharyngeal pain, Platelet count decreased, Pyrexia, SARS-CoV-2 antibody test positive, Serum ferritin increased, Transaminases, Troponin increased, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Pseudomembranous colitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad), Sepsis (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: Sodium 131, creatinine 1.2 on admission, transaminases initially normal, lactic acid 2.6, white blood count 11.0, platelets 110, coronavirus nucleocapsid IgG positive, troponin 18, ferritin 1435, fibrinogen 642, D-dimer 5.22, CRP 284
CDC Split Type:

Write-up: Please reference separately submitted MIS-A form. He had sore throat, high fever, diarrhea, deteriorating in to multisystem failure and apparent acute myocarditis, notably with relative initial sparing of the lungs. He suffered cardiac arrest in radiology after developing aphasia and was transferred to Hospital after cannulation for VA ECMO; he died there 2/8/21.


VAERS ID: 1044459 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-07
Onset:2021-02-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Intestinal obstruction, Pneumonia
SMQs:, Anaphylactic reaction (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), 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: 2021-02-16
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Resperdol lexapro blood pressure med trazodone
Current Illness: None
Preexisting Conditions: High blood pressure Dementia Spinal stenosis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Grandmother had trouble breathing the night she got the vaccine. She went to the hospital. They found pneumonia and a partial bowel obstruction. The obstruction cleared but she died from the pneumonia on 2/16/21.


VAERS ID: 1044704 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Fatigue, Nausea
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   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: None
Preexisting Conditions: High blood pressure, COPD
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Light headedness, fatigue, nausea


VAERS ID: 1045150 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-02-10
Onset:2021-02-20
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 RA / IM

Administered by: Private       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril Levetiracetam
Current Illness: Unknown
Preexisting Conditions: Dyslipidemia Hypertension Seizure Disorder
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient found in home deceased.


VAERS ID: 1045635 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-04
Onset:2021-02-09
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 RA / -

Administered by: Private       Purchased by: ?
Symptoms: Abdominal discomfort, Asthenia, Body temperature, Constipation, Cough, Death, Diarrhoea, Dysphonia, Dyspnoea, Fatigue, Hyperhidrosis, Loss of consciousness, Myalgia, Nasopharyngitis, Nausea, Pain, Pyrexia, Sensation of foreign body, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Pseudomembranous colitis (broad), Parkinson-like events (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Chronic kidney disease stage 4; Kidney disorder
Preexisting Conditions: Medical History/Concurrent Conditions: Pacemaker insertion (cardiac); Type 2 diabetes mellitus
Allergies:
Diagnostic Lab Data: Test Date: 20210209; Test Name: temperature; Result Unstructured Data: Test Result:99.4; Comments: degrees
CDC Split Type: USPFIZER INC2021162618

Write-up: Death; Passed out; Stomach was bothering; Constipated; Difficulty breathing; Weakness/Event: Weakness was reported as worsened; a temperature of 99.4 degrees; Sweaty; Cold; Muscle ache; Body Aches; Diarrhea; Nausea; Vomiting; Fatigue/Tiredness; His raspy throat felt like he had mucus stuck in his throat; Cough; Raspy throat/worsened; This is a spontaneous report from a contactable consumer reporting her husband. A 75-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Batch/lot number: EM9810, Expiry Date: Jun2021) at the age of 74- year-old via an unspecified route of administration on 04Feb2021 09:15 at single dose in Arm, Right for COVID-19 immunisation. Medical history included type 2 diabetes mellitus for about 20-25 years, ongoing kidney disease from 2005, ongoing chronic kidney disease, cardiac pacemaker insertion. The patient was diagnosed with kidney disease in 2005, but it was about 1 to 1-1/2 years ago that his kidney disease progressed to Stage 4 Kidney Disease. She said the Veterans Administration diagnosed her husband with his kidney disease, but her husband saw a private doctor, as well as, a VA doctor for his care. There were no concomitant medications. The patient previously received the first dose of BNT162B2 (Lot Number: EL3248; Expiration Date: Apr2021) at the age of 74- year-old Intramuscularly at approximately 08:45AM on 15Jan2021 in right arm for COVID-19 immunisation and had no reaction. There were no additional vaccines administered on same date of the Pfizer suspect. There were no Prior Vaccinations within 4 weeks. The patient had symptoms start earlier in the day of Tuesday, 09Feb2021, after his second COVID-19 Vaccine shot (04Feb2021). The reporter said she and her husband didn''t think anything of his symptoms at first. The patient had a temperature of 99.4 degrees on 09Feb2021. She didn''t check her husband''s temperature again after that time because the nurse at her husband''s doctor''s office said her husband''s temperature was not at an area of concern. The patient was sweaty, off and on, starting 09Feb2021. She clarified he would be sweaty and the cold, but nothing extreme. The patient developed muscle aches, body aches, diarrhea, nausea, and vomiting on 09Feb2021. She clarified her husband had fatigue, tiredness, and had trouble with a raspy throat. His raspy throat started Tuesday evening (09Feb2021). His raspy throat felt like he had mucus stuck in his throat, and he was unable to clear the mucus from his throat. The reporter called her husband''s primary care doctor on the morning of 10Feb2021 because her husband was having trouble with a raspy throat, and difficulty breathing. She said on Tuesday night (09Feb2021) her husband had to sleep sitting up because he couldn''t lay down with his breathing. He was able to eat breakfast (clarified as oatmeal and an orange), lunch (clarified as soup and a salad), and dinner (clarified as soup and half a sandwich. She said her husband ate all the meat and half of the bread on the sandwich) on 10Feb2021. Her husband''s primary care doctor wasn''t available to speak to on Wednesday morning (10Feb2021), but the doctor''s nurse said it sounded like her husband was having a reaction to his second COVID-19 Vaccine shot. The reporter said her husband''s doctor instructed her later in the day to take her husband to the Emergency Room or Urgent Care if he didn''t feel any better. Her husband''s throat raspiness got worse in the evening of 10Feb2021. His breathing also became worse after dinner in the evening of 10Feb2021. The patient leaned forward over a couple pillows while sitting on their couch as it was easier for him to breath by doing that. They decided at 11:00PM that her husband should go to the Emergency Room. She said her husband was getting very weak, so she and her husband debated if she should call # for an ambulance, or if she should drive him to the Emergency Room. She said her husband was able to dress himself, but with some difficulty, and she assisted walking him from their house to their car. She said she had turned to walk away from her husband while he was at the side of their car, and then she heard her husband make a noise. He had appeared to have passed out. She clarified in the past, her husband had passed out prior to his pacemaker. She said she dialed #, and the # operator told her how to tell if her husband was still breathing. She said she couldn''t tell if her husband was still breathing. She said when the ambulance arrived at her house, the ambulance staff worked on her husband for a long time. The reporter thought her husband had died at the time he had collapsed at the side of their car. The patient took a sugar free cough syrup Tuesday night (09Feb2021), and then again a couple times on Wednesday (10Feb2021) as treatment. The patient had thrown up a couple times, but found that the sugar free cough syrup soothed his cough the night before (09Feb2021). She said her husband had taken 2 TUMS early on Wednesday morning at approximately 2:00AM (10Feb2021). He had said his stomach was bothering him on 10Feb2021. He said he thought he may be constipated, so he took 1 Senokot (Clarified as GeriCare Senna-Plus Natural Vegetable Laxative with Stool Softener) on 10Feb2021. She clarified her husband had diarrhea on 09Feb2021, but felt on 10Feb2021 he may have been constipated. There were no adverse events required a visit to Emergency Room since Patient''s wife stated she was getting her husband to their car, so she could drive him to the Emergency Room, when her husband collapsed and died or to Physician Office as they spoke with the nurse at her husband''s primary care doctor''s office. Weakness was reported as worsened. The outcome of events Sweaty, Cold, Muscle ache, Body Aches, Fatigue/Tiredness, Raspy throat/worsened, Difficulty breathing, Weakness was not recovered; and of the remaining events was unknown. The patient died on 11Feb2021. The patient''s official time of death was Thursday, 11Feb2021, at 12:08AM. Cause of death was unknown. An autopsy was not performed and it would take 3 weeks for a death certificate to be issued. The reporter stated she thought it was important to notify Pfizer of her husband''s passing because his side effects fell within the expected time period after receiving his second COVID-19 Vaccine.; Reported Cause(s) of Death: Death


VAERS ID: 1045803 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-02-15
Onset:2021-02-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Condition aggravated, Death, Fatigue, Nausea, Oropharyngeal pain, Pulse absent, Urine analysis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: atorvastatin, Lisinopril, Lasix, Zoloft, timolol
Current Illness: symptoms of nausea and sorethroat 1 week prior to vaccine
Preexisting Conditions: Hypertension, hyperlipidemia, dementia, lymphedema, glaucoma
Allergies: sulfa
Diagnostic Lab Data: UA done 1000 am 2/15/21 ,Negative, Vital signs stable afebrile
CDC Split Type:

Write-up: Patient was found with no pulse no heart rate by a staff member around 11 pm. Earlier that day seen by myself for fatigue, sorethroat, nausea.


VAERS ID: 1045842 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / -

Administered by: Private       Purchased by: ?
Symptoms: Cough, Death, Oropharyngeal pain, Pneumonia
SMQs:, Anaphylactic reaction (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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: 2021-02-11
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: A few days after the vaccination my father had a sore throat and slight cough. This progressed into pneumonia like symptoms and he died on 2/11/21.


VAERS ID: 1045894 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2020-12-31
Onset:2021-01-27
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       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: 2021-02-07
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID infection, death


VAERS ID: 1045895 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-21
Onset:2021-02-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 UN / SYR

Administered by: Pharmacy       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: Heart meds recently changed by cardiologist . Inhalers for asthma. Other unknown
Current Illness: None know
Preexisting Conditions: Heart arrhythmia, enlarged prostate, low blood pressure, CAD, asthma, season allergies/hay fever, spinal stenosis, with neuropathy
Allergies: Unknown
Diagnostic Lab Data: None at this time
CDC Split Type:

Write-up: He was found deceased in his home by Sheriff and paramedics evening of 2/21/21.


VAERS ID: 1045972 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-06
Onset:2021-02-16
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Death
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:
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: 1046179 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-02-15
Onset:2021-02-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Diarrhoea, Dyspnoea, Nausea, Pulseless electrical activity, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 2
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
Preexisting Conditions: MRDD
Allergies: NKMA
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient was not vaccinated at hospital. Caregiver reports that patient was vaccinated with second dose on Monday 2/15/21. Tuesday patient experienced n/v/d. Went to an ED on Wednesday and was cleared and sent home. Thursday reported shortness of breath to her caregiver and then collapsed. Patient was brought to as PEA arrest and ultimately died.


VAERS ID: 1046230 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-04
Onset:2021-02-20
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 - / IM

Administered by: Public       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes
Preexisting Conditions: Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death. My father-in-law was found unexpectedly deceased in his home Saturday morning. He worked the previous day.


VAERS ID: 1046265 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-19
Onset:2021-02-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   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: A-fib, dementia, BPH, HTN, CEREBROVASCULAR DISEASE and anemia.
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received 2nd dose of COVID19 Pfizer vaccine at 1103 am on 2/19/21, was last seen at 1159, found around 1615 by kitchen staff who were serving dinner.


VAERS ID: 1046317 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure, Cardiogenic shock, Chronic respiratory failure, Condition aggravated, Death, Pulmonary hypertension
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Pulmonary hypertension (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

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: albuterol inhaler, allopurinol, amlodipine, aspirin, atorvastatin, bumex, cardura, lasix, mucinex, humulin NPH, synthroid, Opsumit, Toprol XL, singulair, multivitamin, Revatio, flomax
Current Illness:
Preexisting Conditions: chronic respiratory failure due to pulmonary hypertension, hypothyroidism, right heart failure, chronic kidney disease stage IV, IDDM, BPH, essential hypertension
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away from chronic respiratory failure with cardiogenic shock 24 hours from 2nd dose of vaccine. Patient with longstanding history of pulmonary HTN and heart failure with desire for comfort care only. Entering into VAERS out of abundance of caution.


VAERS ID: 1046347 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-20
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: When family members came to receive the second dose of their COVID vaccine, they informed us that the above patient had passed away.


VAERS ID: 1046397 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Alaska  
Vaccinated:2021-01-07
Onset:2021-02-20
   Days after vaccination:44
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / IM

Administered by: Senior Living       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Morphine, Lorazepam, Haloperidol, Atropine, Citalopram,
Current Illness: Dementia, HTN, Hypothyroid, Intestinal malabsorption, Hx neoplasm, breast,
Preexisting Conditions: Dementia, HTN, Hypothyroid, Intestinal malabsorption, Hx neoplasm, breast,
Allergies: Lisinopril
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death


VAERS ID: 1046447 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Female  
Location: New Mexico  
Vaccinated:2021-02-12
Onset:2021-02-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9809 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time prolonged, Alanine aminotransferase increased, Anaemia, Anion gap, Asthenia, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bilirubin increased, Blood creatinine increased, Blood culture positive, Blood fibrinogen decreased, Blood lactic acid, Blood magnesium increased, Blood urea increased, Carbon dioxide decreased, Chest X-ray abnormal, Culture, Culture urine positive, Death, Escherichia test positive, Haematocrit decreased, Haemoglobin decreased, Hypotension, International normalised ratio increased, Loss of consciousness, Mental status changes, Mouth ulceration, Pancytopenia, Platelet count decreased, Pleural effusion, Pneumonia, Prothrombin time prolonged, Rectal haemorrhage, Red blood cell count decreased, Respiratory failure, SARS-CoV-2 test negative, Sepsis, Urinary tract infection, Urine analysis normal, White blood cell count decreased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Severe cutaneous adverse reactions (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Agranulocytosis (narrow), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (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), Gastrointestinal haemorrhage (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 5
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: Vitamin D3 2000 U daily, Calcium carbonate 500 mg daily, Cyanocobalamin/folic acid/pyridoxine 200mcg-500 mcg-5mg daily, Vitamin B12 1000 mcg daily, Echinacea 450 mg twice daily, St. John''s Wort 300 mg daily, Fish oil 1000mg daily, Vitamin
Current Illness: 1/17/2021 Fell while drunk, right distal humerus fracture, right facial bruising
Preexisting Conditions: Metabolic disorder, anemia
Allergies: Penicillin
Diagnostic Lab Data: 2/17/2021 Labs show pancytopenia with WBCs of 1.4, RBCs 2.18, hemoglobin 6.8, hematocrit 23, platelets 63. PT/INR elevated at 20.4/1.71. PTT elevated at 42. Fibrinogen level low at 147. CO2 level low at 20. Anion gap elevated at 19. Creatinine elevated at 1.63. BUN elevated at 32. Albumin low 1.7. Total bilirubin elevated at 4.5. Alk phos elevated at 154. ALT evaded at 72. Magnesium dated at 2.7. Is low at 48. Lactic acid elevated at 2.9. Urine is negative for infection. COVID-19 test is negative. Cultures x2 obtained. Chest x-ray was done and shows CVP line is in the right atrium. Left lower lobe pneumonia and left pleural effusion. Urine and blood cultures from 2/17/2021 grew Escherichia coli.
CDC Split Type:

Write-up: 2/12/2021 Vaccine 2/13/2021 Weakness, oral ulcers 2/17/2021 Brought to ER for loss of consciousness, altered mental status, rectal bleeding; work up showed sepsis, UTI, anemia, pneumonia, pleural effusion, pancytopenia, hypotension; persistent hypotension and respiratory failure 2/18/2021 Passed away at 5:54AM


VAERS ID: 1046542 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-02
Onset:2021-02-15
   Days after vaccination:44
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1046613 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-02-22
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-22
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: 2021-02-22
   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:
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: 1046666 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-20
Onset:2021-02-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: None
Preexisting Conditions: Heart and artery diseases
Allergies: KNDA
Diagnostic Lab Data: N/a
CDC Split Type:

Write-up: Patient had no adverse events during the observation period after vaccine. He was conscious and having conversation with facility staff. He was observed for 15 minutes at least. When the facility staff returned later, approximately 60 to 90 minutes, patient had passed away.


VAERS ID: 1046698 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-02-20
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / -

Administered by: Senior Living       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? 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: 1046722 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-02-11
Onset:2021-02-14
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9267 / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac disorder, Chills, Death, Diaphragmatic spasm, Toxicologic test
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: UTI
Preexisting Conditions: Congestive Heart Failure
Allergies:
Diagnostic Lab Data: County coroner verified that they conduct toxicology reports on all deaths. Contact Funeral Home for details/follow up if needed.
CDC Split Type:

Write-up: No symptoms or signs on the day 1st dose of vaccine was received (2/11/2021). 3 days later, (2/14/2021) patient experienced chills for approximately 6 hours, followed by severe (visible) chest spasms, and then cardiac arrest. 911 was called upon witnessing chest spasms, but cardiac arrest/death occurred before patient could be transported to the hospital.


VAERS ID: 1046752 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Chest pain, Death, Fall, Hypothermia, Pain, Refusal of treatment by patient, Rhabdomyolysis, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 21 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: apixaban, aspirin, Ativan, baclofen, carbidopa - levodopa
Current Illness: Rhabdomyolysis, dementia d/t Parkinsons disease w/ behavioral disorder
Preexisting Conditions: Atypical Parkinsonism, HTN, diplopia, Neurological gait disorder, osteoarthritis
Allergies: No known allergies
Diagnostic Lab Data: 2/8/21 1642 BP 134/78 - 84
CDC Split Type:

Write-up: Pt was hospitalized Jan 18, 2021 after he had fallen outside overnight and lay there approximately 12 hours until he was found. Hypothermic & rhabdomyolis diagnosis. Gradually improved w/ strength & mental status - was in swing bed @ hospital. He got his first Covid 19 shot on 2-8-21. Was fine @ 0300 on 2-9-21 and @ 0430 he was found unresponsive. Dx: probable arrythmia & pronounced dead @ 0454. Noted on pain scale @ 2/8/21 @ 21:11, clients pain was a 7/10 They offered pain med & he refused They repositioned & distracted him @ 2047 on 2/8/21 Pain had decreased to 3/10 and nothing given. Then @ 0300 check he was sleeping and @ 0430 unresponsive.


VAERS ID: 1046763 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-23
Onset:2021-01-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Anal incontinence, Aphasia, Communication disorder, Death, Decreased appetite, Dysphagia, Injection site pain, Mental impairment, Mental status changes, Mobility decreased
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Noninfectious diarrhoea (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: 4.125mg orenitram (3/day), 40mg sildenafil (3/day), 4mg dexamethasone (1/day), 20mg furosemide (1/day), 3mg budesonide (1/day), 600mg calcium (2/day), 20mg omeprizol (2/day), 168mg cranberry concentrate (2/day), probiotic (1/day), 100mg met
Current Illness: bilateral pneumonia
Preexisting Conditions: lung cancer (metastatic non-small cell carcinoma), emphysema, pulmonary hypertension
Allergies: scallops, contrast dye (ivpDye, iodine containing), epinephrine, reglan, compazine, adhesive tape
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1/23 - Mild injection site discomfort. Appetite loss compared to previous day. Beginning loss of mental acuity compared to previous day. 1/24 - Continued loss of appetite. Near complete loss of ability to move. Continued decline of mental acuity. Very little speaking. 1/25 - Stopped speaking completely. Loss of bowel control in the evening and continued until death. Complete loss of appetite. 1/26 - Near complete loss of ability to swallow. Moved to hospice 4:00pm. 1/27 - Died 4:00am


VAERS ID: 1046795 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-12
Onset:2021-02-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Blood gases, Blood lactic acid, Chest X-ray, Death, Dyspnoea, Full blood count, Hypotension, Metabolic acidosis, Metabolic function test, Oxygen therapy, Pulse absent, Resuscitation, SARS-CoV-2 test, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

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: Flagyl 500 mg TID, Tramadol 50 mg q4h PRN, Gabapentin 400 mg q 8h, lisinopril 10 mg daily, duloxetine 30 mg daily
Current Illness: Recurrent IVb uterine carcinosarcoma, open ventral abdominal wall
Preexisting Conditions: uterine cancer, PE, CHF
Allergies: Sulfa medications
Diagnostic Lab Data: CBC, BMP, COVID, lactic acid, ABG''s, cxray all drawn and completed on 2/21/2021
CDC Split Type:

Write-up: Per ED note: Brought in ED by EMS at 1945 for acute shortness of breath and hypotension. Patient was placed on supplemental oxygen and covid test completed. Patient was placed on BiPAP to maintain oxygen greater than 90%. Found to be in metabolic acidosis. Patient became unresponsive and pulse could not be palpated. Chest compressions were initiated. ACLS medications given and pulses regained. Patient lost pulse 30 mins later and never regained pulse. Per ED noted; likely developed a PE. Passed away at 2127


VAERS ID: 1046845 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: Deceased 02/18/2021 with an unknown cause of death


VAERS ID: 1046881 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardio-respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   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: Carvedilol, Gemfibrozil, Ferrous Sulfate, Folic acid, metoclopramide, mvi, pravastatin, digoxin, clonazepam, Senna, bisacodyl, docusate, memantine, rivastigmine, linaclotide, lansoprazole, fish oil, clonidine, amlodipine, losartan,
Current Illness: UTI
Preexisting Conditions: CHF, CKD, MI, Encephalopathy, Aortic stenosis
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Code blue called at 11:00pm. Patient had code status of Do Not Resuscitate.


VAERS ID: 1046915 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-21
Onset:2021-02-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure immeasurable, Body temperature increased, Cardio-respiratory arrest, Chills, Death, Dyspnoea, Feeling abnormal, Hyperhidrosis, Pain, Pallor, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: Humalog Insulin Sliding scale 4 times daily, Acidophilus Probiotic Blend CP 1 capsule 3 times daily with meals, Amiodarone 200mg 1 tab twice daily, Aspirin 81mg 1 tab once daily, Atorvastatin 40mg 1 tab at bedtime, Bumetanide 0.5mg 1/2 tab
Current Illness:
Preexisting Conditions: Above the knee amputation of left lower extremity, Coronar Artery Disease, Clotted Dialysis access, Previous COVID-19 Virus Infection 11/2/20. Diabetes, Dialysis patient, End Stage Renal Disease, Gastric Bypass status for obesity, Hypertension, Non healing wound of amputation stump, Polyneuropathy, Pneumonia secondary to COVID infection, Atrial Fibrillation, Hx of stroke,
Allergies: Tramadol (vomiting, nausea), Tape (Rash, Itching), Bee stings (anaphylactic reaction), Betadine (rash, Itching), Wasps (anaphylactic reaction), Clonidine( vomiting), Isosorbide (vomiting)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received the 2nd dose of the Covid vaccine approximately around 1105 by pharmacy through the pharmacy LTC partnership vaccination program. Resident had no adverse effects until around 8:00 pm she began complaining of body aches, and chills, Tylenol was given at this time. Around 9:30pm resident was sleeping in bed. Around 12:00 am the CNA called nurse into room to assess resident as the resident stated she did not feel good. Temperature at that time was 102.2, and vomiting. RN came to assess @ 1220 am She was noted to be vomiting, diaphoretic, pale and having trouble breathing. Temp was 97.3 after vomting, Pulse 53, Resp 20, o2 sats were 40-45%, unable to obtain Blood pressure, Applied 5 L of oxygen at this time and had LPN call 911 immediately. Resident was repsonsive and able to follow staff members instructions but was only answering yes or no simple questions at the time time of assessment. Paramedics arrived at 0040 and resident was sent to Hospital. @ 0130 ER nurse called to nursing facility to notify resident had coded in the ER and passed away @ 0110.


VAERS ID: 1047072 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-13
Onset:2021-02-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, General physical health deterioration, Haemoptysis, Headache, Oxygen saturation decreased, Pain, Pain in extremity, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 4
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: Topamax,
Current Illness: COPD, seizures( patient on medications and controlled), Hernia operation 2 years ago
Preexisting Conditions: COPD and seizures, asthma
Allergies: no allergies to medications, or food but allergic to cats
Diagnostic Lab Data: not provided
CDC Split Type:

Write-up: Patient had sore arm on the day of vaccination. Per patient''s nephew , the next morning patient experienced body pains, aches, headache . Onn Tuesday patient had fever. Patient''s condition progressively got worse. He had difficulty breathing by Wednesday night. He had low oxygen levels at 80 per pulse ox reading. Patient was coughing up blood. Family took him to hospital on Thursday morning due to breathing difficulty and patient died 2.18.21 at 10 am


VAERS ID: 1047169 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-06
Onset:2021-02-13
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Haemoglobin decreased, Haemolytic anaemia, Haemorrhagic stroke, Intensive care, Jaundice, Multiple organ dysfunction syndrome, Platelet count decreased, Shock haemorrhagic
SMQs:, Cholestasis and jaundice of hepatic origin (narrow), Haemolytic disorders (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Biliary system related investigations, signs and symptoms (narrow), Biliary tract disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 7
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: risedronate 35 mg po q week levothyroxine 25 mcg po daily lipitor 10 mg po daily azelastine nasal spray 2 sprays nasally as needed
Current Illness: none
Preexisting Conditions: mild anemia hypothyroid "prediabetic" dyslipidemia macular degeneration
Allergies: NKA
Diagnostic Lab Data: Hgb=3.4 on admit 2/16 platelet ct 2/20= 40 have many more lab results, vital signs, too numerous to input here
CDC Split Type:

Write-up: jaundice-$ghemolytic anemia-$g hemorrhagic shock-$gmulti organ failure-$gdeath pt admitted to ICU 2/16 with Hgb=3.4, treated with steroids, supportive care , pressors, pt died 2/20/21


VAERS ID: 1047183 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-14
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Pt had expired before second dose was delivered.


VAERS ID: 1047197 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-12
Onset:2021-02-20
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 RA / IM

Administered by: Pharmacy       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Morphine concentrate, Lorazepam Intensol, Clopidogrel, Vitamin D2, Tamsulosin, Amlodipine, Atovastatin
Current Illness: Pt on hospice
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1047282 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Blister, Chills, Death, Dizziness, Fatigue
SMQs:, Severe cutaneous adverse reactions (broad), Anticholinergic syndrome (broad), Vestibular disorders (broad), Hypersensitivity (broad)

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: duloxetine 20 mg daily cyclobenzaprilne 10 mg as needed for pain meclizine 25 mg as needed for nausea
Current Illness: none
Preexisting Conditions: none, other than back pain
Allergies: Benadryl Diazepam Valium
Diagnostic Lab Data: County Medical Examiner performed an autoposy on Wednesday, February 10, 2021. Results are still pending.
CDC Split Type:

Write-up: Patient felt fine on Friday afternoon and evening after shot. Felt fine on Saturday until the afternoon when she started feeling fatigued and chilled. Decided to take a warm bath at about 6pm. Was found dead in bathtub at approximately 7pm with blisters on arms, legs, and face.


VAERS ID: 1047326 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-25
Onset:2021-01-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pyrexia, Rash macular
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Namenda, Aricept, Multivitamin, Glucophage, Creon
Current Illness: Decubitis Ulcer
Preexisting Conditions: Diabetes Mellitus Type 2, TIA (never diagnosed per Caregiver)
Allergies: Penicillin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: According to patient''s caregiver, patient presented with symptoms of fever (101.6 F) and purple blotches all over the body within an hour. Since patient was in hospice , caregiver called Hospice and a pharmacy and was told to give patient Benadryl and Tylenol. Patient was given both medications and the fever subsided in a few days but the purple blotches never went away. Patient passed away at the facility a week later.


VAERS ID: 1047351 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-01-29
Onset:2021-02-17
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Asthenia, Blood creatinine increased, COVID-19, Decreased appetite, Diarrhoea, Dyspnoea, Fibrin D dimer increased, Gastritis, Hypoxia, Limb injury, Liver function test increased, Lung infiltration, Procalcitonin increased, SARS-CoV-2 test positive, Serum ferritin increased, Skin ulcer, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
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: 2/10/2021: Metoclopromide, Famotidine, 2/13/2021: Remdesivir, Lovenox, Azithromysin, Meropenem
Current Illness: Covid-19 positive on 2/2/2021
Preexisting Conditions: Diabetes type 2, Hypertension
Allergies: Morphine, Zosyn, Piperacillin
Diagnostic Lab Data: Sars PCR 2/2/21
CDC Split Type:

Write-up: Patient was tested for covid on 2/2/21 with positive resulted. Presented to Hospital ER on 2/10/21 with c/o of abdominal pain. Diagnosed with gastritis, prescribed metoclopromide and famotidine and dc home. Returned to ER on 2/13/21 with c/o of weakness, diarrhea, foot ulcer, and loss of appetite. Diagnosed: 1) Dyspnea and hypoxia secondary to Covid-19 2) Extensive bilateral lung infiltrates secondary to Covid-19 3) Increased Cr 4) Increased LFTs, ferritin, d-dimer, troponin secondary to Covid-19 5) Elevated procalcitonin placing the patient at high risk for sepsis 6) Chronic appearing Right foot wound without signs of secondary infection Patient transferred to a different hospital in another city.


VAERS ID: 1047434 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-10
Onset:2021-02-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / SYR

Administered by: Unknown       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: 2021-02-13
   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: none
Current Illness: Completely healthy check-up 2 weeks prior to vaccination and death.
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 3 days after receiving his first dose of the Covid vaccine. He saw his doctor 2 weeks prior to his death with absolutely no complaints, very healthy. He had no prior heart conditions and was pronounced dead of a heart attack.


VAERS ID: 1047455 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-02-19
Onset:2021-02-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 UN / IM

Administered by: Senior Living       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: Amlodipine 10 mg qday, Iron Sulfate 325 mg bid, Lisinopril 20 mg bid, Metoprolol Tartrate 25 mg bid, Milk of Magnesia prn, Tylenol 650 mg prn, Senna Plus prn, Vitamin B 12 1000 mg qday, Vitamin D 50, 000 units qweek
Current Illness: Multiple falls, HTN, TIA, mild cognitive impairment, Gait abnormality, hearing loss, major depressive disorder, osteoporosis, central pontine myelinolysis
Preexisting Conditions: HTN, TIA, mild cognitive impairment, Gait abnormality, hearing loss, major depressive disorder, osteoporosis, central pontine myelinolysis
Allergies: NKDA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Resident deceased


VAERS ID: 1047571 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Washington  
Vaccinated:2021-02-10
Onset:2021-02-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Cerebrovascular accident, Death
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: 2021-02-20
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death after stroke .


VAERS ID: 1047634 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia, SARS-CoV-2 test positive, Urinary tract infection
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to hospital on 2-9-21 for urinary tract infection and tested positive for Covid. Developed pneumonia and expired on 2-12-21.


VAERS ID: 1048786 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Electrocardiogram, Fall, Full blood count, Metabolic function test, Pulseless electrical activity, 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), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? Yes
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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: ? sepsis, CAD, HTN, increased lipids
Preexisting Conditions: hypertension, constipation, hyperlipidemia, CAD, BPH
Allergies: Orudis, Statins (intolerance)
Diagnostic Lab Data: ECG, 2/11 -2/12/21 PEA then asystole CBC with auto diff, CMP
CDC Split Type:

Write-up: Was given vaccine around 1:30Pm on 2-11-2021. He and his wife waited in the building for 15 minutes and then left. he denied complaint. (He was waiting to have both Covid shots before he went to cardiologist Re: CAD.) He had an alarm going off in his house, was going to basement to check it out. Police officer heard alarm, came into house, & heard a thud when Doc fell. He was in PEA (Pulseless Electrical Activity) when brought into ER. Given 5 "rounds of Epinephrine with no response.


VAERS ID: 1048399 (history)  
Form: Version 2.0  
Age: 102.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-02-01
Onset:2021-02-10
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Diet refusal
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: Prilosec 10 mg/daily,Synthroid .110, daily multivitamin
Current Illness: Covid-19 (Pos. antibody 12/20/2020), Dementia
Preexisting Conditions: Hiatal Hernia, Dementia
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stopped eating and drinking and died


VAERS ID: 1048665 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: New York  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Internal haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

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: Died; Internal bleeding and died; A spontaneous report was received from a nurse concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced internal bleeding and died. The patient''s medical history was not provided. No concomitant product use was reported. On unknown date, the patient received their first of two planned doses of mRNA-1273 (Lot number: not provided) intramuscularly for prophylaxis of COVID-19 infection. On unknown date, a nurse reported she read about a doctor who received the COVID-19 vaccine and died 3 days later. She stated she read that the doctor had internal bleeding. It started with bleeding in his hands and feet, then went to his brain and died 3 days later. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not provided. The outcome of the events, internal bleeding and died, was considered fatal.; Reporter''s Comments: Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested.; Reported Cause(s) of Death: Internal bleeding


VAERS ID: 1048672 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-29
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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: 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: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: No adverse event, Continue: [UNK], Comment: No reported medical history.
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Pass away; Got COVID; A spontaneous report was received on from a consumer, concerning an 87-year-old male patient, who received Moderna''s COVID-19 (mRNA 1273) vaccine and experienced pass away (death) and COVID (COVID-19). The patient''s medical history was not provided. No relevant concomitant medications were reported. On 29 Dec 2020, the patient received their first of two planned doses of mRNA-1273 injection for the prophylaxis of COVID-19 infection. Two days after mRNA-1273 injection, the patient''s daughter was diagnosed with COVID-19 infection. The daughter states that her mother also got infected with COVID. On an unknown date, the patient got COVID. It was reported that he passed away. Treatment for the event was not provided. The cause of death was not provided. The plans for an autopsy were not provided. .; Reporter''s Comments: Although the onset date of COVID-19 and the fatal outcome is lacking, Based on the natural history of COVID-19, the reported event, it is assessed as unlikely related with mRNA-1273. The actual cause of death cannot be ascertained but assessed as not related and most likely due to the COVID-19 infection.


VAERS ID: 1048686 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated:2021-01-01
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: SARS-CoV-2 antibody test, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad), 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: Medical History/Concurrent Conditions: Depression; Schizophrenia
Allergies:
Diagnostic Lab Data: Test Date: 202011; Test Name: covid19; Test Result: Positive
CDC Split Type: USPFIZER INC2021166424

Write-up: died just 10 days after being given the vaccine/ put sepsis on her medical records; This is a spontaneous report from a contactable consumer report for Aunt. A 59-year-old female patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration in Jan2021 at single dose for COVID-19 immunization. Medical history included schizophrenia and depression. The patient''s concomitant medications were not reported. Consumer''s aunt (patient) was housed in a facility. She was being treated for schizophrenia and depression. This was one of the facilities that chose to house Covid patients during the pandemic. Many of the patients here contracted covid19 during this time and they had to do a full facility lockdown and quarantine. The patient tested positive in Nov2020 and was quarantined to her room for 10 days. 3 weeks ago (in Jan2021), she received the Pfizer vaccine. Consumer''s family was not given notice of this and we are sad to report that she died just 10 days after being given the vaccine. They put sepsis on her medical records and have not connected this to the vaccine. Consumer stated aunt was just 59 yrs old, though she was being treated for her mental illness, she was physically healthy. Consumer''s family gravely concerned that this facility neglected her health by administering the vaccine without considering possible reactions from the medication she was taking, or the fact she had Covid just months prior. Patient died on an unspecified date. it was unknown if an autopsy performed. Information on Lot/Batch number has been requested.; Reported Cause(s) of Death: died just 10 days after being given the vaccine/ put sepsis on her medical records


VAERS ID: 1048688 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebral infarction, 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: 2021-02-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Coronary artery disease; Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021167871

Write-up: My mother had a stroke on 28Jan2021 sometime after 9:30 AM the morning after getting the first dose of the Pfizer Covid vaccine; Cerebral infarction; This is a spontaneous report from a contactable consumer (reporting for mother). A 94-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number and expiry date unknown as not available or provided to reporter at the time of report completion) via an unspecified route of administration on 27Jan2021 in right arm at single dose for COVID-19 immunization. Medical history included coronary artery disease and hypertension. There were no concomitant medications. The patient was not pregnant. No other vaccine was received in four weeks. The patient did not have covid prior vaccination and not have covid tested post vaccination. The patient had a stroke on 28Jan2021 sometime after 9:30 AM the morning after getting the first dose of the Pfizer Covid vaccine and was hospitalized due to stroke for 6 days from Jan2021. The patient then experienced cerebral infarction in 2021 and died due to it on 04Feb2021. Treatment received for events stroke and cerebral infarction included tPA injection. The outcome of events stroke and cerebral infarction was fatal. An autopsy was not performed. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: Cerebral infarction


VAERS ID: 1048690 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 LA / OT

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac failure
SMQs:, Cardiac failure (narrow), Cardiomyopathy (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: AMLODIPINE BENAZEPRIL; AMLODIPINE; ASPIRIN (E.C.); ATORVASTATIN; BENAZEPRIL; CARVEDILOL; COQ10 [UBIDECARENONE]; FUROSEMIDE; ACETAMINOPHEN; POTASSIUM CHLORIDE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Allergy; Congestive heart failure; Coronary artery disease; Hyperlipidemia; Hypertension; Osteoarthritis; Prosthetic cardiac valve malfunction
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021170473

Write-up: presumed cardiac failure; This is a spontaneous report from a contactable nurse. An 89-year-old female patient (not pregnant) received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL9261), intramuscular at arm left on 10Feb2021 (at the age of 89 years) at single dose for COVID-19 immunization. The patient medical history included congestive heart failure, coronary artery disease, hypertension, hyperlipidemia, osteoarthritis, presence of prosthetic heart valve and allergies, all from an unknown date and unknown if ongoing. The patient''s concomitant medication included amlodipine besilate/benazepril hydrochloride, amlodipine, acetylsalicylic acid (ASPIRIN E.C.), atorvastatin, benazepril, carvedilol, ubidecarenone (COQ10), furosemide, acetaminophen and potassium chloride. The patient previously received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL0142), intramuscular at arm left on 20Jan2021 at single dose for COVID-19 immunization. The patient experienced presumed cardiac failure on 12Feb2021 at 03:30 with fatal outcome. The patient died on 12Feb2021. An autopsy was not performed.; Sender''s Comments: Based on the current available information, the event Cardiac failure is most likely related to an intercurrent or underlying condition which is not related to the suspected drug BNT162B2. The patient medical history of congestive heart failure, coronary artery disease, hypertension, and hyperlipidemia provide plausible explanations for the event. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: presumed cardiac failure


VAERS ID: 1048745 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-08
Onset:2021-02-12
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / UNK LA / SYR

Administered by: Military       Purchased by: ?
Symptoms: Autopsy, Cardiac tamponade, Death
SMQs:

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: Aspirin 81 MG Calcium Carb 600mg Loratadine 10 Mg Multivitamin Lisnopril 10 MG Mirtazapine 30 MG at bed for mood Simvastatin 20 MG
Current Illness:
Preexisting Conditions: Allergic rhinitis benign essential hypertention Depression Generalized Anxiety Hip Pain Total revision of left hip
Allergies: Gabapentin- Pain in eye
Diagnostic Lab Data: Autopsy performed February 18, 2021
CDC Split Type:

Write-up: Death on February 12, 2021 acute cardiac tamponade


VAERS ID: 1048882 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-02-01
Onset:2021-02-12
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

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:
Current Illness:
Preexisting Conditions: diabetes
Allergies: Augmentin (hives)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine was administered 2/1/2021 at approximately 9am. Due to self reporting of allergic reaction (hives) to Augmentin, patient was monitored on site for 30 minutes. After the monitoring period, she was cleared to go with no issues reported at the time. We were later informed that the patient passed away from a pulmonary embolism on 2/12/2021.


VAERS ID: 1048917 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram normal, Death, Fall, Laboratory test, White blood cell count increased, X-ray normal
SMQs:, Neuroleptic malignant syndrome (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 3
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: Aspirin 81 MG EC tablet 1 daily, Latanoprost 0.005% Ophth Soln, Incruse Ellip 62.5MCG/ACT Inh, , Losartan 25 MG tablet, Ompeprazole 20 mg, Potassium CL 20 MEQ ER tablet, Preservision Areds Tablet, Simvastatin 40 MG tablet,
Current Illness: No acute illness
Preexisting Conditions: Diagnosis Codes obtained upon admission in 11.17.2015 I45.10, J30.9, J44.9, E78.0, i10, K21.9, H40.9, D69.6, G93.40, K59.0, Z96.641, sm869, sm859
Allergies: Morphine, Shellfish
Diagnostic Lab Data: Tests ran at Hospital. Unsure of full tests and results. Only received updated from resident representative.
CDC Split Type:

Write-up: Resident yelling for assistance in apartment. Nursing personnel found resident on floor at 6:10 AM on 2/18/2021. Resident was transported to Hospital on 2/18/2021. Status update on 2/18/2021 from son, resident CT & X-rays were done all normal. Labs done and WBC count was elevated and awaiting results. Resident stable and admitted to hospital for observation. Resident passed away on 2.21.2021.


VAERS ID: 1048947 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Endotracheal intubation, Gastrointestinal tube insertion, Hypotension, Hypoxia, Loss of consciousness, Small intestinal obstruction, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Oxybutinin Carvedilol Eliquis allopurinol atorvastatin losartan amiodaron furosemide ezetimibe zofran
Current Illness:
Preexisting Conditions: End stage renal failure on dialysis Hospitalization on 2/5/21 for ESRD and initiation of hemodialysis Anemia of chronic disease Chronic atrial fibrillation on anticoagulation Congestive Heart failure Recurrent abdominal wall hernia
Allergies: keppra decadron
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient experienced an episode of emesis and loss of consciousness several hours after vaccine on 2/16/21. He was taken by EMS to the hospital and was noted to be hypoxic and hypotensive. He was admitted to the hospital and subsequently intubated. He was also found to have a small bowel obstruction and a nasogastric tube was placed to decompress the bowel. He required pressor support as well. He expired on 2/17/21.


VAERS ID: 1049012 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-02-12
Onset:2021-02-19
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   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: lisinopril, lovastatin, diclofenac sodium, nifedipine ER, Anastrozole, Alendronate
Current Illness:
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was given vaccine on friday, one week later she passed away. The family called the pharmacy to inform us on Saturday, Feb 20, 2021. After the phone call was over, we saw in her pharmacy profile that she had received the vaccine one week prior


VAERS ID: 1049284 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Virginia  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / 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: Unevaluable event (underlining health issue)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died; A spontaneous report was received from a consumer concerning a 58-year-old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and patient was died. The patient''s medical history was reported as underlying health issue. Concomitant product use was not provided by the reporter. On an unknown date, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: if reported or unknown) intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, patient with underlying health issue died after getting the Moderna COVID-19 vaccine. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on an unknown date. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 58-year-old female who died on unknown date after first dose of mRNA-1273, lot # unknown. Very limited information regarding this event has been provided at this time, therefore it is difficult to assess a cause and effect relationship. No further information will be available. Of note, patient''s medical history included unknown underlying health issues.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1049389 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Idaho  
Vaccinated:2021-02-09
Onset:2021-02-20
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   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: Spironolactone, Atorvastatin, Gabapentin, Trelegy Ellipta, Januvia, Xarelto, Losartan, Metoprolol Succinate.
Current Illness: No
Preexisting Conditions: Type 2 DM, HTN, COPD, Hyperlipidemia unspecified, A-fib unspecified, Chronic pain, Morbid Obesity
Allergies: No
Diagnostic Lab Data: Nothing wife opted out for any test to be performed.
CDC Split Type:

Write-up: Patient passed away Saturday at 14:04pm. Patient''s wife reports his death was sudden, he passed away sitting in his chair his heart just stopped she said. They tried to perform CPR, 911 was called and paramedics arrived at the scene and he was given medication but never had any return of vital signs and so his death was called at the scene. Wife reports he was not ill, did not have any symptoms prior to the event. They are not going to be doing a autopsy. She wanted us to know based on timing that there may be some possible correlation with his COVID19 vaccine. He obtained the vaccine on 02/09/2021 - wife reports he had no symptoms, not even arm soreness after the vaccine. Had no fever, shortness of breath. Did not complain of chest pain. We can update chart to reflect the patient is deceased and lets make a card for the family.


VAERS ID: 1049406 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-02-21
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Exposure to SARS-CoV-2, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none listed
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient rcvd 1st covid 19 vaccine on 1/26/2021. Patient had house guests on 1/30/21. Those house guests tested positive for covid on 2/1/2021. Patient started getting symptoms on 02/2/2021. Patient tested postivie on 2/4/2021. Patient was hospitalized 2/7/2021. Patient passed away on 2/21/21.


VAERS ID: 1049428 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-28
Onset:2021-02-07
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood albumin decreased, Blood creatinine normal, Blood glucose increased, Blood sodium increased, Blood urea increased, Body temperature increased, Carbon dioxide increased, Death, Decreased appetite, Discomfort, Dysphagia, Dyspnoea, Feeling cold, Heart rate increased, Hyperhidrosis, Lethargy, Mastication disorder, Peripheral coldness, Prealbumin, Respiratory arrest, Restlessness, SARS-CoV-2 test negative, Unresponsive to stimuli, Vomiting, Weight decreased
SMQs:, Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Akathisia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG daily; Calcium Citrate-Vitamin D Tablet 315-200 MG daily; Donepezil HCl Tablet Give 10 mg daily; glipiZIDE Tablet 5 MG daily; HydroCHLOROthiazide Tablet 25 MG daily; Latanoprost Emulsion 0.005 % Instill 1 drop in both e
Current Illness: 1/6/2021-Resident noted with increased irritability and increased signs/symptoms of discomfort. Followed by Palliative APRN. Labs ordered and Tylenol increased for pain management. 1/7 labs BUN 28mg/dl/Creatinine 0.53mg/dl. CBC unremarkable. 1/7/2021-1st Pfizer Covid-19 Vaccine dose given. 1/15/2021 Palliative APRN came to visit reviewed labs Valproic Acid level WNL. Hepatic Panel with Albumin low at 2.6g/dl. Plan of care discussed with Guardian. N.O. DNR/DNH, may have draws labs and treat with ABX if needed. 1/24/2021 Patient vomited large amount of undigested food. 1/28/2021 2nd Pfizer Covid-19 Vaccine dose given.
Preexisting Conditions: Hx Covid + June 4, 2020; HYPERLIPIDEMIA, UNSPECIFIED (E78.5); UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE; TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65); ESSENTIAL (PRIMARY) HYPERTENSION (I10); glaucoma; UNSPECIFIED MOOD [AFFECTIVE] DISORDER (F39); HYPOKALEMIA (E87.6); GASTROESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9); HYPERLIPIDEMIA, UNSPECIFIED (E78.5);
Allergies: Nylons
Diagnostic Lab Data: Labs 2/10 BMP- Glucose 248mg/dl; BUN 31mg/dl; Creatinine 0.54mg/dl; Sodium 149mmol/L; CO2 36mmol/L; Albumin 3.0g/dl; Pre-Albumin 19.9mg/dl
CDC Split Type:

Write-up: 2/7/21 Increased difficulty chewing, swallowing, evaluated by SLP and dietician. Diet texture down-graded x 2 with poor appetite and recent 6lb weight loss. 2/8/21-APRN updated regarding poor appetite and difficulty chewing as well as downgraded texture of diet. Also informed of increased s/s of discomfort and increased use of PRN Oxycodone for pain. 2/9/21- elevated temp 100.7. 2/9/21 Covid pcr test negative. 2/9/21-N.O.?s APRN BMP, Albumin and Pre-albumin Level in am. 2/11/21-elevated temp 100.4. Covid rapid test negative. 2/12/21- CBG recorded at 517 at 5:20 am. Resident also has an elevated temp of 100.9. Tylenol administered per order. Vital signs include resp 24, radial pulse 134, O2 sat 83%. Supplemental oxygen administered via nasal cannula. Head of bed elevated. DR. notified at time via telephone. Order given for sliding scale for CBG. Guardian updated regarding changes in residents condition, poor prognosis. Guardian requests Hospice eval and admit. Guardian requests comfort care no hospitalization, no IV''s, no G-tubes, no labs etc, D/C of Palliative services. ARNP informed. 2/12/21 Acute Telehealth visit with APRN due to increased lethargy, elevated CBG?s despite poor appetite and insulin administration. Resident unresponsive to verbal and noxious stimuli at time of visit. N.O. Morphine sulfate 20mg/ml, give 2.5mg PO/SL Q4hr PRN pain/shortness of breath. 2/12/2021-Admitted to Hospice, Lethargic, diaphoretic, T 98.1 P 130''s R 18 O2 high 80''s to low 90''s via O2 mask at 3L. 2/12/2021- Resident legs and arms noted to feel cool this afternoon, 02 sat was 97% with 02 on @ 3L with mask Noted resident with sob and increased pulse. Prn morphine 0.25ml sl. given with good effect. Resident was less restless and quiet in her bed. Checked on resident several times this shift for needs. Resident noted to not move in her bed @ 8:15pm and noted she was not breathing. Supervisor called and pronounced resident deceased.


VAERS ID: 1049648 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-02
Onset:2021-02-20
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebrovascular accident, Death
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: 2021-02-20
   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: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: I was notified on 2/22/21 that this patient passed away over the weekend. I do not know the details, nor can I confirm anything beyond what I was told. I believe the death occurred on 2/20/21 due to a massive stroke.


VAERS ID: 1049724 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Illinois  
Vaccinated:2020-12-30
Onset:2021-01-11
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatine phosphokinase, Blood creatine phosphokinase MB, Blood culture, Blood lactic acid, Chest X-ray, Choking, Condition aggravated, Culture urine, Depressed level of consciousness, Differential white blood cell count, Electrocardiogram, Full blood count, Metabolic function test, Pyrexia, Slow response to stimuli, Troponin, Urine analysis
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   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: Current Outpatient Medications: ? albuterol (PROAIR HFA) 108 (90 Base) MCG/ACT inhaler, Inhale 2 puffs by mouth every 6 hours as needed for Wheezing, Disp: , Rfl: ? amLODIPine (NORVASC) 5 MG tablet, Take 5 mg by mouth daily, Disp: , Rfl
Current Illness:
Preexisting Conditions:
Allergies: Bandage adhesive Celebrex Latex Lincomycin Macrobid
Diagnostic Lab Data: Urine culture ONE TIME, Status: Canceled 01/11/21 1033 0.9% NaCl infusion CONTINUOUS, Status: Discontinued 01/11/21 1024 acetaminophen (OFIRMEV) injection 1,000 mg ONCE 01/11/21 1024 Insert peripheral IV ONE TIME 01/11/21 0951 Pulse Oximetry CONTINUOUS, Status: Canceled 01/11/21 0951 Cardiac Monitoring CONTINUOUS, Status: Canceled 01/11/21 0951 CBC w Auto Diff ONE TIME 01/11/21 0951 Comprehensive metabolic panel ONE TIME 01/11/21 0951 Urinalysis with reflex to culture, if indicated ONE TIME 01/11/21 0951 Lactic Acid, Serum ONE TIME 01/11/21 0951 CULTURE, BLOOD ONE TIME 01/11/21 0951 CULTURE, BLOOD ONE TIME 01/11/21 0951 EKG ONE TIME 01/11/21 0951 Troponin Series ONE TIME 01/11/21 0951 CKMB ONE TIME 01/11/21 0951 CK (CPK) Creatine Phosphokinase ONE TIME 01/11/21 0951 XR Chest Portable RAD ONE TIME 01/11/21 0951
CDC Split Type:

Write-up: Emergency room 1/11/21 Patient is a 72 year old female who presents with decreased level of consciousness. The patient is a nursing home patient and had an episode of choking yesterday that was treated with a Heimlich maneuver. Nursing staff at the nursing home reports that she seems to be a bit less responsive today. However, the patient has been for the most part unresponsive for 3-4 months time following a COVID-19 infection. Of note, her oxygen saturation on room air is 72%. The patient is also febrile to 100.8?. She was unable to provide any information and the aforementioned information is gathered from nursing home staff report.


VAERS ID: 1049773 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-12
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none listed on consent form
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient died on 02/20/2021. Cause of death was pulmonary embolism.


VAERS ID: 1049787 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death, 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: None
Current Illness: None
Preexisting Conditions: High Cholastrol
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Without showing any side effect symtoms, patient suddenly fell unconscious and passed away within an hour. Though 911 was called and Paramedic was trying to revive the patient.


VAERS ID: 1049852 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: vitamin d 1.25 mg 1 per week
Current Illness:
Preexisting Conditions: cvd
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: When calling to get billing information we were notified that patient had passed away. Patient''s daughter said patient was having cvd a/s on 2.1.2021 got vaccine 2.2.2021 and passed away 2.5.2021. Cardiologist said not related


VAERS ID: 1049864 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-22
Onset:2021-01-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood thyroid stimulating hormone, Cardiac arrest, Chest X-ray, Cyanosis, Death, Differential white blood cell count, Dyspnoea, Electrocardiogram, Endotracheal intubation, Full blood count, Metabolic function test, Oxygen saturation decreased, Pulse absent, Pulseless electrical activity, Resuscitation, Syncope, Troponin, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), 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), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Current Outpatient Medications: ? albuterol 108 (90 Base) MCG/ACT inhaler, inhale TWO PUFFS every FOUR hours as needed FOR FOR WHEEZING OR shortness OF breath, Disp: , Rfl: ? aspirin 81 MG EC tablet, Take 81 mg by mouth daily, Disp: , R
Current Illness:
Preexisting Conditions:
Allergies: Sulfa Antibiotics
Diagnostic Lab Data: TSH Third Generation ONE TIME 01/27/21 1319 Troponin Series ONE TIME 01/27/21 1319 EKG ONE TIME 01/27/21 1319 Oxygen Therapy Maintain O2 Sat at or Greater: 94%; Liter Per Minute: 4 LPM ONE TIME, Status: Canceled 01/27/21 1319 XR Chest Portable RAD ONE TIME 01/27/21 1319 CBC w Auto Diff ONE TIME 01/27/21 1319 Comprehensive metabolic panel ONE TIME 01/27/21 1319 BAG/MASK OXYGEN 1 Time ONE TIME, Status: Canceled 02/10/21 0727 EPINEPHrine PF 0.1 mg/mL (1:10,000) injection ONCE PRN 02/10/21 0657 sodium bicarbonate 8.4 % injection ONCE PRN 02/10/21 0657 EPINEPHrine PF (ADRENALIN) 1 mg/mL (1:1,000) injection ONCE PRN 02/10/21 0656 atropine syringe ONCE PRN 02/10/21 0655
CDC Split Type:

Write-up: 1/27/21 Emergency room: HPI Patient is a 77 y.o. male who presents after a syncopal episode with cyanosis and shortness of breath. Patient came from rehab where they stated he was sitting on his bed, his oxygen saturation dropped down to 76% on 4L and he became cyanotic. By the time EMS arrived, patient was back to 95% on 4 L. On arrival to the ER, he is 98-100% on 4L. He has a history of COPD and has a chronic cough due to this.Currently, he has no pain, no shortness of breath, no weakness, no cyanosis. He is afebrile and sitting comfortably in bed. 2/10/21 emergency room HPI Patient is a 77 y.o. male who presents with in full cardiac arrest. Patient is resident of local nursing home. According to nursing home staff, a tech was in his room talking with him as patient was laying in bed. Tech began walking out of patient''s room and turned around to tell him one last thing when the tech noticed patient had gone unresponsive. Patient had no spontaneous respirations or pulse, subsequently CPR was started immediately. 911 was called. This occurred around 5:30 a.m.. Upon EMS arrival on scene, they found a male unresponsive with CPR being performed. There was no spontaneous respirations or circulation. Thus, ET tube was placed and life support guidelines initiated. Patient was found to be in PEA, and according to EMS, patient was given a total of 6, 1 mg epinephrine IV push and 1, 1 Amp sodium bicarb. Patient was worked on at the scene for approximately 40 min before being transferred to ER. Upon arrival to ER trauma room 1 patient is still in full arrest. ET tube in place with good ventilation. Patient remains in PEA. Chest compressions and life support guidelines initiated. In reviewing patient''s chart and nursing home notes, patient is a full code. Patient has a significant cardiac history including known coronary artery disease with 4 vessel CABG. Patient also has history of 3rd degree heart block and pacemaker placement. Patient has history of ischemic cardiomyopathy but last echo performed in 2020 shows ejection fraction of 45%.


VAERS ID: 1049963 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-12
Onset:2021-01-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Myocardial infarction, Pulse absent, Respiratory arrest, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: chlorpromazine 800mg QHS amantadine 100mg BID divalproex 1000mg QAM, 1500mg QHS haloperidol decanoate 225mg Q2weeks amlodipine 5mg QHS carvediol6.25mg BID docusate sodium 250mg BID fluticasone propionate 1 spray each nostril BID lisinopril
Current Illness:
Preexisting Conditions: obese, pre-diabetic, hypertension, atherosclerotic disease, coronary artery blockage, schizoaffective disorder Tested COVID-19 positive on 1/21/2021, asymptomatic, 1-1/2 weeks after first COVID-19 vaccination
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found lying face down without respiration or pulse, believed to be within 5 minutes of event. ACLS procedures unsuccessful. Unable to get autopsy. Believed to be heart attack secondary to COVID infection, but unconfirmed. Relative contribution of recent vaccination unknown.


VAERS ID: 1049997 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Other       Purchased by: ?
Symptoms: Aphasia, Death, Hypotension, Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: Pliavis, tramadol, aspirin, statin, remeron, protonix
Current Illness: none identified
Preexisting Conditions: Heart Rhythm Irregularity, High Cholesterol, Arthritis, Hypertension, CVA/TIA/Stroke, GERD/Reflux, Sleep Apnea, Heart Disease
Allergies: Ace inhibitors, solifenacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine was administered at Nursing Facility. Patient is an 89-year-old female with prior medical history of CVA with dysphagia, history of possible dementia, GERD, hyperlipidemia, and a pacemaker. She is a resident from town. She was sent for hypotension with a blood pressure of 90/52, tachypnea respirations of 54, possible aspiration pneumonia. Status post Covid vaccine earlier today. History is limited as patient is nonverbal on my exam. Death within 24 hours of vaccination


VAERS ID: 1050128 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-02-06
Onset:2021-02-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Death, Dyspnoea, Fatigue, Gait disturbance, Loss of consciousness, Respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2014-02-14
   Days after onset: 2550
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Eliquis 5MG, Carvedilol 6.25MG, Ramipril 2.5 MG, Atorvastatin 80 MG 1 tab daily ,Stiolto Respimat Inhalation spray 2 puffs per day; Albuterol Sulfate Inhaler as needed, Ipratropium Bromide 0.5 mg and Albertol Sulfate0.3mg inhalation soluti
Current Illness: none
Preexisting Conditions: 1.COPD started in 2008 from a Neurosurgery and had to be on a ventalator: 2 Open Heart Surgery Had a pacemaker
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: 02/07/21 through 2/13/21 slightly fatiqued, took all his prescribed medications, ate breakfast, lunch and dinner was drinking eight 10 oz bottles of water. On 02/14/21 was very tired had a difficult time breathing after taking the normal meds. He took a breathing treatment with his prescribed Ipratropium Bromide and Albuterol Sulfate via home nebulizer. This did not improve his breathing. He was very weak and breathing was labored. 911 was called by wife. 911EMTchecked pulse and breathing. Informed him they would give him a breathing treatment.He started to go limp. EMT''s got him to Ambulance and to Medical Center to the ER. Heroics done. He died. Pulmonary and Cardiac Arrest


VAERS ID: 1050137 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-21
Onset:2021-02-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Agonal death struggle, Back pain, Blood chloride decreased, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood potassium increased, Blood sodium normal, Blood urea increased, Brain natriuretic peptide increased, C-reactive protein increased, C-reactive protein normal, Chest X-ray abnormal, Contusion, Death, Electrocardiogram, Electrocardiogram abnormal, Haematocrit increased, Haemoglobin increased, Headache, Hyperglycaemia, Hypotension, Lung opacity, Pacemaker generated rhythm, Petechiae, Troponin, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   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: Entresto, Metoprolol, Spironolactone, Vit D, Lasix, Flomax, Digoxin, Eliquis, Tradjenta, ASA, Novolog Flex pen, Levothyroxine, Vit B12, Lipitor, Aricept, Temazepam, Lorazepam, Glucose prn.
Current Illness: Fall on 2/15/21 pm resulting in skin tear requiring dressing. Pt Seen on 2/16 for skin tear repair secondary to fall the pm prior. Vital signs WNL. Pt returned on 2/20/21 for dressing change. Vital signs WNL. Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes Home Health nurse sent secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization)
Preexisting Conditions: Hypertension, MI, CHF, DM, CRF, Thyroid, High Cholesterol, Prostate
Allergies: Shrimp, Red Man Syndrome, Cleocin, Clindamycin
Diagnostic Lab Data: 2/22/21: CBC WBC 11.74, H/H: 8.6/26.8. Glu $g625mg/dl, BUN 70, Creatnine $g4.10, Sodium <114, Potassium $g6.8, Cl 81, Troponin 0.583, CRP 1.5 BNP 26900, Lactate 8.4 CXR: Subtle inter stitial opacities could represent atelectasis, superimposed mild bronchitis or edema suspected.EKG: Ventricular Paced rhythm. Unsure if death applicable as adverse event secondary to vaccination. Physician noted Vascular Collapse post covid vaccine.
CDC Split Type:

Write-up: Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes states that Home Health nurse sent patient to ER secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization). Patient was treated with IVF bolus in addition to initiating Dopamine for hypotension, patient became agonal and daughter at bedside presented Adv. Directive, pt was DNR. Pt pronounced time of death was 2110pm. (Pt only reported a sore shoulder secondary to vaccine).


VAERS ID: 1050158 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-28
Onset:2021-02-23
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Pulmonary congestion, Respiratory tract congestion, Vomiting
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad)

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: Tramadol HCI tab 50mg po Qday, Ambien titrate 5 mg PO QHS PRN, Promethazine DM Syrup 6.25-15mg/5ml give 5ml Q4hrs prn, Zofran 4mg 1 tab PO Q 4 hours PRN, Morphine sulfate 15mg give 0.5mg PO Q 4hours PRN , Bowel care
Current Illness: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Preexisting Conditions: Dementia, History of CVA affecting left side, history of COVID 19 in December 2020, Aphasia.
Allergies: No known allergies
Diagnostic Lab Data: Change of condition was acute and on same day passed away - 1-23-2021
CDC Split Type:

Write-up: Resident is a Hospice patient. On 1-23-2021 am shift resident was observed by nursing have chest congestion and had a emesis times 1 with SOB, Zofran 4 mg was given. HOB (02 sats 88%) was elevated resident on 02 via nasal canula with 02 sat now @ 90% . no respiratory distress noted. MD was called with response pending for orders. @ 1400 resident with no signs of life. vs 90%-24-97/71-97.6. Hospice on site and time of death 1436


VAERS ID: 1050172 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Diarrhoea, Musculoskeletal discomfort, Nausea, Pain, Pyrexia, Unresponsive to stimuli, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Unknown
Current Illness: Inpatient admission to Medical Center 12/26/2020 - 01/07/2021 for Congestive Heart Failure
Preexisting Conditions: Pulmonary Hypertension, Congestive Heart Failure, Insulin Dependent Diabetes, Oxygen dependant
Allergies: Unknown
Diagnostic Lab Data: None. Family requested an autopsy and the medical examiner declined.
CDC Split Type:

Write-up: Individual developed severe body aches, severe shoulder discomfort, high fevers (documented max temp. 103.7 F). Daughter reported that she became non-responsive with high fevers, and when the fevers decreased she was more lucid. Her condition rapidly progressed to nausea vomiting, diarrhea and patient died on 2/9/2021.


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