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From the 10/15/2021 release of VAERS data:

Found 4,236 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died



Case Details

This is page 11 out of 43

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VAERS ID: 1111924 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-03-16
Onset:2021-03-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
   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: Prednisone 5mg QDay Folic Acid 1mg Q Day Colace Sodium 100mg BID Hydroxyzine 25mg 2 tabs TID Lactulose 40ml M, W, F Culturelle 1 capsule once daily Mircera 300mg IM once per month Prilosec 20mg once daily Gentamicin topical applied to cathe
Current Illness: ESRD HTN Dyslipidemia Skin Cancer Vitamin B12 Deficiency Osteoporosis
Preexisting Conditions: ESRD HTN Dyslipidemia Skin Cancer Vitamin B12 Deficiency Osteoporosis
Allergies: Scallops and clams, anaphylaxis
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient found demised at home on 3/17/2021


VAERS ID: 1111957 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-03-03
Onset:2021-03-07
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metformin
Current Illness: unknown
Preexisting Conditions: stage 4 kidney disease; peripheral vascular disease; emphysema; GERD; HTN; A-Fib; cardiac disease; current smoker
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Received vaccine on 3/3/2021 then was found dead in bed by her husband on 3/7/2021.


VAERS ID: 1112104 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-09
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 - / -

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

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

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


VAERS ID: 1112123 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Utah  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Vit C, Coreg, Excitalopram, Ferrous Sulfate, Pravastatin, Senna Plus, Torsemide
Current Illness: CKD, muscle weakness, Heart Failure, CAD, Diabetes, HTN, Hyperlipidema, Palliative Care
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: This patient was on hospice, we are reporting this to VAERS at the Medical Directors request d/t patient''s death within 48 hours of the second dose vaccine. The death occurred the morning following his second dose of the Moderna COVID-19 Vaccination, vaccine received on 03/11/21 and patient date of death 03/12/21 at 9:41 am. This was a hospice patient with a terminal dx of CKD. This is being reported at the request of the Medical Director for the hospice team, d/t the patient''s death occurred within 48 hours of receiving the second dose of this vaccine. The nurse case manager stated the pt was declining as they were on hospice for a terminal condition and had co-morbidities, Pt did show more decline after receiving COVID-19 vaccination and patient passed away within 48 hours of receiving second vaccination dose.


VAERS ID: 1112136 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-03
Onset:2021-02-11
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / -

Administered by: Senior Living       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:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1112164 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-04
Onset:2021-03-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Other       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: 2021-03-07
   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: Individual was a number of medications. His Psyciatrist wants Clozapine Emphasized CARBAMAZEPINE 200 MG TABLET Carbamazaepine 100mg ER Tab 12h Clozapine FLUTICASONE PROP 50 MCG SPRAY FOLIC ACID 1 MG TABLET Gabapentin 300mg caps Gabapentin
Current Illness: Had COVID November
Preexisting Conditions: 299.00 - Autistic disorder, current or active state 307.50 - Eating disorder, unspecified PICA 318.0 - Moderate mental retardation 493.9 - Asthma, unspecified 780.39 - Other convulsions
Allergies: Amoxicillan Lactose
Diagnostic Lab Data: Unknown
CDC Split Type: Unknown

Write-up: lndividual Suddenly passed away on 3/7/21.....His Psychiartrist stated that there could be an adverse effect with COVID, the COVID Vaccination and medications, with an emphasis on Clozapine


VAERS ID: 1112185 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-03-04
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 - / -

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

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

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


VAERS ID: 1112223 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-21
Onset:2021-03-05
   Days after vaccination:43
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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:
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: 1112264 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-21
Onset:2021-01-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / UNK - / SYR

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

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1112370 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-03-02
Onset:2021-03-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Angiogram, Aortic dissection, Blood test, Computerised tomogram abdomen, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   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: Irbesartan 75 mg daily; pravastatin 40 mg daily; famotidine 20 mg twice daily, Saw Palmetto 160 mg daily, Vitamin D3 1000 units daily; clobetasol cream; triamcinolone cream
Current Illness: No acute illnesses
Preexisting Conditions: Hypertension, hypercholesterolemia, thrombocytopenia, obstructive sleep apnea, benign prostatic hypertrophy, multinodular goiter
Allergies: Sulfa antibiotics
Diagnostic Lab Data: Was seen in the emergency room at Hospital. Had CTA chest and CT abdomen and pelvis, as well as blood tests.
CDC Split Type:

Write-up: The patient got the Moderna vaccine on 3/2/2021. On 3/3/2021 he suffered a dissection of the ascending thoracic aorta and died.


VAERS ID: 1112420 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-02-18
Onset:2021-03-04
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

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

Write-up: Patient was contacted about coming in to receive second dose and family member had informed us that she had passed away from COVID two weeks after vaccine was given.


VAERS ID: 1112517 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-05
Onset:2021-03-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Cerebral haemorrhage, Death
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril
Current Illness: mild diabetes
Preexisting Conditions: high blood pressure
Allergies: shellfish allergy
Diagnostic Lab Data: she was admitted to hospital on 3/7/2021 with major brain bleed, and taken off life support on 3/8/2021
CDC Split Type:

Write-up: My mother died of a brain hemorrhage 5 days after receiving the vaccine.


VAERS ID: 1112585 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-28
Onset:2021-02-18
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / -

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: 2021-03-06
   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: zyrtec 10 mg daily generic tylenol 2 bid gas relief 126 mcg prn ducolax as needed pepto as neededvit d3 2000 units 2 qd vit b12 1000 mg 1qd asa 81 mg qd
Current Illness: hbp thyroid copd severe sleep apnea renal failure renal transplant 2016
Preexisting Conditions: see above
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient diagnosed with covid on 2.18.2021 and died of covid 3.6.2021


VAERS ID: 1112743 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-12
Onset:2021-03-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 LA / IM

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

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

Write-up: PATIENT PASSED AWAY ON 3/14/2021 @ 6:10 PM


VAERS ID: 1112773 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Endotracheal intubation
SMQs:, Angioedema (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: nebulizer with medications (unknown specifics), had O2 at home, had epipen Rx already from past
Current Illness: Asthma with home O2 and regular exacerbations and nebulizer use.
Preexisting Conditions: severe chronic asthma with home O2
Allergies: no known specific allergies to us, just history of severe asthma
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Moderna #1 vaccine given at 130pm March 11th 2021. Pt had history of asthma and frequent nebulizer use and had it in car with her for drive-thru vaccine clinic we did at location, which has a large parking lot. We gave 80 doses. Pt checked off anaphylaxis on the intake form so Dr spoke to her and she changed it to no history of anaphylaxis and only has history of asthma. So we gave her the vaccine. About 5 minutes later in car parking lot she started to use her personal nebulizer. I saw her in passenger side of car using a personal nebulizer so I talked to her and her daughter to find out what was going on. They said she has exacerbations all the time and this was not out of ordinary for her. I checked pulse ox and did a lung exam, etc, and she was stable. She seemed baseline according to history by her and her daughter. As she seemed at baseline and clinically was comfortable and conversant whole time, and she felt better after her nebulizer, I told them to have a low threshold for going to ER or calling 911 if her asthma was worse or different than her usual symptoms. They agreed. According to daughter, she did well until about 24 hours the next day. The daughter said she was fine and she went to store and when she returned EMTs were intubating patient and apparently the patient used her epipen and called 911 herself. Approximate time of expiration was 230pm on March12th 2021.


VAERS ID: 1112825 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Arkansas  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain, Arthralgia, Death, Epistaxis, Fatigue, Feeling abnormal, Mouth haemorrhage, Nausea, Pain, Pain in extremity, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Received vaccine on afternoon of 3/15/2021 and began experiencing nausea and vomiting, left arm and shoulder pain, fever, body aches, fatigue, and abdominal pain the morning of 3/16/20. He notified the pharmacy that administered the vaccine to him and they told him that some people have those symptoms with it. On 3/16/21 he went to bed around 11:30 PM feeling terrible and was found dead in his bed the next day (3/17/21) with dried blood coming out of his nose and mouth.


VAERS ID: 1113563 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN, CHECK / 2 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Aphonia, Breath sounds abnormal, Chills, Death, Dry throat, Dyspnoea, Eye movement disorder, Fatigue, Immobile, Nasopharyngitis, Pain in extremity, Pallor, Pneumonia, Respiratory tract congestion, Rhinorrhoea, Tremor
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 9
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: Multiple Systemic Atrophy (MSA-C)
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/25/21 - sore arm, profound fatigue 2/26/21 - chills, fatigue, runny nose (cold-like sx) 2/27/21 - dry throat 3/02/21 - lost voice 3/03/21 - 3/04/21 - chest congestion, difficulty breathing, sounded like water in lungs 3/05/21 - became pale, eyes rolled back, shaking, immobile, caregiver called ambulance, taken to Hospital ER 3/06/21 - death, Hospital dx him with "pneumonia" but I believe that hospital medical staff were unaware of his sx following the COVID vaccine #2 shot.


VAERS ID: 1116094 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-11
Onset:2021-03-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Gun shot wound, Lung neoplasm malignant, Suicide attempt
SMQs:, Suicide/self-injury (narrow), Accidents and injuries (narrow), Hostility/aggression (broad), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 2
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: Attempted Suicide Narrative: 93 year old received his 2nd dose of moderna vaccine on 3/11/21 in his home (nurse went there to give it). He attempted to take his life via gunshot wound to the head on 3/13/21. Sent to an outside hospital and passed away 3/16/21. He recently was diagnosed with cancer. Had an appointment with oncologist on 3/11/21 and found out cancer was limited to lung only and discussed treatment options. No Mental Health issues in the past. Cancer diagnosis and covid vaccine timing may have contributed.


VAERS ID: 1116096 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-01-29
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK RA / IM

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

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

Write-up: Death Narrative:


VAERS ID: 1116097 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-01-21
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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:


VAERS ID: 1116098 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-28
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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:


VAERS ID: 1116099 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-13
Onset:2021-03-16
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Malaise
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: 2021-03-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac Arrest Narrative: Patient received vaccine at 1209 on 3/13/2021, observed for 15min no reaction noted. Later that evening patient was not feeling well presented to ER where he was admitted. Had cardiac arrest during hospitalization on 3/16/2021 where patient passed away. Had a Hx of CHF, A-Fib, had a cardiac stent placement in 2020..


VAERS ID: 1116100 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-03-12
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium, Blood chloride normal, Blood creatinine increased, Blood glucose increased, Blood magnesium normal, Blood phosphorus normal, Blood potassium normal, Blood sodium normal, Blood urea increased, Carbon dioxide normal, Death, Ejection fraction decreased, Fatigue, Glycosylated haemoglobin, Haematocrit decreased, Haemoglobin increased, Hepatitis viral test, Neutrophil count normal, Platelet count normal, Prostatic specific antigen increased, Protein total, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Tumour markers (narrow), Biliary system related investigations, signs and symptoms (broad), Cardiomyopathy (narrow), Prostate tumours of unspecified malignancy (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 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: PATIENT HEIGHT: 67 IN [170.2 cm] (11/20/2020 10:37) PATIENT WEIGHT (last two): 11/20/20 @ 1037 WEIGHT: 229 lb. (104.09 kg.) 8/20/20 @ 1114 WEIGHT: 226 lb. (102.73 kg.) BMI: BMI - 35.9 (NOV 20, 2020@10:37:26) BSA: 2.22 SODIUM SERUM, 09/18/20@1007 137 mEq/L (135 - 145) POTASSIUM SERUM, 09/18/20@1007 4.7 mEq/L (3.8 - 5.1) CHLORIDE SERUM, 09/18/20@1007 101 mEq/L (97 - 109) CO2 SERUM, 09/18/20@1007 28 mEq/L (22 - 32) UREA NITROGEN SERUM, 09/18/20@1007 35 H mg/dl (9 - 26) CREATININE SERUM, 09/18/20@1007 1.6 H mg/dl (0.7 - 1.4) GLUCOSE SERUM, 09/18/20@1007 201 H mg/dl (70 - 115) ALBUMIN SERUM, 09/18/20@1007 3.9 g/dl (3.4 - 4.5) CALCIUM: 9.1 (09/18/20 10:07) MAGNESIUM SERUM, 09/18/20@1007 2.1 mg/dl (1.5 - 2.3) PO4 SERUM, 06/22/20@1018 3.0 mg/dl (2.5 - 4.5) HGB BLOOD, 09/18/20@1007 12.7 L g/dl (13.5 - 17) HCT BLOOD, 09/18/20@1007 38.0 % (38 - 50) PLT BLOOD, 09/18/20@1007 252 K/mm3 (140 - 375) WBC BLOOD, 09/18/20@1007 10.5 K/mm3 (4.4 - 10.7) NE#: 5.93 (07/28/2020 10:05) Collection DT Specimen Test Name Result Units Ref Range 09/18/2020 10:07 BLOOD A-1C 10.5 H % 4.3 - 6.1 06/22/2020 10:19 BLOOD A-1C 10.4 H % 4.3 - 6.1 GLUCOSE (V2), SERUM, 09/18/20@1007 201 H mg/dl (70 - 115) GLUCOSE (V2), SERUM, 07/28/20@1005 185 H mg/dl (70 - 115) Collection DT Spec CHOL TRIGLYC HDL.. LDL.. 06/22/2020 10:18 SERUM 148 361 H 27 48.8 07/19/2019 07:56 SERUM 135 393 H 27 29.4 02/22/2019 08:25 SERUM 113 276 H 29 28.8 06/08/2018 07:27 SERUM 105 121 33 47.8 10/20/2016 08:25 SERUM 152 219 H 40 68.2 HEPATIC FUNCTION PANEL SERUM - Partial Panel found PROTEIN, TOTAL SERUM, 09/18/20@1007 7.2 g/dL (6.3 - 8.0) ALBUMIN SERUM, 09/18/20@1007 3.9 g/dl (3.4 - 4.5) BILIRUBIN,TOTAL SERUM, 09/18/20@1007 0.6 mg/dl (0.1 - 1.0) ALKALINE PHOPHATASE SERUM, 09/18/20@1007 158 H units/L (50 - 136) AST SERUM, 09/18/20@1007 33 H units/L (6 - 32) ALT SERUM, 09/18/20@1007 46 units/L (10 - 55) PSA: 5.8 (06/22/2020 10:18) 130/58 (11/20 2020 10:37, L ARM, SITTING, CUFF-MANUAL, LG ADULT CUFF) EJECTION FRACTION on 4/4/17@10:00:04: 31%-40% Moderately depressed
CDC Split Type:

Write-up: extreme fatigue then patient passed away while asleep Narrative: Unclear if the vaccine is connected to his death. Chart reviewed. He has medical conditions which could have caused his death. Unclear who completed his death certificate. Death was close to a month ago. Whether he had an autopsy or not is unclear. We can report as a suspicious death after vaccination.


VAERS ID: 1116101 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-03-02
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   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:


VAERS ID: 1116102 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-02-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: Death Narrative:


VAERS ID: 1116103 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-02-17
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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:


VAERS ID: 1116104 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-02-19
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Other       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? 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:


VAERS ID: 1116105 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-02-11
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Other       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? 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:


VAERS ID: 1116106 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-02-11
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Other       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? 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:


VAERS ID: 1116107 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-02-06
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

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

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

Write-up: Death Narrative:


VAERS ID: 1116108 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-02-21
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 5 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Death, Fall, Hepatic encephalopathy
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Dementia (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Accidents and injuries (narrow), Hostility/aggression (broad), 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: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient received dose 1 of COVID vaccine on 1/27/21. Was observed x15 minutes, no reactions noted. Later that day patient''s spouse reports patient has been acting out (reports behaviors the night before) and that she cannot care for him any longer. Patient falls sometime in the 48 hours after vaccine and is admitted to the hospital with an unknown diagnosis. Not certain of patient''s history after this hospitalization until 2/9 when patient is admitted again to the hospital with hepatic encephalopathy. Patient is switched to hospice status by 2/12, and passes on 2/21/21.


VAERS ID: 1118953 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-16
Onset:2021-02-24
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away unrelated to covid vaccine Narrative: The patient had end stage COPD and placed in hospice care. Patient received first dose of Moderna vaccine on 1/20 and second dose of Moderna vaccine on 2/16. No adverse reaction was reported. Patient passed away at home on 2/24/2021. Cause of death not documented. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1118956 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-02-04
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chronic obstructive pulmonary disease, Condition aggravated, Death, No adverse event, Road traffic accident, SARS-CoV-2 test positive
SMQs:, Accidents and injuries (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away unrelated to COVID vaccine Narrative: The patient has COPD and congestive heart failure. Patient received first dose of Moderna vaccine on 1/11/2021 and no adverse reaction was reported. Patient''s son reported patient had a minor car accident and was taken to ER where he was tested positive for COVID pneumonia and he passed away in his sleep on the morning of 2/4/2021. Patient''s son stated due to his COPD, he was not able to survive the COVID pneumonia. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1118957 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-23
Onset:2021-02-19
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Write-up: DEATH Narrative: Patient passed away approximately 1 month after receiving first COVID-19 vaccination. No report of a significant reaction to this vaccine, so unlikely a correlation.


VAERS ID: 1118958 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-08
Onset:2021-03-15
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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:


VAERS ID: 1118959 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-09
Onset:2021-03-08
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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:


VAERS ID: 1118960 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-03-11
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

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

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

Write-up: Death Narrative:


VAERS ID: 1118961 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-13
Onset:2021-03-10
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   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:


VAERS ID: 1118962 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-10
Onset:2021-02-25
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: Death Narrative:


VAERS ID: 1118963 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-03-08
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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:


VAERS ID: 1118964 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-03
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   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:


VAERS ID: 1118966 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-01-27
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away unrelated to covid vaccination Narrative: The patient had hx of chronic heart failure on palliative milrinone with hospice. Patient received his first dose of Moderna on 1/11 and patient had a prior positive PCR on 1/12/2021. Patient passed away on 1/27/2021. Family member stated patient didn''t seem to be struggling for breath, any pain or other discomfort. Cause of death is not related to COVID 19 vaccination.


VAERS ID: 1118967 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-09
Onset:2021-03-03
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chronic obstructive pulmonary disease, Cognitive disorder, Condition aggravated, Death
SMQs:, Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad)

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

Write-up: Patient passed away unrelated to covid vaccine Narrative: The patient had worsening COPD and cognitive deficits. Patient''s last hospital visit is 2/2021 for COPD exacerbation. Patient received his first dose of Moderna on 1/13 and second dose of Moderna on 2/9. Patient passed away at home on 3/3. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1113647 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-01
Onset:2021-03-18
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Coreg Lasix
Current Illness: Liver failure
Preexisting Conditions: Liver failure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 3 days after vaccination


VAERS ID: 1114256 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Florida  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Aneurysm, Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), 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? 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
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Aneurysm; red splotches on arm skin; A spontaneous report was received from a Consumer concerning a HCP, male patient of unknown age who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced developed red splotches on his arm skin and patient died from an aneurysm. The patient''s medical history was not provided. No concomitant medications were reported. On an unknown date, prior to the onset of the events, the patient received their unknown of the two planned doses of mRNA-1273 (lot/batch: unknown) via unknown route for prophylaxis of COVID-19 infection. On an unspecified date, after vaccination the patient had a reaction and developed red splotches on his arm skin. Then four to five days, later in the hospital the patient died from an aneurysm (Seriousness criteria: death). The cause of death was aneurysm. No autopsy details reported No Laboratory investigations were provided. No Treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of aneurysm was fatal and for erythema was unknown.; Reporter''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Aneurysm


VAERS ID: 1114257 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-28
Onset:2021-03-06
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Angiogram, Chills, Death, Headache, Myalgia, Nausea, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse reaction (no adverse events reported.)
Allergies:
Diagnostic Lab Data: Test Date: 20210224; Test Name: cardiac angiography; Test Result: Inconclusive ; Result Unstructured Data: unknown
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: fever; chills; headaches; excruciating generalized body aches like he had just be ran over by a truck; nausea; patient has passed away; A spontaneous report from was received from a Consumer concerning a 74 Years-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced nausea, headaches, chills, fever, excruciating generalized body aches like he had just be ran over by a truck, patient has passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 23-02-2021, prior to the onset of the events, the patient received the second of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, The patient experienced nausea, headaches, chills, fever, excruciating generalized body aches like he had just be ran over by a truck. The patient had a cardiac angiography on 24-02-2021. The result was unknown. The patient was found dead on 06-03-2021. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events nausea, headaches, chills, fever, excruciating generalized body aches like he had just be ran over by a truck was recovering. The patient died on 06-03-2021. The information about the autopsy was unknown. The cause of the death was unknown.; Reporter''s Comments: Very limited information regarding this events has been provided at this time. The patient must have been in some form of cardiac issues before death, that''s reason why cardiac angiography was done. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1114448 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-25
Onset:2021-02-18
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiopulmonary failure, Condition aggravated, Dementia Alzheimer's type, Pulmonary oedema, Vital functions abnormal
SMQs:, Cardiac failure (narrow), Dementia (narrow), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), 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: Clonazepam 3 times a day, Plavix 75mg, Depakote 500mg, Dofaxil 10mg, Ferrous Sulftate, Folic Acid, Isosorbide 30mg, Losartan 50mg, Namenda 10mg, Olanzapine 5mg at night and 2.5mg in the morning, Zoloft 50mg, Simvastatin 20mg, Trazodone 50mg
Current Illness: Pulmonary edema
Preexisting Conditions: Hypertensive, Alzheimer''s, cardiovascular conditions (pacemaker)
Allergies: Not reported
Diagnostic Lab Data: Not reported
CDC Split Type: PR-61-21

Write-up: He was sent to the hospital two weeks earlier for Pulmonary Edema, he was discharged and sent to hospice. When the caregiver takes her rounds, she finds the resident without vital signs, prior to that he had not manifested any symptoms. Certification of cardio-respiratory failure secondary to Alzheimer''s disease


VAERS ID: 1114454 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-18
Onset:2021-02-01
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Heart rate decreased, Vomiting
SMQs:, Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Losartan 100mg, Aricept 10, Insulin, Crestor, Isosorbide 30 mg, Protonix 40 mg
Current Illness: Not reported
Preexisting Conditions: Operated on 3 occasions for Cancer, Diabetes, Hypertension, Strokes, Gastro, Bedridden, and Alzheimer''s terminal stage.
Allergies: Not reported
Diagnostic Lab Data: Not reported
CDC Split Type: PR-62-21

Write-up: On 2/1/2021 he vomited and his pulse began to drop. A doctor from the hospice visited him days before and found him in good health and pressure. Patient was in the Home Care hospice.


VAERS ID: 1114496 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal distension, Condition aggravated, Emotional distress, Hepatic cirrhosis, Pain, Vital functions abnormal
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine 25 mg, Laxis 40 mg, Espironolactona 50mg, Omeprazole 20mg, Enalapril 10 mg.
Current Illness: None reported
Preexisting Conditions: Hepatic Cirrhosis, Alzheimer''s Stage 1, Hypertensive, Hypothyroidism
Allergies: Not reported
Diagnostic Lab Data: Not reported
CDC Split Type: PR-63-21

Write-up: Impaired emotional state, the abdomen began to inflate, 8/2/2021 is taken by ambulance to the hospital where corresponding studies were carried out. He was having complications from cirrhosis. Then you are discharged on the same day 8/2/2021. On 2/18/2021 he was complaining of generalized pain, they call hospice to be evaluated, caregivers when they proceed to take vitals he was without vital signs.


VAERS ID: 1114511 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-29
Onset:2021-02-13
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Discomfort, Vital functions abnormal
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: Donepezil 10mg, Rispeldar 1mg, Benadryl, Mirtazapine 30mg, Temazepan 30mg
Current Illness: Not reported
Preexisting Conditions: Alzheimer (Phase 6-7), Hypertension
Allergies: Not reported
Diagnostic Lab Data: Not reported
CDC Split Type:

Write-up: Chills, presenting discomfort . Then they give him a bath. When they went to report to the nurse of each of the residents, they found him without vital signs.


VAERS ID: 1114735 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-27
Onset:2021-02-18
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038KWA / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Gastrointestinal necrosis, Intestinal ischaemia, Shock
SMQs:, Anaphylactic reaction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Ischaemic colitis (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril; Metoprolol; Sulfamethoxazole-Trimethoprim; Fluconazole; Acyclovir; Atorvastatin; Loratadine; CoQ10; Glucosamine Chondroitin; Lutein; Vitamins C, D3, B-complex; Collagen.
Current Illness:
Preexisting Conditions: Myelodysplastic Syndrome
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute mesenteric ischemia; shock secondary to necrotic bowel.


VAERS ID: 1114822 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2020-12-30
Onset:2020-12-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM

Administered by: Work       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Dyspnoea, Headache, Myalgia, Pyrexia, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: COVID test 12/31/2020
CDC Split Type:

Write-up: Diagnosed with COVID (confirmed with a positive COVID test) the say after her vaccine. Eventually died from complications of COVID. Because vaccine was administered prior to her illness, I am putting this in the VAERS system. Symptoms included SOB, coughing, muscle aches. headache, fever.


VAERS ID: 1114885 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-06
Onset:2021-02-11
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Aortic aneurysm; Aortic stenosis; Atrial fibrillation; Cardiac pacemaker insertion; Congestive heart failure; Coronary artery disease; Heart failure; Hypersensitivity pneumonitis; Hypertension; Hypotension; Palpitations; Peripheral vascular shunt; Small bowel obstruction; Ventricular fibrillation
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Asthenia; Nausea; Vomiting; A spontaneous report was received from a Pharmaceutical Company concerning a 90 Years-old male patient who received Moderna'' s COVID-19 vaccine (mRNA-1273) and experienced nausea, vomiting, generalized weakness with a fatal outcome. The patient''s medical history is aortic aneurysm, aortic stenosis, coronary artery disease, hypertension, cardiac heart failure, atrial fibrillation, HLD, ischemic heart failure, pacemaker, ventricular fibrillation, peripheral vascular shunt, palpitations, hypotension, and small bowel obstruction. No concomitant medications were provided. On 06 FEB 2021, prior to the onset of the events, the patient received his first of two planned doses of mRNA-1273 (Lot number: unknown) intramuscularly in an unknown arm for prophylaxis of COVID-19 infection. On 11 FEB 2021, the patient experienced the events, nausea, vomiting, generalized weakness. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 12 FEB 2021. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: Very limited information regarding this events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1114894 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Massachusetts  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Product administered at inappropriate site, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Drug abuse and dependence (broad), Medication errors (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? 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: Thrombocytopenia; Vaccinators are vaccinating very high up on the shoulder; A spontaneous report was received from a nurse concerning a patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced Vaccinators are vaccinating very high up on the shoulder, thrombocytopenia. The patient''s medical history, was not provided by the reporter.No Concomitant medications were reported. On an unknown date, the patient received their planned dose of mRNA-1273 (Lot number: unknown) for prophylaxis of COVID-19 infection. The reporter stated that Vaccinators are vaccinating very high up on the shoulder. They need to go down on the deltoid. She also reported the event of thrombocytopenia of which one involved a doctor who died. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event, vaccinators are vaccinating very high up on the shoulder was resolved . The outcome of the events thrombocytopenia is fatal.; Reporter''s Comments: This report refers to a patient who experienced non-serious of vaccinating very high up on the shoulder, (Vaccine administered at inappropriate site). There were no reported AEs associated with this case of vaccine administered at inappropriate site.; Reported Cause(s) of Death: Thrombocytopenia


VAERS ID: 1115045 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   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: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a 57 years old male patient who received mRNA-1273 for prophylaxis of COVID-19 infection and had died (death). The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. On 2 Mar 2021, approximately three hours prior to the onset of the symptoms, the patient received hia second of two planned doses of mRNA-1273 for prophylaxis of COVID-19 infection. It was reported that the patient died three hours after receiving the 2nd dose in the ER. Treatment information was not provided. The cause of death was unknown. Plans for an autopsy were unknown. Action taken with mRNA-1273 in response to the event was not applicable. The outcome of the event of death was considered as fatal.; Reporter''s Comments: This is a case of sudden concerning a 57 year old male who died three hours after receiving the second dose of the vaccine. Very limited information regarding this event has been provided at this time.; Reported Cause(s) of Death: unknown cause of Death


VAERS ID: 1115126 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-12
Onset:2021-03-09
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Fatigue, Myocardial infarction, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: His breathing problem worsened on 02/23/2021, short of breath and tired. He died of a pulmonary embolism and heart attack in the hospital on 3/9/21 after being there for 9 days.


VAERS ID: 1115216 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-03-11
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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:
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: NA Patient hx COPD,CAD,


VAERS ID: 1115348 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: no adverse event, Continue: [UNK], Comment: No medical history reported
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: death; A spontaneous report was received from a HCP concerning about a 86 years old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patient''s medical history was not reported. Concomitant medications were not reported. On 05 Mar 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Batch number: 026A21A) via intramuscular in left deltoid for prophylaxis of COVID-19 infection. On 06 Mar 2021 the patient died next day after vaccination, who left quite well after vaccination from the facility, the reason for death is not known. Treatment information was not provided. Action taken with mRNA-1273 in response to the event is not applicable. The outcomes of all the event is not applicable.; Reporter''s Comments: This is a case of death in a 86 years old female patient, with unknown past medical hx or current co morbid conditions and concomitant medications, who died one day after receiving first dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1115581 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-10
Onset:2021-02-15
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / UNK LA / IM

Administered by: Other       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: Unattended Death, symptoms and timeframe unknown, death occurred approximately 1 week post vaccination


VAERS ID: 1115715 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-23
Onset:2021-03-01
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Death, Fall, Malaise
SMQs:, Guillain-Barre syndrome (broad), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinol, ASA, atorvastatin, carvedilol, ferrous sulfate, Furosimide, gabapentin, metformin, spironolactone, tamsulosin, tradjenta,
Current Illness: Unknown
Preexisting Conditions: Diabetes, dementia, HTN, MI, CHF, Pacemaker
Allergies: No reported allergies
Diagnostic Lab Data: ED workup
CDC Split Type:

Write-up: Family, daughter, reports that patient felt "a little sick" on 2/24/21 and "sick" on 2/25/21. She reports that approximately 1 week later her father had weakness and and frequent falls, was evaluated in the E.D. and ultimately admitted to hospital (3/4-3/15) Patient was discharged to nursing home where he died on 3/16/21.


VAERS ID: 1115862 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure abnormal, Death, Laboratory test, Lethargy, Somnolence, Wheelchair user
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (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? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alprazolam, Amlodipine, Atenolol, Elliquis, Ferrex, Flecainide, Furosemide, ProAir Resiclick Aer, Simvastatin, eye drops: Vyzulta, Simbrinza Centrum Silver Men, Caltrate, Vitamin C Nebulizers: Yupelri, Perforomist, Budesonide
Current Illness:
Preexisting Conditions: Severe COPD, A-fib
Allergies: none
Diagnostic Lab Data: He was in Clinic, Hospital and had many tests.
CDC Split Type:

Write-up: I could not wake him up fully in the morning after the shot. He was terribly lethargic. Instead of him using the rollater to come from his bedroom I got the wheel chair out of the care and got him to the table where I fed him a little breakfast. His blood pressure was low then high (I don''t now have the readings) By 5 pm I called the ambulance. He was in the hospital until I transferred him to hospice 6 days later. He died in hospice 4 days after that.


VAERS ID: 1115944 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-18
Onset:2021-03-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / N/A RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest pain, Death, Refusal of treatment by patient
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   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: Unknown
Current Illness: Unknown. On date of vaccination he stated he was not feeling ill/sick.
Preexisting Conditions: History of CVA with paralysis of face and arm and ischemic heart disease.
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 1-2 hours after receiving Moderna vaccination patient began complaining of chest pain to family members but refused to seek medical attention. He was found deceased this morning (03/19/21) by his family. Medical Examiner determined time of death was around 8:40pm on 03/18/21.


VAERS ID: 1115994 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-08
Onset:2021-03-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Apnoea, Death, Diarrhoea, Heart rate irregular, Hypophagia, Illness, Lethargy, Malaise, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   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: Tylenol, Ativan, Diabetic Tussin, Dulcolax, Garamycin, Glucerna, Haldol, Imodium, Milk of Magnesia, Nystatin topical, Risperdal, Senna S
Current Illness: The patient was on hospice for Alzheimer?s disease but no acute illnesses.
Preexisting Conditions: Alzheimer?s Disease, Parkinson?s disease, Diabetes
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 03/02/21 the patient was visited by nurse. No signs of distress. Normal vitals. No GI concerns according to staff. Her appetite was her usual described as fair. She received her 2nd Moderna vaccination on 03/08/21. Within hour she because very ill according to facility staff. She began to vomit up to 5 times. Her stools because loose. She became more lethargic. She was started on compazine for the vomiting. Her oral intake was minimal. Her symptoms did not resolve and she was visited by the nurse again on 03/11/2021 where she was not very responsive. Her vitals included an irregular pulse and apnea noted in her breathing up to 15 seconds. She died on 03/12/21


VAERS ID: 1116006 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-25
Onset:2021-03-09
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

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

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

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


VAERS ID: 1116073 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-19
Onset:2021-02-28
   Days after vaccination:40
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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: 1116236 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-10
Onset:2021-03-11
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M02A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1116259 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: California  
Vaccinated:2021-01-21
Onset:2021-01-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Dysstasia, Gait inability, Malaise
SMQs:, Anticholinergic syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Lung disease (on oxygen support prior to vaccination)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; not able to stand up or walk; extreme weakness; he did not feel well; not able to stand up or walk; A spontaneous report was received from the patient''s wife concerning a male (age not provided) who experienced extreme weakness/asthenia, did not feel well/malaise, unable to walk/gait inability, and unable to stand/dysstasia. The patient''s medical history included lung disease which required oxygen support. Per patient''s wife, no concomitant products were in use within two weeks of the event. The patient''s wife also stated he does not take any daily medications. On 21 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 ( Batch number 029L20A) by injection into his left arm for prophylaxis of Covid-19 infection. After receiving the vaccine, the patient''s wife stated he did not feel well. He experienced extreme weakness. He was not able to stand up or walk for the first few days after getting the shot. "He could not walk even 3 steps and get in the car". On 09 Feb 2021, the patient felt a little bit better and could walk from one bedroom to another. No Medications were used to treat the patient''s symptoms. No relevant medical tests were provided. The patient had an appointment with his healthcare provider (date and time not provided) and was told he could not get the second dose of vaccine unless he got better. The patient''s wife stated she is not blaming the vaccine because her husband had a lung disease prior to getting the vaccine. His doctor said, (per his wife) this lung disease had weakened him to the point he could not drive his car anymore. His brain was fine before the vaccine. On 03 Mar 2021, the patient''s wife called to say that the patient had finally passed away on 13 Feb 2021. The second dose of mRNA-1273 was withheld in response to the events while waiting for the patient''s condition to improve however; it was never given due to the patient''s death. The events of did not feel well, extreme weakness, unable to walk, and unable to stand were not resolved (presumably) prior to the patient''s death. The patient died on 13 Feb 2021. The cause of death was not provided. Plans for an autopsy were not provided. Company Comment: The reported events, death, malaise, asthenia, gait inability, and dysstasia were considered possibly related to mRNA-1273.; Reporter''s Comments: This is a case of death in a male subject with a hx of lung disease requiring oxygen, who died 23 days after receiving first dose of vaccine. Very limited information is available and based on the reporter''s causality assessment the event is considered unlikely related to the vaccine"; Reported Cause(s) of Death: cause of death unknown


VAERS ID: 1116373 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death
SMQs:, Guillain-Barre syndrome (broad)

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

Write-up: Passed away; so weak she was no longer able to use her walker and declined steadily each daythereafter; A spontaneous report was received from a consumer concerning a 88-year-old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced being so weak she was no longer able to use her walker and declined steadily each day thereafter (asthenia) and passed away (death). The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. The patient received their first of two planned doses of mRNA-1273 (Batch number not provided) on an unspecified date. On an unspecified date, approximately 15 days prior to the onset of the symptoms, the patient received their second of two planned doses of mRNA-1273 (Batch number not provided) intramuscularly for prophylaxis of COVID-19 infection. On an unspecified date, two days after their second dose of the vaccine, the patient was so weak that she was no longer able to use her walker and declined steadily each day thereafter. On an unspecified date, 17 days after their second dose of the vaccine, the patient passed away. Treatment information was not provided. The outcome of the event, asthenia, was unknown. The outcome of the event, passed away (death), was fatal. The cause of death was reported as unknown. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1116386 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-12
Onset:2021-03-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Fatigue, Nausea, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: synthroid, rosuvastatin, levemir, xarelto, metformin, omeprazole, proair
Current Illness:
Preexisting Conditions: diabetes, CAD, a-fib
Allergies: cat dander, diazepam
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient developed nausea and vomiting 3/14/21. was seen at clinic by this provider 3/16/21 and reported at that time continued fatigue but overall symptom improvement. Vital signs were stable. pt was advised to orally hydrate and routinely monitor blood sugars and f/u as needed. On 3/18/21 patient was found down in his motel room by shelter staff unresponsive. 911 was called. pt transported to hospital by EMS receiving BLS. Clinic staff was advised by family that patient was pronounced dead that date.


VAERS ID: 1116400 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-25
Onset:2021-03-17
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1116407 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient got sick over the weekend. Went to facility on 03/02/2021 and then passed on 03/18/2021


VAERS ID: 1116408 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-02-02
Onset:2021-02-10
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Heart rate increased, Hepatic failure, Hypotension, Internal haemorrhage, Oxygen saturation decreased, Pericardial effusion, Pulmonary oedema
SMQs:, Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Respiratory failure (broad), 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: 2021-03-07
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 25 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Warfarin
Current Illness:
Preexisting Conditions: A-VIB
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: severe internal bleeding fluid build up around lungs/heart high heart rate low blood pressure low oxygen liver failure death


VAERS ID: 1116436 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-27
Onset:2021-03-16
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   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 the COVID vaccine series


VAERS ID: 1116594 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / UNK - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Death, Hypoxia, Respiratory arrest, Respiratory distress, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

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

Write-up: Patient called EMS from for respiratory distress. EMS arrived, noted severe distress and hypoxia. Patient transported to Hospital Emergency Dept. Patient deteriorated to respiratory arrest and cardiac arrest. Per ED note, after 30 minutes of aggressive resuscitation (including approximately 19 minutes in the ED), no ROSC was achieved. Patient expired


VAERS ID: 1117316 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-18
Onset:2021-03-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   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: Unknown - Patient has never filled prescriptions
Current Illness: Unknown
Preexisting Conditions: Unknown - Patient did not see a health provider in the past year
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Sister in law called on 3-19-2021 to report that had died a day after receiving his Moderna vaccine. She stated he was found in his driveway and was unable to be resuscitated after being rushed to the hospital.


VAERS ID: 1122172 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-03-05
Onset:2021-03-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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:
Current Illness:
Preexisting Conditions: Hypertension and diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna COVID-19 (mRNA-1273) vaccine treatment under Emergency Use Authorization(EUA): The decedent received the shot at 4:30pm and was found deceased at 10pm the same day.


VAERS ID: 1122392 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-02-10
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli, Ventricular arrhythmia
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Ventricular tachyarrhythmias (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away related to covid vaccination Narrative: The patient had CHF, cardiomyopathy, A-fib and COPD. Patient received his first dose of Moderna on 1/20. No adverse reaction was reported. Patient was found unresponsive and confirmed dead by Sheriff on 2/10. Cardiologist was notified of his death and suspect patient''s death is related to ventricular arrhythmia. He also has a history of noncompliance. Cause of death is not related to COVID 19 vaccination.


VAERS ID: 1122393 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-18
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cheyne-Stokes respiration, Death, Diet refusal, General physical health deterioration
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   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: Around the end of January 2021, patient was admitted to a home hospice program due to worsening of patient''s Parkinson''s Disease and Dementia. It was noted on the hospice programs Plan of Care that patient had severe, progressive dysphagia due to disease. Patient lost 20 pounds over the last 2 months prior to admission to hospice program. Patient had severe tremors, dystonia, and was dyspneic with minimal exertion. Patient received Moderna''s Covid vaccine on 3/3/21. On 3/13/21, patient got progressively worse. He stopped eating and drinking and started to exhibit Cheyne-Stokes breathing. Hospice nurse noted that patient only had a few days remaining. On 3/18/21, patient passed away.


VAERS ID: 1119393 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-06
Onset:2021-03-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 1 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Death. Unknow cause as of reporting date. -Severe, Additional Details: PT caregiver called to report that the Pt passed away on 3/8/21 2 days post vaccince, Caregiver was distrot and not very able to provided more details due to reccent nature of report.


VAERS ID: 1120493 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-06
Onset:2021-03-10
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029A21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death, Pulse absent, 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: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril (40mg daily), Glyburide (500mg daily); (Valsartan 320mg daily)
Current Illness:
Preexisting Conditions: Type-2 Diabetes; Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac arrest five days after administration of the 2nd dose at 9pm, ambulance was called and EMTs attempted resuscitation, but no pulse was detected after 1 hour of compressions and CPR; time of death was recorded at 10:06pm


VAERS ID: 1120756 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-18
Onset:2021-03-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046AZ1A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Dyspnoea, Epistaxis, Mouth haemorrhage, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: High Cholesterol
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type: CA134B1001

Write-up: On Friday night, 3/19/21, patient spiked a fever, had shortness of breath, and had blood coming out of his nose and mouth per patient''s daughter-in law. 9-1-1 was called, paramedics arrived at the home at 5AM on Saturday, 3/20/21 per patient''s daughter. Patient died.


VAERS ID: 1120816 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Bee allergy
Diagnostic Lab Data: No autopsy performed. Medical examiner declined to recommend one.
CDC Split Type:

Write-up: Death. No autopsy performed.


VAERS ID: 1120842 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Abnormal behaviour, Brain operation, Death, Endotracheal intubation, Lung disorder, Mechanical ventilation, Renal disorder, Seizure, Thrombosis
SMQs:, Angioedema (broad), Systemic lupus erythematosus (broad), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 42
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: unknown
Current Illness: none known of
Preexisting Conditions: type 2 diabetes, other unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: this is all per family, 4 to 5 days after 2nd COVID vaccine he was acting unusual and was taken to the hospital. He had a clot in his brain and underwent brain surgery. He experienced seizures after the surgery, but it was ultimately reported the surgery went well. He remained intubated and on a ventilator after surgery. He developed complications of his lungs and kidneys while on the ventilator. Ventilator was removed 3/16/2021 and he passed away that day. The hospital providers thought the clot in the brain may have been from hitting his head over a month ago. From my understanding he was A&O, independent with ADLs, and lived in his private residence prior to these complications.


VAERS ID: 1121585 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

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

Write-up: died; A spontaneous report from was received from a Consumer concerning a female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and mentioned that a patient who had received the Moderna vaccine had died, and so they were concerned about getting the second dose. The patient''s medical history was not provided. No relevant concomitant medications were reported. On unknown date, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, The patient mentioned that a patient who had received the Moderna vaccine had died, and so they were concerned about getting the second dose. Laboratory details are not provided. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not reported. The outcome of the events was considered Fatal.; Reporter''s Comments: This is a case of death of an unknown age female subject with unknown medical history, who died on an unknown day after receiving first dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1121847 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Female  
Location: New York  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Hepatic failure, Palpitations, Renal failure, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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

Write-up: Kidneys and liver shutting down; Kidneys and liver shutting down; Heart started racing 3 days later; Vomiting; A spontaneous report was received from a consumer concerning a 39-year-old, female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced heart racing, kidney failure, liver failure,vomiting and death. The patient''s medical history included Sjogren''s syndrome, Hashimoto''s, inflammatory joint disease, osteoporosis, osteoarthritis. She has history of fractured tail bone and leg in three places. Concomitant medications included D3 2 pills a day, folic acid, B12, and calcium citrate. She was allergic to 15 different antibiotics two of which she had anaphylaxis; had huge autoimmune issues; had had reaction to Pneumovax vaccine. On an unown date ,prior to the onset of the events, the patient received their second of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. Approximately after three days of receiving second dose vaccine patient experienced heart racing and went to the emergency room .The patient started vomiting and developed a kidney and liver failure. And on the next day she died.Autopsy is doing and the results are not available at the time of report. Action taken with mRNA-1273 in response to the events was reported as not applicable. The events heart racing, kidney failure, liver failure and death were considered serious and medically significant. The outcome of the events renal failure,hepatic failure,palpitations and vomiting was considered as Fatal.; Reporter''s Comments: This is a case of death in a 39year-old female subject with unknown medical history of anaphylactic reactions, allergic reactions to pneumovax vaccine, Sjogren''s syndrome, Hashimoto''s, inflammatory joint disease, osteoporosis, osteoarthritis, who died 4 days after receiving second dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Renal failure; Hepatic failure


VAERS ID: 1122080 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-12
Onset:2021-03-19
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Agonal respiration, Angiogram pulmonary abnormal, Areflexia, Blood lactic acid increased, Cardiac arrest, Complication associated with device, Corneal reflex decreased, Cyanosis, Death, Device malfunction, Disseminated intravascular coagulation, Dyspnoea, Fatigue, Intensive care, Loss of consciousness, Lung assist device therapy, Malaise, Metabolic acidosis, Mobility decreased, Presyncope, Pulmonary embolism, Pulseless electrical activity, Pupillary reflex impaired, Pyrexia, Respiratory acidosis, Resuscitation, Therapy cessation, Thrombectomy, Unresponsive to stimuli, Vena cava thrombosis
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Lactic acidosis (narrow), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (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), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Parkinson-like events (broad), Thrombophlebitis (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), Corneal disorders (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Medication errors (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 2
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: Xulane birth control patch Prescribed prednisone the day prior to presentation
Current Illness: None
Preexisting Conditions: None
Allergies: Augmentin-itching
Diagnostic Lab Data: As above.
CDC Split Type:

Write-up: Patient''s received 2nd dose of Moderna vaccine Friday 3/12. Her husband reported she had not unexpected fatigue, malaise, and fever for 1 day but better after that. On Monday she began complaining of shortness of breath. This progressively worsened and she started having presyncopal episodes. On Saturday she was unable to come down the stairs in the house so husband planned to take her to the hospital but she stood up and passed out and woke up quickly. He decided to call EMS. By the time she presented to our hospital she was cyanotic and agonal breathing. On moving her from EMS stretcher to ED bed she had PEA cardiac arrest. She underwent mechanical device CPR with only brief (<1 min) ROSC x1. She at some point did have a shockable rhythm. Cath lab was notified and she was taken emergently to the cath lab with ongoing mechanical device CPR. Peripheral VA ECMO was placed after about 1.5 hours. Pulmonary angiogram was done which showed massive saddle PE with near complete obliteration of the right pulmonary tree and some filling defects in the left tree as well. At that time she had severe mixed respiratory and metabolic acidosis with a lactate of 24. She also had no gag or corneal reflex, minimally responsive pupils, and no response to noxious stimuli. Mechanical thrombectomy was attempted with some result. She was transferred to the SICU with increasing pressor requirement, and DIC. Ultimately, the venous catheter of the ECMO circuit malfunctioned thought to be secondary propagating IVC thrombosis. Family decided to withdraw care and she passed away.


VAERS ID: 1122640 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   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: suboxone amlodipine carvedilol clopidegrel glipizide lantus atrovastatin melatonin
Current Illness: DM-II w/ peripheral neuropathy
Preexisting Conditions: DM_ Ii w/ peripheral neuropathy opioid use disorder in sustain remission HTN HLD CAD history of CABG
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 3/11/21


VAERS ID: 1122714 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Florida  
Vaccinated:0000-00-00
Onset:2021-03-13
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: illness and very very sick; Death; A spontaneous report was received from a lawyer concerning a 70 or 71-years-old, female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and who died following illness. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. The patient received their first of two planned doses of mRNA-1273 (Batch number not provided) on an unspecified date. On an unknown date, approximately 24 hours prior to the onset of the symptoms, the patient received their second of two planned doses of mRNA-1273 (Batch number not provided) via an unknown route for prophylaxis of COVID-19 infection. Within 24 hours, of vaccination the patient got very ill and sick and on the 4th day patient went to have a shower and found dead by patient''s husband. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event, illness and very sick was unknown. The patient died on 13 Mar 2021. The cause of death was unknown. Plans for an autopsy were denied due to COVID-19 relation and are reporting to Moderna. Autopsy was not performed.; Reporter''s Comments: This is a case of death in an 70/71-year-old male subject with unknown medical history, who was sick from day 1 and died on day 4 after receiving first dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1123167 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-11
Onset:2021-03-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 4
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: Furosemide, Levothyroxine, Mirtazipine, omeprozole, pravastatin, thiamine,centrum,caltrate,Vitron-c
Current Illness: none
Preexisting Conditions: Chronic Back Pain with recent hospitalization, osteoporosis, anxiety disorder, Chronic heart failure, chronic atrial fib, hypothyroidism, ckd gerd
Allergies: none
Diagnostic Lab Data: ct,mri
CDC Split Type:

Write-up: Stroke


VAERS ID: 1123229 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-05
Onset:2021-03-08
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Confusional state, Death, Influenza, Influenza B virus test positive, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   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: NONE REPORTED
Preexisting Conditions: TYPE II DIABETES; HYPERTENSION; DEMENTIA; HEPERLIPIDEMIA; HX OF PROSTATE CANCER
Allergies: NKA
Diagnostic Lab Data: On admission to the hospital the patient was antigen positive for COVID and Influenza B positive. Death was related to COVID Pneumonia per reports.
CDC Split Type:

Write-up: Patient received Moderna Dose #1-01/08/2021 and Dose #2-02/05/2021. He was admitted to Medical Center on 03/08/2021 with confusion and decreased O2 sats; date of death was 03/12/2021.


VAERS ID: 1123247 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-22
Onset:2021-03-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   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 - did list Eliquis as being taken.
Current Illness: none noted
Preexisting Conditions: unknown
Allergies: indicated none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Our agency was alerted that the patient passed away on 3/16/2021


VAERS ID: 1123405 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-02
Onset:2021-03-19
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   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: Flovent, Magnesium, Senna
Current Illness: ESRD, aortic stenosis, DM
Preexisting Conditions: ESRD, aortic stenosis, DM
Allergies: codeine, hydrocodone
Diagnostic Lab Data:
CDC Split Type:

Write-up: None stated.


VAERS ID: 1123737 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-25
Onset:2021-03-20
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   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 ON 3.20.2021


VAERS ID: 1123768 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-25
Onset:2021-03-19
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT DIED AT HOME ON 03/19/2021


VAERS ID: 1123847 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-15
Onset:2021-03-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   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: DM, HTN, CHF, ESRD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had no reactions to first vaccine post dialysis. The morning after the patient received the vaccine, patient expired at home. Police stated that the death was vaccine related.


VAERS ID: 1123977 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-13
Onset:2021-03-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Doxycycline 100mg once a day, Hydrocodone 7.5 mg 3 times a day, lisiprol daily, nature?s health vitamin daily
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Not even 20 hrs after she received the vaccine she couldn?t breathe, she?s been fine nothing wrong at all. 7am she was awake sitting up in bed doing crosswords told her great granddaughter to have a good day at work and would see her shortly . 739 I walked out the room to take my kid to work was gone till 751 not even 12 minutes and I came in and my gram couldn?t breathe was yelling for me saying she couldn?t breathe. It sounded like my gram had come over with upper respiratory problems in a matter of 10 minutes she was gasping for air called 911 spoke to operator my gram was talking saying she couldn?t breathe she was trying to breathe, my grams last words were if they don?t hury I?m going to die I?m 100% sure my gram was dead in my arms before EMS arrived. Yes she was 95 but she is a healthy lady have had no issues of health problems lately. We?ve done everything to keep her save from the virus and then she gets her 2nd moderna shot and she?s dead 20 hrs later there?s a huge problem old age or not


VAERS ID: 1124307 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-03-10
Onset:2021-03-18
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   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: Unknown. Patient was taking medications for the treatment of the following conditions: hypertension, asthma, congestive heart failure, chronic psoriasis, and possibly a few others. He was definitely taking a blood thinner or was, at least,
Current Illness: Patient was undergoing treatment for a variety of chronic medical conditions, but he was not acutely ill or reported being acutely ill at time of vaccination.
Preexisting Conditions: Patient was undergoing treatment for a variety of chronic medical conditions with documentation with this public health center dating back to 2017. Patient was reported to have the following conditions: hypertension, asthma, congestive heart failure, and chronic psoriasis. He also had a history of alcoholism and obesity, although he had lost a significant amount of weight in the last several years and was considered in recovery from alcoholism.
Allergies: NKA
Diagnostic Lab Data: Unknown. The patient''s body was removed from his home by members of the community as there is no medical care or emergency services provided in this region. He was then transported. It is unclear it the patient was transported straight to the morgue or if he was transported to the facility prior to the morgue.
CDC Split Type:

Write-up: The patient was found dead in his home on 3/18/2021, 8 days after vaccination. Due to the remoteness of where the individual lives and his lack of housemate, it is unknown how long he had been dead, but it is not believe that he was dead for more than 1-2 days. He had no adverse reactions in the 15-30 minutes that he was observed post-injection. He also reported only a sore arm to the public health nurse in an email a few days after his vaccination.


VAERS ID: 1124363 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-03-06
Onset:2021-03-20
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA W1010A21A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   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: Lipitor 10 mg tablet 1 tab(s) orally once a day at bedtime Benicar HCT 25 mg-40 mg tablet 1 tab(s) orally once a day metformin 1000 mg tablet 1 tab(s) orally BID Tenormin 50 mg tablet 1 tab(s) orally once a day ASA 81mg enteric
Current Illness: none
Preexisting Conditions: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, obesity, alcohol abuse
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient died at home. apparently he awoke in the middle of the night and asked for help, then collapsed. CPR failed. patient and family did not want an autopsy. suspect sudden cardiac death


VAERS ID: 1124383 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-01-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / 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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No recent labs 10/20/2020 COVID-19 TEST WAS NEGATIVE 3/19/20 hemoglobin A1C 5.8;CBC and urine WNL, except MCV 96 and urine WBC 6
CDC Split Type:

Write-up: DEATH Narrative: Events surrounding patient''s death are unknown- nothing is documented in medical record regarding event. Causality of death is unknown. This event is being reported due to the timing of the death in relation to the receipt of vaccine (4 days).


VAERS ID: 1124577 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-02
Onset:2021-03-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Computerised tomogram abnormal, Death, Dysphagia, General physical health deterioration, Pain, Troponin increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Myocardial infarction (narrow), 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: 2021-03-18
   Days after onset: 14
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: Nadolol, esomeprazole,
Current Illness: Liver cancer
Preexisting Conditions: Liver cancer
Allergies: None
Diagnostic Lab Data: Troponin 7807 Alt 694 AST 248
CDC Split Type:

Write-up: My father received the first Covid shot 3/2; he woke up 3/3 with severe body aches and weakness, which we thought nothing of. However, every day, he got weaker and weaker. He has been treated for Liver cancer, he received his first infusion of Opdivo almost 4 weeks before the vaccination. About 7 days after the shot, he was having trouble swallowing so he went to the ER to get a CT scan. He was found to have greatly elevated troponins, the DR was baffled he wasn?t having any chest pain; they were apparently not trending either., he has never had a heart attack or any other heart problems, takes Nadolol for high blood pressure. The CT scan showed significant growth of his tumors which had been stable for a year and the last CT scan was the end of January; liver enzymes were also significantly elevated whereas they were stable before. My father deteriorated rapidly, and died on 3/18/21. The day he got the shot just prior, he was hauling wood, shoveling snow and living a normal life feeling good. The day after the shot he could barely get out of bed he was so weak, until he finally died 16 days later.


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