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From the 9/17/2021 release of VAERS data:

Found 15,386 cases where Vaccine is COVID19 and Patient Died



Case Details

This is page 12 out of 154

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VAERS ID: 1050201 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-02
Onset:2021-02-09
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M2QA / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: multiple
Current Illness: Metastatic Lung Cancer
Preexisting Conditions: see above
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Died 7 days after receiving 2nd dose of Moderna vaccine. Had underlying hx Lung CA w/mets.


VAERS ID: 1050281 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-09
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cardiac arrest, Death, Malaise, X-ray abnormal
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), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 MG Tablet Delayed Release, 1 Tablet Orally once a day Norvasc 10 MGTtablet, 1 Tablet orally once a day Lisinopril 20 MG Tablet, 1 Tablet orally once a day Terazosin HCl 10 MG tablet, 1 tablet orally once a day Metformin HCl 1000
Current Illness:
Preexisting Conditions: Z86.39 History of vitamin D deficiency Z99.89 Uses continuous positive airway pressure (CAPAP) ventilation at home E11.40 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin I10 HTN (hypertension) N40.0 BPH (benign prostatic hyperplasia E11.29 Microalbuminuria due to type 2 diabetes mellitus Z87.09 Hx of emphysema G47.33 Severe obstructive sleep apnea G47.30 Sleep apnea H25.13 Age-related nuclear cataract, bilateral Z68.36 BMI 36.0-36.9, adult I83.813 Varicose veins of both lower extremities with pain E00.36 Type 2 diabetes mellitus with diabetic cataract, without long-term current use of insulin
Allergies:
Diagnostic Lab Data: X-rays were taken at Medical Center, Patient was diagnosed with Cardio arrest secondary to COVID-19 pneumonia.
CDC Split Type:

Write-up: Per family, patient has been feeling sick since he was vaccinated, patient went to ER on 02/15/2021, and after few hours at ER patient passed away.


VAERS ID: 1050431 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-02-02
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Bradykinesia, Fall, Pulse absent, Resuscitation, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: To the best of my knowledge these are the drugs he took that morning. Furosemide 20 mg; Isosorbide Mononitrate-ER 60 mg; Calcitrol .25 mcg; Levothyroxine - .15 mg; Folic Acid 800 mcg; MultiVits; Metamucil 525 mg capsule; Metroprolol ER -
Current Illness: None
Preexisting Conditions: Heart disease, diabetes in the past but not for the past 4 years; had 3 toe amputations; poor circulation in his legs.
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Since I was not with my husband I can only tell you what was told to me. He walked out of the store toward our car. Someone watched him, concerned, because he was walking very slowly (normally has a slow gait because of leg braces and toe amputations so I don''t know if it was unusually slow). The woman saw him fall and she ran to help-administered CPR immediately-and told me he died instantly. Medics tried to resuscitate and failed to bring a pulse. (My husband left our home around 11:15 to drop a package off at store. The store is one mile from our home. At around 12:30 a deputy came to my door and when I saw him my knees buckled. I knew something horrible happened.


VAERS ID: 1050441 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-20
Onset:2021-02-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: reported "Zelcor", may have meant Zocor
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccination and observation period successfully completed without adverse event. The patient''s significant other reported neither of them were feeling well on 2/21/2021. Approximately 28 hours after vaccination, the patient was found unresponsive in the bathtub. EMS arrived within 5 minutes, resuscitation attempt was unsuccessful, CPR terminated at 1503 and the patient pronounced dead. The Medical examiner refused the case on the basis of lack of jurisdiction, and the remains were moved to a local funeral home. No autopsy was performed. This event is not thought to be related to the vaccination event or the vaccine, the death is thought to be from natural causes.


VAERS ID: 1051263 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 5
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: PHENOBARBITAL; LAMICTAL; KEPPRA
Current Illness: Seizures
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Found unconscious; Coma; Lack of oxygen to the brain; A spontaneous report was received from a consumer, concerning his mother, a 71-year-old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away, prior to death, patient experienced lack of oxygen to the brain and was found unconscious and went to coma. The patient''s medical history reported included seizures. Concomitant medications included phenobarbital, lamotrigine and levetiracetam. On 27 Jan 2021, approximately six days prior to the onset of events, the patient received their first of two planned doses of mRNA-1273 (lot number: 030L20A) intramuscularly for prophylaxis of COVID-19 infection. On 01 Feb 2021 at 4 am, the patient was found to be unconscious on the couch, hence she was rushed to the hospital with lack of oxygen to the brain. Later, she went into a coma, hence she was in hospital for 30 hours and then was transferred to a different hospital for a second opinion on 06-Feb-2021, where she was passed away at 02:20 PM. Treatment information was not provided Action taken with mRNA-1273 in response to the events were not applicable. The outcome of events, lack of oxygen to the brain, found unconscious and coma were considered unknown. The outcome of event passed away was fatal as she died on 06 Feb 2021 at 2:20 pm. The cause of death was not provided. Plans for an autopsy were unknown.; Reporter''s Comments: This is a case of 71-year-old female subject with a history of seizures who died 6 days 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: Passed away


VAERS ID: 1051267 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031I20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Injection site pain
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cardiovascular disease, unspecified; Depression; Diabetes mellitus; Hypercholesterolemia; Hypertension; Stroke (Previous stroke.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Slight soreness in arm; A regulatory report was received from a pharmacist concerning a 72-year-old male patient who received Moderna covid-19 vaccine and death occurred 4 days after the vaccine and also experienced soreness in his arm after the vaccine administration. The patient''s medical history includes diabetes mellitus, Hypertension, Hypercholesterolemia, CVD, previous stroke and Depression. No relevant concomitant medications were reported. No information on allergies. On 4-FEB-2021 at 10:43 am, prior to the onset of events, the patient received his first of two planned doses of covid-19 vaccine for the prophylaxis of covid-19 infection. He had soreness in his arm the day following the shot, but he had no other symptoms. He passed away on 08-FEB-2021 at 10 am. As per his wife, they never made it to the hospital, and he had poor health prior to vaccination. Action taken with 2nd dose of Moderna Covid-19 vaccine was not applicable. The outcome of the event death is fatal.; Reporter''s Comments: This is a 72 year old male with hx of diabetes mellitus, hypertension, hypercholesterolemia, and CVD who died 4 days after the vaccine was administered. No autopsy report provided. No further information is expected in this regulatory report case.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1051445 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-01-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood culture, Brain stem haemorrhage, Brain stem syndrome, Chest X-ray, Chest X-ray abnormal, Condition aggravated, Culture, Death, Diarrhoea, Dyspnoea, Nausea, Product use issue, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Medication errors (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 18
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: ACYCLOVIR [ACICLOVIR]; ALBUTEROL HFA; LIPITOR [ATORVASTATIN]; ZITHROMAX; WELLBUTRIN XL; CALCIUM + VITAMIN D [CALCIUM CITRATE;COLECALCIFEROL]; ZORTRESS; ADVAIR; NEURONTIN; CLARITIN [LORATADINE]; LOPRESSOR; ROGAN [MINOXIDIL]; ZOFRAN [ONDANSET
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Alopecia; Antibody-mediated rejection; Bronchiolitis obliterans syndrome (grade 0P); Chronic insomnia; Hepatocellular carcinoma; Hoarseness of voice; Immunosuppression; Iron deficiency anemia; Laryngomalacia; Lung transplant; Lymphangioleiomyomatosis; Major depressive disorder; Memory impairment; Myopia; Nuclear cataract; Obstructive sleep apnea syndrome; Osteoporosis; Pure hypercholesterolemia; Restless legs syndrome; Sciatica
Allergies:
Diagnostic Lab Data: Test Date: 202102; Test Name: blood cultures; Result Unstructured Data: Test Result:negative; Test Date: 202102; Test Name: chest x-ray; Result Unstructured Data: Test Result:shows numerous bilateral patchy opacities; Comments: Patient chest x-ray shows numerous bilateral patchy opacities which is significantly different from her previous chest x-ray here.; Test Date: 202102; Test Name: respiratory cultures; Result Unstructured Data: Test Result:negative; Test Date: 202102; Test Name: SARS-COV-2 test; Test Result: Negative
CDC Split Type: USPFIZER INC2021173324

Write-up: chest x-ray shows numerous bilateral patchy opacities; catastrophic brain bleed; Brainstem reflexes were lost; Patient died; shortness of breath; nausea; diarrhea; worsening shortness of breath/numerous bilateral patchy opacities; immunosuppressed status; This is a spontaneous report from a contactable pharmacist and a contactable other health professional. A 61-year-old female patient (not pregnant) received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL9261), intramuscular at arm right on 28Jan2021 (at the age of 61 years) at single dose for COVID-19 immunization. The patient medical history included bilateral lung transplant on 23Jun2017, lymphangioleiomyomatosis, hepatocellular carcinoma, antibody mediated rejection of lung transplant , bronchiolitis obliterans syndrome, grade 0P, major depressive disorder, RLS (restless legs syndrome), chronic insomnia, long term current use of systemic steroids OSA (obstructive sleep apnea), iron deficiency anemia, bilateral sciatica, hoarseness of voice, memory change, laryngeal stridor, pure hypercholesterolemia senile nuclear cataract, bilateral myopia of both eyes, osteoporosis without current pathological fracture, alopecia, immunosuppressed status, all from an unknown date and unknown if ongoing. Concomitant medication included acyclovir (formulation: capsule, strength: 200 mg) oral at 200 mg twice daily, salbutamol (ALBUTEROL HFA) as needed (MCG/ACT inhaler take 2 puffs by inhalation every 4 hours as needed) for wheezing (shortness of breath), atorvastatin (LIPITOR, formulation: tablet) oral at 80 mg once a day, azithromycin (ZITHROMAX, formulation: tablet)oral at 250 mg (every Monday, Wednesday, Friday), bupropion hydrochloride (WELLBUTRIN XL, formulation: tablet, strength: 150 mg) oral at 150 mg once a day, calcium citrate/cholecalciferol (CALCIUM + VITAMIN D, formulation: tablet) oral at 2 dose form once a day (every morning), everolimus (ZORTRESS, formulation: tablet, strength: 1 mg) oral at 2 mg twice a day, fluticasone propionate/salmeterol xinafoate (ADVAIR, strength: 500 ug/ 20 ug) twice daily (1 puff by inhalation), gabapentin (NEURONTIN, formulation: capsule, strength:100 mg) oral at 300 mg daily (by mouth nightly), loratadine (CLARITIN, formulation: tablet, strength: 10 mg) oral at 10 mg as needed, metoprolol tartrate (LOPRESSOR, formulation: tablet, strength: 25 mg)oral at 50 mg twice daily, minoxidil (ROGAN, strength: 5%) topical apply 1 cap full every other day to affected area on scalp for alopecia, ondansetron (ZOFRAN, formulation: tablet, strength: 4 mg) oral at 4 mg as needed for nausea, pantoprazole sodium sesquihydrate (PROTONIX, formulation: tablet, strength: 40 mg) oral at 40 mg once a day, prednisone (DELTASONE, formulation: tablet, strength: 5 mg) oral at 5 mg daily (every morning), sertraline hydrochloride (ZOLOFT, formulation: tablet, strength: 100 mg) oral at 100 mg twice a day (every morning), sulfamethoxazole/trimethoprim (BACTRIM) 400-80 mg per tablet (1 tablet by mouth every Monday, Wednesday, Friday), tacrolimus (formulation: capsule) at 3 mg daily (2 mg every morning and 1 mg at night), salbutamol sulfate (PROVENTIL HFA) as needed for wheezing (shortness of breath), salbutamol sulfate (VENTOLIN HFA) as needed for wheezing (shortness of breath) , salbutamol sulfate (PROAIR HFA) as needed for wheezing (shortness of breath), ascorbic acid/ferrous fumarate/folic acid/ retinol (PRENATAL, formulation: tablet) oral daily. The patient previously took NSAIDs and voriconazole and experienced drug allergies. It was reported that the patient presented to emergency department (ED) on 04Feb2021 with chief complaint of worsening shortness of breath, nausea and diarrhea for past week since receiving since receiving COVID-19 vaccine. Full viral panel including COVID-19 was not detected. All blood cultures and respiratory cultures were negative. Patient chest x-ray shows numerous bilateral patchy opacities which is significantly different from her previous chest x-ray here. Empiric rejection treatment initiated including high dose methylprednisolone, plasmapheresis, IVIG, thymoglobulin. She continued to decline and ultimately required intubation, proning and paralyzing on 08Feb2021 and then VV ECMO cannulation on 13Feb2021. Acute pupil exam changes in the early am hours of 15Feb2021 prompted urgent head CT which revealed catastrophic brain bleed. Brainstem reflexes were lost soon after. Despite placing an EVD emergently at bedside, brain stem reflexes were not recovered. The events were all serious. The patient outcome of the events was fatal. The patient died on 15Feb2021. It was not reported if an autopsy was performed.; Sender''s Comments: Based on available information, a possible contributory role of the subject product, BNT162B2 vaccine, cannot be excluded for the reported events due to temporal relationship. However, the reported event may possibly represent intercurrent medical conditions in this patient. There is limited information provided in this report. Additional information is needed to better assess the case, including complete medical history, diagnostics, counteractive treatment measures and concomitant medications. This case will be reassessed once additional information is available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Chest x-ray shows numerous bilateral patchy opacities; Catastrophic brain bleed; Brainstem reflexes were lost; shortness of breath; nausea; Diarrhea; Worsening shortness of breath/numerous bilateral patchy opacities


VAERS ID: 1051451 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021179726

Write-up: died 15 min later; This is a spontaneous report from a Pfizer Sponsored Program. A non-contactable consumer reported that a female patient (mother) of an unknown age received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) at single dose via an unknown route on an unknown date for Covid-19 immunization. Medical history and concomitant drug were not provided. The reporter stated her mother took the vaccine and died 15 min later. No follow-up attempts are possible. Information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: died 15 min later


VAERS ID: 1051637 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-09
Onset:2021-02-11
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Decreased appetite, Endotracheal intubation, Fatigue, Headache, Intensive care, Malaise, Pneumonia
SMQs:, Angioedema (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hypertension, Chronic Kidney Disease Stage 2, DM2
Allergies:
Diagnostic Lab Data: 2/17/2021 admitted to hospital for severe pneumonia requiring high levels of supplemental oxygen. Transferred to ICU and intubated on 2/20/2021. Infectious Disease team on the case and cannot find infective organism.
CDC Split Type:

Write-up: 2/9 received 2nd vaccine in series. 2/10 mild headache and fatigue. 2/11 worsening headache, extreme fatigue, and general malaise. In bed except for bathroom use and minimal food consumption starting 2/11 until hospitalization on 2/17/2021.


VAERS ID: 1051651 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-23
Onset:2021-02-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Abdominal pain, Acidosis, Activated partial thromboplastin time prolonged, Alanine aminotransferase increased, Angiogram pulmonary abnormal, Angiogram pulmonary normal, Anion gap, Ascites, Aspartate aminotransferase increased, Atelectasis, Atypical mycobacterial infection, Bilirubin conjugated, Blood albumin, Blood alkaline phosphatase increased, Blood bicarbonate decreased, Blood bilirubin, Blood creatinine increased, Blood glucose decreased, Blood lactic acid, Blood lactic acid normal, Blood pH decreased, Blood pH increased, Blood potassium decreased, Blood urea increased, Cholelithiasis, Computerised tomogram abdomen abnormal, Computerised tomogram pelvis abnormal, Death, Dyspnoea, Enteritis, Fibrin D dimer, Hypoglycaemia, Ileus, International normalised ratio increased, N-terminal prohormone brain natriuretic peptide increased, Nausea, PCO2 increased, Pericardial effusion, Platelet count decreased, Pleural effusion, Proctitis, Retching, Troponin, Varices oesophageal, Vomiting, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (narrow), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Pulmonary hypertension (broad), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow), Infective pneumonia (broad), Hypokalaemia (narrow), Opportunistic infections (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Lisinopril, metoprolol, simvastatin, acetaminophen, ibuprofen, calcium carbonate, furosemide, diphenoxylate/atropine, magnesium chloride, omeprazole, Carafate, testosterone, vitamin D3, levothyroxine
Current Illness: None
Preexisting Conditions: Colon Cancer Hypothyroidism Hyperlipidemia GERD Hypertension
Allergies: NKDA
Diagnostic Lab Data: 2/23/21: White count is 2.1, platelet 26, INR 1.7, PTT 107.5, D-dimer greater than 5000 pH is 7.03 with PCO2 of 50, potassium 3.3, bicarb of 16, anion gap of 21, BUN of 26, creatinine 2.5, glucose of 39, lactic acid of 14.6, total bilirubin of 4.58, direct bilirubin of 3.87, AST 134, ALT of 43, alk phos of 194. Troponin is negative. proBNP of 4229. Albumin 1.9. CT scan of the abdomen pelvis shows complex fluid attenuation the posterior right hepatic lobe, possibly metastasis, nonspecific hepatic morphology, possibly cirrhosis. Small volume ascites, punctate calcified gallstone with pericholecystic fluid related to ascites. Infiltration of the submucosal fat of the ascending colon. Possible wall thickening of a short segment of jejunum possibly infectious or inflammatory process such as enteritis. Distention of a few loops of jejunum which may represent localized ileus. Fluid within the distal thoracic esophagus which can be seen in reflux. Mild wall thickening of the GE junction with intraluminal nodularity which may represent esophageal varices. Limited evaluation of bladder due to incomplete distention with possible mucosal hyperenhancement. CT angiogram of the chest demonstrates no evidence of pulmonary thromboembolic disease. Small segmental and subsegmental pulmonary emboli cannot be excluded. Distention of the entirety of thoracic esophagus with simple fluid. Trace bilateral pleural effusions. Overlying compressive atelectasis. Small pericardial effusion. Small focal atelectasis or atypical infection in the inferior lingula.
CDC Split Type:

Write-up: Abdominal pain, nausea and vomiting, shortness of breath, acidosis, hypoglycemia, death. Onset of abdominal pain was 30 minutes after administration of the vaccine followed by 20+ episodes of vomiting and dry heaving.


VAERS ID: 1051666 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH VEN5318 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Anaemia, Arteriosclerosis, Blood lactic acid increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Computerised tomogram thorax normal, Condition aggravated, Death, Dyspnoea, Electrocardiogram normal, Emphysema, Endotracheal intubation, Fibrin D dimer increased, Mitral valve incompetence, Pulmonary oedema, Tricuspid valve incompetence
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Haematopoietic erythropenia (broad), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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:
Current Illness: None
Preexisting Conditions: CHF,DM2,OSA,HTN,Diabetic Neuropathy, CKD3
Allergies: Heparin,Cipro,Imdur
Diagnostic Lab Data: CT PE Study: No PE, mild to moderate emphysematous changes,bil renal stones, no acute inflammatory process in the abdomen or pelvis. XR Chest: No acute cardiopulm disease. EKG: ventr
CDC Split Type:

Write-up: Pt presented to ER with SOB on 01-29-2021. He was admitted to Healthcare with acute CHF exacerbation, elevated lactate, anemia and elevated d-dimer. Pt reports getting SOB getting up to go to the bathroom. Pt was intubated. He developed pulmonary edema. Pt expired on 02-02-2021 at 10:13 PM.


VAERS ID: 1051675 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-01-28
Onset:2021-02-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated, Death
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: congestive heart failure
Preexisting Conditions: congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 2/1/21 at the Health System. She was there for congestive heart failure (CHF) which had been a problem for her since contracting COVID-19 (symptoms began 10/29/20 and tested positive 10/30/20). She had been to see her medical provider several times after her isolation period as well as a few trips to the hospital for, what they called "CHF flare-ups". Her last hospitalization began on January 30, 2021. Her social worker reported on t1/31/21 that "she would likely be returning in another day or two".


VAERS ID: 1051699 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-27
Onset:2021-02-15
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH VEL9261 / 1 LA / IM

Administered by: Public       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: None
Preexisting Conditions: COPD
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 02.15.2021.


VAERS ID: 1051803 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-08
Onset:2021-01-15
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown- not the facility that administered the vaccine
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown- not the facility that administered the vaccine
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown, was informed by Health Director that person had passed away


VAERS ID: 1051923 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-31
Onset:2021-02-21
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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: 1051942 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-11
Onset:2021-02-18
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death, Hepatorenal syndrome
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Casodex, Sinemet CR, Plavix, Namenda, Midodrine, Protonix, Crestor, Zoloft, Trazadone,
Current Illness: Acute Hepatitis,
Preexisting Conditions: CAD, MI, RLS, Peripheral Neuropathy, PD, hyperlipidemia, orthostatic hypotension, Shy-Drager
Allergies: Intolerance to Morphine, Propoxyphene, Statins, Bisphosphonates, Tramadol, Methadone, and Meperidine
Diagnostic Lab Data: Partial autopsy. Results not complete
CDC Split Type:

Write-up: Hepatorenal syndrome- Death


VAERS ID: 1051975 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-19
Onset:2021-02-23
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK - / -

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

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

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


VAERS ID: 1051993 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-05
Onset:2021-02-14
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Notified on 2/24/2021 that patient passed away on 2/14/2021. Other cause of death - non-covid -19 related


VAERS ID: 1052014 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-06
Onset:2021-02-15
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dyspnoea, Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: Digoxin, Levothyroxine, Atorvastatin, Pregabalin, Sertraline, Monteleucast, Tylenol, Aspirin 81 mg,, Vitamin D3, Vitamin C, probiotic, Benadryl
Current Illness: COPD exascerbation'' UTI flare-up
Preexisting Conditions: Advanced severe COPD, UTI
Allergies: None
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Extreme difficulty breathing upon exertion, collapsed shortly after walking started, loss of conciousness, and death


VAERS ID: 1052045 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-02-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M02A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1052049 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-23
Onset:2021-02-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6203 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Malaise, Pain in extremity, Peripheral swelling, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Multivitamin and Glucosamine. Started on Prednisone after the vaccine was administered
Current Illness: None known at the time of the vaccination. However, patient did have a podiatry visit after the vaccination for right foot pain and swelling
Preexisting Conditions: None
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was into the clinic on the afternoon of 2/23/21 for a COVID-19 vaccine. He had a podiatry clinic visit after his vaccine same day. It was reported by the patients family physician that patient stated he didn''t feel well and suddenly collapsed at home at approximately 4:45 pm. Emergency medical personnel were not able to revive him. Patient died at approximately 4:45 pm on 2/23/21.


VAERS ID: 1052070 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Infrequent bowel movements, Nausea, Retching
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin EC tablet delayed release 81mg once a day, Lasix 20mg tablet once a day, Multivitamin once a day, Omeprazole tablet delayed release 20mg once a day, Probiotic Capsule 2 per day, Refresh PM eye ointment at bedtime, Tylenol Extra Str
Current Illness: No
Preexisting Conditions: Acute Diastolic (Congestive) Heart Failure, Bell''s Palsy, Essential Hypertension, Unspecified Atrial Fibrillation, Unspecified Macular Degeneration, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Gastro-esophageal Reflux Disease without Esophagitis, Dementia without Behavior Disturbances, Muscle Weakness, Overactive Bladder, H/O Ottis Media, Legal Blindness and Dysphagia
Allergies: No known drug or food allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: 2/22/2021 10:09 pm resident reported 1 episode of being nauseous and having dry heaves, no temperature, MD notified and nurse was told to continue to monitor, no new orders, daughter made aware. Vital signs being done every 4 hours. 2/23/2021 3:04am resident complains of nausea, scant BM amount x 2, MD notified and no new orders, continue to monitor and encourage fluids, vital signs continue every 4 hours.


VAERS ID: 1052106 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-11
Onset:2021-02-17
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood cholesterol increased, Blood creatinine normal, Blood glucose increased, Blood potassium normal, Blood triglycerides increased, Blood urea increased, Cardiac arrest, Death, Low density lipoprotein normal, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Lipodystrophy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin 500 2 tablets bid glipizide 10 mg bid Alopliptan 25 mg daily Prescribed statin, ASA and ace inhibitor but she was not taking them
Current Illness: DM with proteinuria and foot complications hyperlipidemia
Preexisting Conditions: DM with proteinuria and foot complications Renal insufficiency hyperlipidemia alcohol abuse
Allergies: Augmentin and NSAID
Diagnostic Lab Data: none Last hgbA1c was Jan 19 when if was 9.6%. BUN on that date was 36 and creatinine was 1.27. Potassium was 4.6. Random glucose was 185. LDL was 127 and total cholesterol was 211. Triglycerides were 232.
CDC Split Type:

Write-up: While at counseling appointment on February 17 patient had witnessed sudden cardiac arrest and was not able to be resuscitated. She was pronounced dead at 12:09. At the time of death her glucose was about 500.


VAERS ID: 1052108 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-02-19
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1052138 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-29
Onset:2021-01-17
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arteriovenous fistula operation, Haemodialysis, Hypotension
SMQs:, Acute renal failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received Moderna 1st dose on 12/29/2020. Was in the hospital on 1/17/21-1/21/21 for severe hypotension and removal and replacement of hemodialysis shunt.


VAERS ID: 1052164 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / UNK AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Cardio-respiratory arrest, Death, Dyspnoea
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Stage 4 Kidney Disease Hypertension Ischemic Bowel Hyperlipidemia GERD CAD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 911 called to patients house for trouble breathing and abdominal pain. Patient coded, wife presented DNR paperwork. Patient presented to Hospital DOA at 0958.


VAERS ID: 1052172 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   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
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: statins- stated no allergic reaction but can''t take
Diagnostic Lab Data: Autopsy completed 2/20/2021 at medical school by MD
CDC Split Type: na

Write-up: Agency contacted 2/19 In evening by employer representative- client Died Suddenly after work"


VAERS ID: 1052179 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-25
Onset:2021-02-21
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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: 1052217 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-18
Onset:2021-02-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Dyspnoea, Flushing, Heart rate increased, Pulmonary oedema, Vomiting
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol, eliquis, diltiazem
Current Illness: none
Preexisting Conditions: diabetes, arterial fibrillation
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Elevated heart rate, flushing of the face and ears, vomiting, trouble breathing, pulmonary edema


VAERS ID: 1052226 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-02-11
Onset:2021-02-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cyanosis, Death, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: Alveso, Xopenex, Aspirin, Atorvastatin, Cetirizine, Fiber, Hydralazine, Hydrochlorothiazide, Levothyroxine, Lisinopril, Meloxicam, Metformin, Metoprolol, Novolin,
Current Illness:
Preexisting Conditions: Arthritis, Diabetes Mellitus, Diabetic Neuropathy, Venous Insufficiency in Lower Extremity, Hypothyroidism, Chronic Obstructive Pulmonary Disease, Hypothyroidism, Obesity
Allergies: Bactrim
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient discovered unresponsive in cell, blue coloration to skin, vital signs, undetectable. CPR initiated, Ambulance summoned. Following EMS arrival with additional unsuccessful attempts to revive patient, patient was determined to have expired.


VAERS ID: 1052273 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
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: 2021-02-23
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted to the hospital the day after receiving a COVID vaccine x 5 days. Patient passed away on 2/23/2021.


VAERS ID: 1052645 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-06
Onset:2021-02-10
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Angiocardiogram, Arteriogram carotid normal, Aspartate aminotransferase increased, Blood creatinine increased, Cardiogenic shock, Death, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (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: 2021-02-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: prednisone, Armour thyroid, folic acid, cholecalciferol, coenzyme Q 10, tumeric pemetrexed/pembrolizumab - 12 doses, last dose o 02/09/2021
Current Illness: Stage IV adenocarcinoma of lung
Preexisting Conditions: Stage IV adenocarcinoma of lung diagnosed on 05/19/2020
Allergies: Latex, penicillin, sertraline
Diagnostic Lab Data: See above
CDC Split Type:

Write-up: Cardiogenic shock occurred on 2/10/2021, approximately 12 hours after patient received her 12th dose of pemetrexed/pembrolizumab and 4 days after COVID vaccine. Coronary angiography was done on 2/10/2021 and no significant coronary narrowing or blockage were noted. Baseline troponin on 2/10/21 was 0.02 and later on 2/10/21, troponins were 9.99 & 25.27. Creatinine increase from 1.2 to 3.4 within 24hours, and AST/ALT increased from 23 & 31 to 4,220 & 4,786 respectively on 2/11. Patient expired on 02/11/2021.


VAERS ID: 1052700 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

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

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

Write-up: 71 year old male patient recived the Moderna vaccine on 12/28/2020 and 1/27/2021. Tested positive for Covd-19 on 2/1/2021 (aysmptomatic). Passed away on 2/23/2021. Report came from facility.


VAERS ID: 1052738 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pyrexia, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

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

Write-up: He vaccine on 2/5/2021 I went to see my husband the next day he was shaking and his mouth was open shaking, and he had fever of 105, they gave him Tylenol suppositories and he passed away 2 hours later. They should not have given him should not have given him the vaccine that is on hospice, it was not the right decision. I am worried about the elderly and those very sick.


VAERS ID: 1052809 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Private       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Neurontin, Proscar, Glucophage XR, Norvasc, Glucotrol, Lasix, Lipitor, Cozaar, Hygroton, Protonix, Hytrin
Current Illness: Pressure ulcers
Preexisting Conditions: BPF, CAD, Essential HTN, Diverticulosis of colon, Hyperlipidemia, Osteoarthritis, chronic respiratory failure, DM2 with peripheral vascular disease, peripheral edema, GERD, obstructive sleep apnea, osteoarthritis of knees,
Allergies: Lisinopril
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient passed away


VAERS ID: 1052820 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Hip fracture, Hip surgery, Pneumonia bacterial, Poor peripheral circulation, Stent placement, Surgery
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations: Breathing issues ~2 weeks after first dose of mRNA vaccine in the series but were not nearly as acute or severe as they were fol
Other Medications: A variety of medications for diabetes, blood circulation, hypertension
Current Illness: Diabetes, hypertension, cancer (lung)
Preexisting Conditions: cancer for many years.
Allergies: none
Diagnostic Lab Data: Bacterial pneumonia
CDC Split Type:

Write-up: Approximately 2 weeks after the first COVID vaccine she developed shortness of breath that was much more significant than she had previously. This was the first time she had expressed this symptom to me as being something she was concerned about and difficult for her to manage (we have spoken almost daily for many years). Within 24 hours of the second dose of the mRNA vaccine, they called an ambulance to get her and she was taken to the hospital and diagnosed with bacterial pneumonia. The doctors said it was unrelated, but I found a study with a different vaccine (LAIV) that also seemed to increase the incidence of bacterial pneumonia. They hypothesized through diverting the immune system. So while I don''t think the vaccine gave her the bacteria, I do think it may have caused her immune system to be temporarily compromised allowing the bacteria to grow out of control. I feel this is important to report to look for these types of patterns as perhaps it can help others avoid the death spiral that happened to my mother. There were also intervening events between her hospitalization and her death including two successful surgeries (one for a broken hip and another to put in stents in her leg). So to summarize, the first vaccine was within about 2 weeks of the onset of her breathing problems. Within 24 hours of the second vaccine she was hospitalized and diagnosed with bacterial pneumonia. As she was battling bacterial pneumonia in the hospital she broke her hip and was found to have reduced peripheral circulation and had 2 surgeries to correct those. They were successful according to the surgeons, however she died within a week or so of the surgeries. She had other comorbidities as well which I''m sure predisposed her such as diabetes, hypertension and cancer for many years.


VAERS ID: 1052972 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-23
Onset:2021-02-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / SC

Administered by: Senior Living       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: NO
Current Illness: NO
Preexisting Conditions: ACUTE KIDNEY DISEASE, DIABETES, HYPERTENSIVE HEART
Allergies: NO
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: RESIDENT EXPIRED


VAERS ID: 1053191 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-08
Onset:2021-02-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Communication disorder, Contusion, Death, Thrombocytopenia, Thrombosis
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine administered 02/08/2021 , by Thursday 02/11/2021 patient almost nonverbal, by Monday 02/15/2021 patient went to the hospital with bruising, sores on her stomach and clots reported as thrombocytopenia, deceased by Friday 02/19/2021.


VAERS ID: 1053322 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Missouri  
Vaccinated:2020-12-29
Onset:2021-01-31
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose


VAERS ID: 1053393 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Death, Dizziness, Fatigue, Malaise, Pain
SMQs:, Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: cardiovascular disease smoker
Allergies:
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient felt achy, tired starting the day after the vaccine. Per his wife, he was very tired and "losing stamina". On 2/13/21, he woke up feeling dizzy and weak. His wife asked him if he wanted to go to the doctor and he declined. He ate breakfast and went to rest in his easy chair. He passed away an hour later.


VAERS ID: 1060528 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-01-22
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / -

Administered by: Other       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? 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 due to underlying condition for hospice pt. Narrative: This was a 95 yo patient residing at home with daughter. Patient reported to PCP on 1/4 c/o poor appetite and weight loss. Daughter reported that patient was very frail and requested a hospice referral. Outside medical records indicate that patient was dx with pneumatosis of the cecum and peritonitis. Patient also had severe atherosclerotic disease with near complete occlusion of the infrarenal abdominal aorta. Due to age and frailty, patient was placed in hospice care where he passed away on 1/22/21.


VAERS ID: 1053694 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-08
Onset:2021-02-17
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Tamsulin, Xarelto, Lasix
Current Illness: A-FIB, DM2,
Preexisting Conditions: DM2, A-FIB
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden Death on 2/17/2021


VAERS ID: 1053758 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-02
Onset:2021-02-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Headache, Intracranial aneurysm
SMQs:, Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

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

Write-up: Systemic: Brain aneurysm-Severe, Systemic: Headache-Severe


VAERS ID: 1053788 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-02
Onset:2021-02-15
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Public       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: None reported
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Received call that patient is now deceased


VAERS ID: 1053879 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-20
Onset:2021-01-30
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Esophageal Cancer with Radiation and Chemotherapy. Patient chose to stop treatment
Preexisting Conditions: Malignant neoplasm of the breast, Esophageal cancer, CAD,
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Shortness of breath - related to chronic comorbidities


VAERS ID: 1053978 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Death, Pain, Pyrexia, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol sulfate inhaler, atenolol, ipatropium-albuterol nebulizer, Sensipar, lisinopril, Incruse Ellipta, lovastatin, pantoprazole, furosemide, trazodone, diclofenac gel, triamcinolone cream, fluticasone nasal spray
Current Illness: none
Preexisting Conditions: CKD Stage 3, COPD, hyperlipidemia, secondary hyperparathyroidism
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt woke up at 0400 with fever, chills, and body aches progressing over 4 hours to the point when she became unresponsive. husband called 911, pt was declared dead at the time of EMS arrival around 1200


VAERS ID: 1054080 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-18
Onset:2021-02-21
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   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: amlodipine, centrum silver, vitamin C, Vitamin D, vitamin E, zinc, Lexapro, Seroquel, trazodone.
Current Illness: none
Preexisting Conditions: hypertension, COPD, schizophrenia
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest, death: 2/21/21


VAERS ID: 1054114 (history)  
Form: Version 2.0  
Age: 102.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-27
Onset:2021-02-22
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Ascites, Death, Hypoxia, Pyrexia
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data: All done at hospital from 2/11/2021-2//18/2021
CDC Split Type:

Write-up: Patient was hospitalized 15 days after receiving vaccine. Admission was not due to vaccine and was admitted for acute ascites and patient had reported fever and hypoxia. Patients admission resulted in death 7 days after being admitted to hospital.


VAERS ID: 1054160 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Back pain, Death, Headache, Nausea, Pain in extremity, Seizure
SMQs:, Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Generalised convulsive seizures following immunisation (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: not applicable
Preexisting Conditions: Right VP shunt at birth.
Allergies: Latex and Ceclor
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/12/2021 woke up with sore arm and back. 2/13/2021 woke up with headache around 1am. Headache and nausea all morning. Mid-late afternoon started having seizures. Admitted to Hospital 2/15/2021 expired. Reported per wife on 2/25/2021.


VAERS ID: 1054171 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-17
Onset:2021-02-21
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Pradaxa, Amiodarone, Vitamin C, Atorvastatin, Bumex, Colace, Vitamin B12, ferrous sulfate, Flomax, Flonase, Lyrica, Mag Oxide, Metroprolol Succinate, Potassium, Caridopa-Levadopa, Ultram,
Current Illness: ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE, HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE, PARKINSON''S DISEASE, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, CHRONIC KIDNEY DISEASE, STAGE 3 UNSPECIFIED
Preexisting Conditions: ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE, HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE, PARKINSON''S DISEASE, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, CHRONIC KIDNEY DISEASE, STAGE 3 UNSPECIFIED,
Allergies: Ropinirole
Diagnostic Lab Data: Not Applicable
CDC Split Type:

Write-up: Resident found unresponsive in his room. CPR performed and patient expired.


VAERS ID: 1054175 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-17
Onset:2021-02-23
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix, allopurinol, amlodipine, aspirin, Colace, donepezil, finasteride, losartan potassium, oxybutynin, polyethylene glycol, rosuvastatin, vitamin d, Tamsulosin,
Current Illness: Acute Kidney Failure
Preexisting Conditions: Cognitive communication deficit, dysphagia, gout, hyperlipidemia, other abnormalities of gait and mobility, personal history of TI and cerebral infarction without residual deficits, unspecified osteoarthritis, benign prostatic hyperplasia with lower urinary tract symptoms, constipation, essential hypertension, history of falling, obstructive and reflux uropathy, overactive bladder, unspecified dementia without behavioral disturbance.
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident found unresponsive, CPR initiated and EMS called. EMS called time of death after arrival.


VAERS ID: 1054192 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-16
Onset:2021-02-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unk
Current Illness: None listed
Preexisting Conditions: None listed
Allergies: NKA
Diagnostic Lab Data: Unk
CDC Split Type:

Write-up: Pt''s wife reports death 2/23/2021


VAERS ID: 1054337 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: several including METOPROLOL ER SUCCINATE 50 MG TABS
Current Illness: NONE
Preexisting Conditions: HEART CONDITION
Allergies: UNKNOWN
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: FOUND DEAD IN HIS OWN BED


VAERS ID: 1054434 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-29
Onset:2021-02-24
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reported to emergency room on 2/20 with increasing of shortness of breath, quantitated unable to walk from room to room in his house. Patient was admitted.


VAERS ID: 1054435 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 RA / IM

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

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

Write-up: Patient passed on 01/28/2021 per family member.


VAERS ID: 1054551 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-16
Onset:2021-02-18
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3294 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A, under hospice care for end of life
Preexisting Conditions: Major Neurocog Disability
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident expired on 2/29/21.


VAERS ID: 1054592 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-16
Onset:2021-02-24
   Days after vaccination:39
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, ASA, Cogentin, Bisacodyl, Cetrizine, B12, Depakote, Ativan, Metformin, Multivitamin, Risperdal, Senna tabs.
Current Illness: N/A
Preexisting Conditions: 1. Mood disorder with behavioral disturbance #2 psychotic disorder #3 atypical anxiety #4 dementia with behavioral disturbance #5 cognitive communication deficit #6 impulse control disorder #7 chronic constipation #8 generalized chronic pain #9 hypomagnesia anemia #10 seborrheic dermatitis #11 B12 deficiency #12 type 2 diabetes mellitus #13 hypertension #14 anemia #15 degenerative joint disease #16 seizure disorder #17 GERD #18 hyperlipidemia #19 history of peptic ulcer disease #20 diverticulosis of the colon #21 thrombocytopenia unspecified
Allergies: NKA
Diagnostic Lab Data: Resident had been treated for sepsis a week prior, returned to hospice services after hospital readmission.
CDC Split Type:

Write-up: Resident expired on 2/24/21, under hospice care.


VAERS ID: 1054694 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-01-29
Onset:2021-02-13
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HTN, BPH, OSA, Obesity
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt received vaccine on 1/29/2021 and died on 2/13/2021. Wife called agency and noted the pt received his 1st dose of vaccine and was having "side effects and began declining". It is unknown what side effects he was having.


VAERS ID: 1054698 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-18
Onset:2021-01-30
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: SEROQUEL, METOPROLOL, TRAMADOL, LASIX
Current Illness:
Preexisting Conditions: PVD, A. FIB, HYPERLIPIEMIA, HYPOTHYROIDISM, DEPRESSION
Allergies: PENICILLIN, PRADAXA, REMERON, VESICARE
Diagnostic Lab Data:
CDC Split Type:

Write-up: THE RESIDENT WAS ROUTINELY TESTED FOR COVID ON 1/29/21 AND POSITIVE RESULTS RETURNED ON 1/30/21; WAS ASYMPTOMATIC AT FIRST, BUT DEVELOPED SYMPTOMS ON 1/31/21 THAT PROGRESSED AND THE RESIDENT DIED ON 2/7/21


VAERS ID: 1054699 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / -

Administered by: Senior Living       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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep


VAERS ID: 1054813 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-29
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Urinary tract infection
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chest clear - Hospitalized for a UTI


VAERS ID: 1054859 (history)  
Form: Version 2.0  
Age: 102.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-15
Onset:2021-01-22
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013120A / UNK RA / IM

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: not reported
Current Illness:
Preexisting Conditions: COPD, chronic kidney disease, heart disease
Allergies: not reported
Diagnostic Lab Data: none reported
CDC Split Type:

Write-up: No details - patient died on 1/22/2021


VAERS ID: 1054966 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-12
Onset:2021-02-16
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Angiogram pulmonary normal, Apnoeic attack, Blood creatine, Blood creatine phosphokinase increased, Blood potassium normal, Blood urea increased, CSF glucose increased, CSF protein increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram head normal, Decreased appetite, Dehydration, Fibrin D dimer increased, Glomerular filtration rate decreased, Hypophagia, Protein total increased, SARS-CoV-2 test negative, Tenderness
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Acute pancreatitis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol inhaler Allopurinol Aspirin Carvedilol Cyanocobalamin Escitalopram Fanny Cream Fluticasone nasal spray Furosemide Glipizide Insulin detemir Ipratropium/albuterol nebs Losartan Melatonin Metformin Olanzapine Fish oil Pravastatin Ps
Current Illness: None. Recently in hospital for a fall.
Preexisting Conditions: Dementia, atrial fibrillation, type 2 diabetes, heart failure with reduced ejection fraction, gout, hyperlipidemia
Allergies: None
Diagnostic Lab Data: 2/16/2021: Chest X-ray - boarderline CHF 2/16/2021: Head CT - no intracranial abnormality. stable severe chronic changes 2/16/2021: Chest CTA - no pneumothorax COVID-19 tests all negative CSF glucose: 137 CSF total protein: 176 D-dimer: $g5250 BUN: 41-111 eGFR: 54.2-11.9 Potassium: 4.1-7.3 SCr: 1.28-4.75
CDC Split Type:

Write-up: Mentation has declined since hospital discharger for fall on 2/6/20201. Patient has also had significant poor oral intake. Brought in due to apneic episodes. Abdominal pain - diffuse tenderness (right sided) Elevated liver enzymes - likely secondary to dehydration Increased serum creatine kinase - likely due to dehydration


VAERS ID: 1055009 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-09
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient deceased 2/9/2021 when called for second dose vaccine appointment


VAERS ID: 1055027 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-29
Onset:2021-02-15
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient deceased no show to 2nd appointment notified by family


VAERS ID: 1055070 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-19
Onset:2021-02-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cetirizine, ferrous gluconate, atorvastatin, acetaminophen, aspirin EC, sertraline, clozapine, risperidone, clozapine, polyethylene glycol, sennosides, glipizide, levothyroxine,
Current Illness: Morbid obesity, hypothyroidism, Diabetes, Iron deficiency anemia, QT prolongation, hyperlipidemia, chronic hypoxia, psychosis, luteal phase dysphoria, anxiety, early onset schizophrenia, moderate intellectual disability, left ankle ORIF.
Preexisting Conditions: Same as item 11, remove left ankle ORIF
Allergies: No known allergies
Diagnostic Lab Data: Post pending
CDC Split Type:

Write-up: Client died on 02/21/2021 and had received the second dose of the vaccine series on 02/19/2021.


VAERS ID: 1055107 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-29
Onset:2021-01-15
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

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

Write-up: No documented vaccine reaction Hospitalized due to co-morbities


VAERS ID: 1055122 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Idaho  
Vaccinated:2021-02-20
Onset:2021-02-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypoxia, Lethargy, Pallor, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Loperamide , Tylenol 500mg, Acidophilus, Alka-Seltzer, Citalopram, D-Mannose, Docusate, Ensure, Losartan, MacuHealth, Naproxen, Omeprazole, Refresh tears, Gas X, Vagisil,
Current Illness: Nausea, Vomiting, Diarrhea on 2/19
Preexisting Conditions: Macular Degeneration, HTN
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pale, Short of Breath, Hypoxic, Lethargic within minutes became unresponsive and died.


VAERS ID: 1055149 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027LZOA / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Respiratory distress, Use of accessory respiratory muscles, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (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: 2021-02-22
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, lasix, toprol XL, PRN: lorazipam and morphine
Current Illness: MEDICAL HISTORY; CHF (EF=20%), CAD, AAA (NO REPAIR) 5.3CM, ANEMIA (HISTORY TRANSFUSIONS ARANESP/PROCRIT), CKD STAGE 5 (BUN=110/CREATININE=6.09), HTN, ISCHEMIC CARDIOMYOPATHY, GLAUCOMA, HOH, COVID-19 PNEUMONIA 11-27-2020 THROUGH 12-12-2020, SEVERE NONRHEUMATIC MITRAL VALVE REGURGITATION, NSTEMI 03-27-2019, CAROTID ARTERY STENOSIS, CABG 2009, CARDIAC STENT PLACEMENT, FORMER SMOKER.
Preexisting Conditions: see above
Allergies: ace inhibitors, codeine, lysynopril
Diagnostic Lab Data: none
CDC Split Type:

Write-up: This is a hospice patient under the care of Hospice at an affiliated nursing home. Pt received the vaccination around noon on 2-16-21 by a representative from Pharmacy. The following afternoon 2-17-21 at 14:45 the pt started to experience severe SOB resp rate 36, audible wheezing and use of respiratory accessory muscles. BP180/80, 113 pulse temp 98. Pt was given morphine and ativan. The respiratory distress was eased however pt never returned to baseline and died 2-22-21 around 4am.


VAERS ID: 1055203 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood lactic acid increased, Brain natriuretic peptide increased, C-reactive protein increased, Clostridium difficile colitis, Colitis, Computerised tomogram abdomen abnormal, Computerised tomogram thorax abnormal, Cough, Death, Dyspnoea, Endotracheal intubation, Full blood count abnormal, Metabolic function test abnormal, Pneumonia, Sepsis
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Haematopoietic leukopenia (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific inflammation (narrow), Ischaemic colitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin, Lisinopril, Atorvastatin, Aspirin, Dulaglutide, Insulin Glargine, Loratadine, Fenofibrate, Fluticasone, Multivitamin
Current Illness:
Preexisting Conditions: Essential hypertension, benign ? Other and unspecified hyperlipidemia ? Hypertrophy of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) ? Injury of left rotator cuff ? Adhesive capsulitis of left shoulder ? Suppurative otitis media of both ears ? Bronchitis, acute ? Acute myeloid leukemia in remission ? Type 2 diabetes mellitus without complication ? Acute midline low back pain without sciatica ? Sinistrocardia ? Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, with long-term current use of insulin ? Thrombocytopenia ? Splenomegaly ? Cirrhosis of liver without ascites ? Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, with long-term current use of insulin ?
Allergies: Cat hair extract, Pollen extract, Mold and Smuts
Diagnostic Lab Data: Nearly all of CMP and CBC abnormal, lactic acid 24.8, CRP 241, BNP $g3000. CT of chest/abdomen reveals pneumonia, acute colitis, cirrhosis.
CDC Split Type:

Write-up: Began having SOB and cough on 2/18/21, the day after his first vaccine. Had a routine physician appointment for diabetes on 2/15/21 with no documentation of these complaints. Presented to the hospital on 2/23, soon after required intubation. Admitted with severe pneumonia, diffuse colitis, and sepsis. Condition continued to worsen until patient passed away on 2/24/21 @ 1632.


VAERS ID: 1055267 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 AR / IM

Administered by: Senior Living       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? 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: 1055290 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-02-08
Onset:2021-02-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M208 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not known at this time. I can research if needed
Current Illness: unknown
Preexisting Conditions: elderly
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death occurred 02/14/2021


VAERS ID: 1055298 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-20
Onset:2021-02-06
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute respiratory failure, Bladder catheterisation, Blood creatinine increased, Blood glucose increased, Blood lactic acid increased, Body temperature increased, COVID-19, COVID-19 pneumonia, Cardio-respiratory arrest, Chest X-ray abnormal, Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram thorax, Culture urine, Death, Differential white blood cell count, Dyspnoea, Emphysema, Fibrin D dimer increased, Full blood count, Glycosylated haemoglobin, Hypotension, Lung opacity, Metabolic function test, Myocardial necrosis marker normal, Oxygen therapy, Physical examination, Pleural effusion, Pulmonary fibrosis, SARS-CoV-2 test positive, Scan with contrast, Sepsis, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Ordered DISCHARGE PATIENTon Discharge Date: 2/12/2021 ONE TIME 02/12/21 1617 DISCHARGE PATIENTon Discharge Date: 2/12/2021 ONE TIME 02/12/21 1618 LORazepam (ATIVAN) injection 1 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 1101 LORazepam (ATIVAN) injection 1 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 1122 morphine injection 2 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 1122 Case management to consult Hospice ONE TIME, Status: Canceled 02/12/21 1144 LORazepam (ATIVAN) injection 1 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 0839 morphine injection 2 mg EVERY 4 HOURS, Status: Discontinued 02/12/21 0839 scopolamine (TRANSDERM-SCOP) 1 mg/3 days TD patch EVERY 72 HOURS, Status: Discontinued 02/12/21 0840 morphine injection 2 mg EVERY 2 HOURS PRN, Status: Discontinued 02/12/21 0839 LORazepam (ATIVAN) injection 1 mg EVERY 2 HOURS PRN, Status: Discontinued 02/12/21 0839 Path review, smear ONE TIME, Status: Canceled 02/12/21 0610 alum & mag hydroxide-simeth (MYLANTA) 200-200-20 MG/5ML suspension 30 mL EVERY 6 HOURS PRN, Status: Discontinued 02/12/21 0528 CBC w Auto Diff TOMORROW 0500 ONCE, Status: Canceled 02/11/21 1420 Basic metabolic panel TOMORROW 0500 ONCE 02/11/21 1420 Diet type: Full Liquid, Supplements; Nutritional Supplements: Mighty Shake; Frequency: Three times per Day DIET EFFECTIVE NOW, Status: Canceled 02/11/21 0929 Comprehensive metabolic panel ONE TIME 02/11/21 0649 furosemide (LASIX) injection 40 mg ONCE 02/10/21 1337 PREPARE CONVALESCENT PLASMA, 2 Units Blood - Once 02/10/21 1232 Transfuse Convalescent Plasma , 2 Units Transfusion, Status: Canceled 02/10/21 1232 iohexol (OMNIPAQUE) 300 MG/ML injection 80 mL ONCE 02/10/21 1210 CT Head Wo Contrast RAD ONE TIME 02/10/21 1127 CT Chest For Pulmonary Embolism w Contrast RAD ONE TIME 02/10/21 1127 venlafaxine (EFFEXOR) tablet 75 mg 3 TIMES DAILY BEFORE MEALS, Status: Discontinued Note to Pharmacy: OP SIG:Take 75 mg by mouth 3 t... 02/10/21 1014 Path review, smear ONE TIME, Status: Canceled 02/10/21 0552 CBC w Auto Diff TOMORROW 0500 ONCE 02/09/21 1045 Comprehensive metabolic panel TOMORROW 0500 ONCE 02/09/21 1045 Lactic Acid, Serum TOMORROW 0500 ONCE 02/09/21 1045 Insert Foley Catheter ONE TIME, Status: Canceled 02/09/21 1347 Activity: Up in Chair 3 TIMES DAILY, Status: Canceled 02/09/21 1031 vitamin B-1 (THIAMINE) 100 mg DAILY, Status: Discontinued 02/09/21 1031 OT EVALUATE/DEVELOP POC/IMPLEMENT Reason for OT: weakness ONE TIME, Status: Canceled 02/09/21 1031 budesonide (PULMICORT) nebulizer suspension 500 mcg RT BID (RT ONLY), Status: Discontinued 02/09/21 0910 CHG Bath DAILY, Status: Canceled 02/08/21 1820 Oxygen Therapy Maintain O2 Sat at or Greater: 88% (titrate to maintain 88% or higher); Liter Per Minute: 6 LPM; Device: Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/09/21 0714 Oxygen Therapy Maintain O2 Sat at or Greater: 88% (titrate to maintain 88% or higher); Liter Per Minute: 6 LPM; Device: Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/09/21 0714 Oxygen Therapy Maintain O2 Sat at or Greater: 88% (titrate to maintain 88% or higher); Liter Per Minute: 4 LPM; Device: Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/09/21 0646 CBC W AUTO DIFF EVERY 3 DAYS, Status: Canceled Comments: Low molecular weight heparin o... 02/06/21 1711 CBC w Auto Diff TOMORROW 0500 ONCE, Status: Canceled 02/08/21 1141 Comprehensive metabolic panel TOMORROW 0500 ONCE 02/08/21 1141 Lactic Acid, Serum TOMORROW 0500 ONCE 02/08/21 1141 XR Chest 1 View RAD ONE TIME 02/08/21 2224 melatonin tablet 5 mg AT BEDTIME, Status: Discontinued 02/08/21 1129 LORazepam (ATIVAN) injection 1 mg ONCE 02/08/21 1810 INCENTIVE SPIROMETER Q2H While awake EVERY 2 HOURS WHILE AWAKE, Status: Canceled 02/08/21 1831 May use PICC Line ONE TIME, Status: Canceled 02/08/21 1820 Measure picc line every shift and document., Change Picc dressing in 24 hours from placement., Change Picc line every 7 days on Tuesday and prn. ONE TIME, Status: Canceled 02/08/21 1820 Have Consent Signed For: Picc line ONE TIME, Status: Canceled 02/08/21 1820 Obtain Consent For: PICC line ONE TIME, Status: Canceled 02/08/21 1811 Central line insertion ONE TIME, Status: Canceled 02/08/21 1811 levoFLOXacin (LEVAQUIN) IVPB 750 mg EVERY 48 HOURS, Status: Discontinued 02/08/21 1152 zinc sulfate (ZINCATE) capsule 220 mg DAILY, Status: Discontinued 02/08/21 1129 vitamin D3 tablet 2,000 Units DAILY, Status: Discontinued 02/08/21 1129 doxycycline (VIBRAMYCIN) 100 mg in dextrose 5 % 250 mL IVPB EVERY 12 HOURS, Status: Discontinued 02/08/21 1114 Diet type: Full Liquid DIET EFFECTIVE NOW, Status: Canceled 02/08/21 1110 Hemoglobin A1c ONE TIME 02/08/21 1111 ipratropium-albuterol (DUO-NEB) 0.5-2.5 (3) MG/3ML nebulizer solution 3 mL RT QID (RT ONLY), Status: Discontinued 02/08/21 1041 CBC w Auto Diff ONE TIME 02/08/21 0934 Comprehensive metabolic panel ONE TIME 02/08/21 0934 Lactic Acid, Serum ONE TIME 02/08/21 0934 iohexol (OMNIPAQUE) 300 MG/ML injection 80 mL ONCE 02/08/21 0750 CT Abdomen Pelvis W Contrast RAD ONE TIME 02/08/21 0619 remdesivir 100 mg in sodium chloride 0.9 % 100 mL infusion EVERY 24 HOURS, Status: Discontinued 02/06/21 1711 remdesivir 100 mg in sodium chloride 0.9 % 100 mL infusion EVERY 24 HOURS 02/07/21 1348 Oxygen Therapy Maintain O2 Sat at or Greater: 88%; Liter Per Minute: 5 LPM; Device: High Flow Nasal Cannula; Ambulate with O2: Yes Continuous, Status: Canceled 02/07/21 1715 morphine injection 2 mg EVERY 3 HOURS PRN, Status: Discontinued 02/07/21 1011 ferrous sulfate tablet 325 mg DAILY WITH BREAKFAST, Status: Discontinued Note to Pharmacy: OP SIG:Take 325 mg by mouth da... 02/06/21 1301 Basic metabolic panel TOMORROW 0500 ONCE 02/06/21 1711 CBC with Auto Diff TOMORROW 0500 ONCE 02/06/21 1711 meperidine (DEMEROL) injection 25 mg EVERY 3 HOURS PRN, Status: Discontinued 02/07/21 0032 ipratropium-albuterol (DUO-NEB) 0.5-2.5 (3) MG/3ML nebulizer solution 3 mL EVERY 6 HOURS PRN, Status: Discontinued 02/06/21 2046 LORazepam (ATIVAN) injection 1 mg EVERY 6 HOURS PRN, Status: Discontinued 02/06/21 2046 budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT inhaler 2 puff 2 TIMES DAILY, Status: Discontinued Note to Pharmacy: OP SIG:Inhale 2 puffs by mouth... 02/06/21 1301 alcohol (NOZIN) nasal sanitizer 2 TIMES DAILY, Status: Discontinued 02/06/21 1700 venlafaxine (EFFEXOR) tablet 75 mg 3 TIMES DAILY WITH MEALS, Status: Discontinued Note to Pharmacy: OP SIG:Take 75 mg by mouth 3 t... 02/06/21 1301
CDC Split Type:

Write-up: Emergency Room HPI: The patient is a 71 y.o. female with a PMH notable for COPD, hypertension and anxiety and depression who presented on 2/6/2021 for evaluation of shortness of breath. Patient presented to our emergency room yesterday morning from local nursing facility rehab nursing staff reported that she had had a increased shortness of breath for the last 3 days she has been diagnosed with COVID-19 on 2-2-2021. Patient has also received both COVID-19 vaccines. Patient presented to the emergency room with labored respirations conscious awake and was on a non-rebreather at 15 L. upon arrival to our emergency room patient''s temperature 101.6?, pulse 169, respirations 40 to blood pressure 142/91 and oxygen saturation 100% on 15 L non-rebreather. Patient received a chest x-ray that showed chronic emphysema and fibrotic changes in the lung no acute processes identified. Patient''s white count 12.8, glucose 197, creatinine 1.2, lactic acid 4.6, cardiac enzymes negative, D-dimer 1180, patient has urine culture pending. Patient has received about 3 L normal saline boluses patient was having hypotension 86/52. Patient also received IV acetaminophen a 1000 mg IV in the emergency room along with Decadron 10 mg IV piggyback. Patient was admitted acute care for the need of IV fluids and IV antibiotics for COVID-19 and sepsis 2/12 admit Brief history and initial physical exam: Patient is a 71 year old long-term resident of Rehab and Healthcare. Unfortunately, she contracted coronavirus (COVID-19) at the nursing home. Her respiratory status started to decompensate and so she was brought into the hospital. Initial workup showed significant bilateral pleural effusions and ground-glass opacity of both lungs. She had a significant supplemental oxygen requirement. She was admitted for further evaluation and treatment. Hospital course: The patient was admitted and started on IV Remdesivir. She was given IV Decadron. She was given immune support vitamins. Despite this, her sepsis worsened. When it became apparent that the patient was not going to recover, her daughter did make her comfort care only and hospice was consulted. The patient was found to be appropriate for general inpatient hospice and was made comfort care. Her requirement for morphine and Ativan did slowly rise. Eventually, the patient did succumb to her respiratory failure. Time of death was called at 10:00 p.m. on February 15, 2021 Discharge Condition: expired. Presume cause of death with cardiopulmonary arrest secondary to acute respiratory failure secondary to coronavirus (COVID-19) pneumonia Disposition: Deceased


VAERS ID: 1055341 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-29
Onset:2021-02-13
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

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

Write-up: Sudden death two weeks after first dose of vaccine was administered. No previous symptoms or signs. Family opted not to do an autopsy so cause of death (stroke or heart attack) not known.


VAERS ID: 1055418 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-15
Onset:2021-02-24
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

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

Write-up: Patient suffered a stroke and passed away


VAERS ID: 1055563 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-18
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021 and died from illness related to COVID-19 on hospice at home on 2/18/2021, per care facility.


VAERS ID: 1055588 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-15
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021 and was hospitalized on 2/15/2021 and deceased on 2/18/2021 at the hospital of admission, per caregiver.


VAERS ID: 1055613 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-10
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021 and was deceased on 2/16/2021 per the caregiver.


VAERS ID: 1055618 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-16
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021, and was deceased on 2/16/2021 at.


VAERS ID: 1055629 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-12
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021, and deceased on 2/12/2021, per caregiver at.


VAERS ID: 1055691 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-19
Onset:2021-01-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 - / SC

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aspiration, Death, Ischaemic stroke, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Zoloft, ASA, Lipitor
Current Illness: dyslipidemia, mild dementia, lumbar stenosis with indwelling suprapubic catheter - no known infection/symptoms of infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Massive ischemic stroke with aspiration, unable to arouse on the morning of 1/21/2021 and placed on Hospice with death 1/24/2021


VAERS ID: 1055791 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-11
Onset:2021-01-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 UN / SYR

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Hives
Other Medications: Yes
Current Illness: Yes Dementia
Preexisting Conditions: Yes
Allergies: Yes
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Was given without consent from POA patient got severely sick and never recovered later passed away only live 1 month POA did not allow second vaccine to be given just wanted to report this vaccine was given illegal without POA knowledge


VAERS ID: 1055819 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Dyspnoea, Gait inability, Laboratory test normal, Mechanical ventilation, Pyrexia, Sudden death, Vaccination complication
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 39 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Taking various meds/antibiotics for UTI, CDIF, high sodium, high blood pressure, diabetes
Current Illness: Treated for COVID pneumonia. Tested positive on Jan 2, 2021. This caused other infections (UTI, CDIF), required oxygen.
Preexisting Conditions: Treated underlying conditions for diabetes, high sodium, high blood pressure, kidney disease.
Allergies: NA
Diagnostic Lab Data: See above
CDC Split Type:

Write-up: On January 1, 2021, patient was admitted to Medical Center with COVID. Tested positive on January 2, 2021. Spent 10 days in hospital. Once recovered from pneumonia and fever gone, on January 10, 2021, she was transferred to Rehabilitation Center for continued treatment. She spent 16 days there. She developed UTI and CDIF infections and was on/off oxygen. She started physical therapy. She was scheduled to be released to go home on January 27, 2021. On January 26, 2021, the day before going home, Rehabilitation Center gave her the Moderna vaccine. On January 27, the day she went home, she started feeling very weak and couldn''t walk. My dad tried lifting her and they both fell to the ground. My dad called 911 and she was taken to Medical Center, with high fever and possible stroke symptoms (which later was negative). Two days later, she had difficulty breathing and was put on a ventilator. She was on a ventilator for about three days. They took it off and she slowly started recovering. The doctors did all kinds of tests (blood clot in lung, heart, etc.) and all was negative. The only thing they could trace it to was an adverse reaction to the vaccine. After spending 11 days at hospital and treating her for various infections, her heart stopped and she passed away suddenly.


VAERS ID: 1059621 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-12
Onset:2021-01-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Chest X-ray normal, Death, Dyspnoea, Hypoxia, Lethargy, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Obesity, Diabetes Type 2, Heart Failure, Bipolar Edema, CVA, GERD, Cardiomegaly
Preexisting Conditions: See above
Allergies: Daptomycin, Penicillin, Vancomycin, Cipro, Cubicin, Rocephine
Diagnostic Lab Data: CXR - no CHF, pneumonia or effusion. No acute findings
CDC Split Type:

Write-up: 1/14/21 - Resident complained of SOB. SPO2 66% on RA, vs 105/66-96-20 T98.2 O2 administered Pox 97% Binax test revealed (+) COVID results. Resident transferred to COVID wing. Family (HCP) updated and declined transfer to hospital Resident continued with fever, hypoxia and lethargy. Family elected CMO and Hospice notified. Resident died on 1/16/2021 @ 930AM.


VAERS ID: 1059622 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-02-02
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Metabolic encephalopathy, Resuscitation, Unresponsive to stimuli, Urinary tract infection, 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 (narrow), 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: 2021-02-08
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lipitor Renvela caps, Pantoprazole, Humalog, Midodrine, Neptro caps, Metoprolol, Levemir, Levothyroxine
Current Illness: UTI & metabolic encephalopathy
Preexisting Conditions: Chronic Kidney Di Stage 5 with Renal Dialysis Diabetes Type 2, CHF, H/o Bladder CA, HTN
Allergies: Ace Inhibitors
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident rec''d COVID vaccine #2 on 02/02/2021 and was hospitalized on 02/03/2021. Diagnosed with UTI & Metabolic Encephalopathy. He was re-admitted to facility on 02/05/2021. On 02/08/2021 resident was found to be unresponsive with small amount of tan emesis in mouth and on bed. CPR initiated and resident was transferred to ER. ER MD notified facility that resident had died.


VAERS ID: 1060524 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN9581 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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, unknown cause Narrative: Patient received COVID19 vaccine on 2/23/2021 at 14:27. On 2/24/21, patient''s family found patient deceased at 12:08am. The local coroner had called the MC to let us know on 2/24/21 at 12:55am. Coroner did not suspect foul play.


VAERS ID: 1056011 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-07
Onset:2021-02-10
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiovascular disorder, Cerebrovascular accident, Death, Dyspnoea, Endotracheal intubation, Feeling abnormal, Hemiparesis, Sedation, Thrombosis
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Blood pressure medication, cholesterol medication, some other vitamins and supplements.
Current Illness: Kidney disease
Preexisting Conditions: Kidney disease
Allergies: None.
Diagnostic Lab Data:
CDC Split Type:

Write-up: My grandpa had a stroke on the 15th of February. He claimed he had been feeling "off" for a few days, but didn''t say anything. A blood clot had formed in his brain. He was doing better and about to go to rehab to strength his right side of his body. On the 22nd he took a turn for the worst. He was having trouble breathing and they sedated and partially paralyzed him to put a tube in his mouth. I believe another blood clot had formed and oxygen wasn''t properly going through his body. They could not stabilize him, and he passed away the same day.


VAERS ID: 1056196 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-01-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Coma
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Congenital cardiovascular disorder (He had been stable and closely monitored for the past 20 years. He had no history of arrhythmia.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021188576

Write-up: He collapsed due to a cardiac arrest on Friday 15Jan and passed away on 19Jan; He collapsed due to a cardiac arrest on Friday 15Jan and passed away on 19Jan; his cardiac arrest was caused by an arrhythmia; This is a spontaneous report from contactable pharmacist via Pfizer Sales Representative. A 45-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number not reported), via an unspecified route of administration on 11Jan2021 at single dose for covid-19 immunisation. Patient had a long history of congenital heart issues. He had been stable and closely monitored for the past 20 years. He had no history of arrhythmia. The patient''s concomitant medications were not reported. Patient collapsed due to a cardiac arrest on Friday 15Jan2021 and passed away on 19Jan2021. The doctors feel that his cardiac arrest was caused by an arrhythmia. Reporter reported this through the v safe app. And received a message stating reporter would be contacted by the cdc. After patient passed away reporter replied stop to v safe. But still had not been contacted by anyone. This may or may not be related. Reporter have no way of knowing. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: The Company cannot completely exclude the possible causality between the reported "collapsed due to a cardiac arrest", "cardiac arrest was caused by an arrhythmia" and the administration of COVID-19 vaccine, BNT162B2, based on the reasonable temporal association. The patient''s pre-existing long history of congenital heart issues might have provided alternative explanations. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to RA, IEC, as appropriate.; Reported Cause(s) of Death: He collapsed due to a cardiac arrest on Friday 15Jan and passed away on 19Jan; his cardiac arrest was caused by an arrhythmia; He collapsed due to a cardiac arrest on Friday 15Jan and passed away on 19Jan


VAERS ID: 1056518 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-18
Onset:2021-02-13
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: VITAMINS NOS
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Bypass surgery
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: The coroner said it was some type of heart attack; A spontaneous Report Received from a Health care professional concerning a 84 year old male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and who experienced a heart attack / myocardial infarction. The patient''s had undergone triple bypass surgery years ago. Concomitant medications were vitamins. On 18-Jan-2021 prior to onset of events the patient received his first of first two planned doses of (mRNA-1273) COVID-19 vaccine of unknown batch no, unknown route and unknown site of administration for prophylaxis of COVID-19 infection. On 13-Feb-2021 the patient experienced death 27 days after the first dose of the vaccine. The coroner said it was some type of heart attack and think he expired sometime Saturday 13-Feb-2021. On 16-Feb-2021 the patient was supposed to have his second dose of (mRNA-1273) COVID-19 vaccine. The event, heart attack, was fatal.; Reporter''s Comments: This is a case of death to heart attack in a 84-year-old female subject with a hx of triple bypass surgery, who died 27 days after receiving first dose of vaccine. Very limited information has been provided at this time. No death certificate provided. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of Death


VAERS ID: 1056659 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: New Jersey  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac disorder
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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021186885

Write-up: heart issue; This is a spontaneous report from a contactable consumer. A male patient of an unspecified age received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. The patient medical history and concomitant medications were not reported. The patient passed away after taking the vaccine. He was healthy but developed heart issue after taking vaccine. The patient died on an unspecified date. It was not reported if an autopsy was performed.; Reported Cause(s) of Death: heart issue


VAERS ID: 1056660 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PRALUENT; LEXAPRO; ELIQUIS; NITROGLYCERIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: AFib; Prostate cancer (Survivor)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021187052

Write-up: Cardiac Event MI or Stroke; Cardiac Event MI or Stroke; This is a spontaneous report from a contactable consumer (Son in law). A 73-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration at left arm on 17Feb2021 14:00 at single dose for covid-19 immunisation. Medical history included atrial fibrillation (AFib), prostate cancer Survivor. Concomitant medication included alirocumab (PRALUENT), escitalopram oxalate (LEXAPRO), apixaban (ELIQUIS), nitroglycerin and Ca channel blocker. The patient received the first dose of BNT162B2 on an unknown date for covid-19 immunisation. The patient experienced cardiac event myocardial infarction (MI) or stroke on 17Feb2021. Adverse event result in Doctor or other healthcare professional office/clinic visit. It was unknown if treatment received for the events. Prior to vaccination, the patient was not diagnosed with COVID-19 and since the vaccination, the patient was not been tested for COVID-19. The patient died on 19Feb2021. It was unknown if an autopsy was performed. The outcome of the events was fatal. The reporter didn''t know if this was associated or not. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: Cardiac Event MI or Stroke; Cardiac Event MI or Stroke


VAERS ID: 1056669 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Nevada  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021203949

Write-up: She knows one person did die; This is a spontaneous report from a contactable consumer. A patient of unspecified age and gender received BNT162B2, via an unspecified route of administration on an unspecified date at single dose for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. The reporter mentioned that ''she knows one person did die'' on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: She knows one person did die


VAERS ID: 1056842 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-11
Onset:2021-02-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: The medical facility did not treat patient as her primary care, but were informed that she passed away on 15 February 2021 of a stroke. I do not have further information on the medical aspect of this as we were not her treating provider but did administer the vaccine on 12 February.


VAERS ID: 1056845 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-23
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Death, General physical health deterioration, Laboratory test abnormal, Lethargy
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Retroperitoneal fibrosis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Medical records are on file at facility. Executor of the patient will grant FDA access to medical records.
Current Illness: Patient diagnosed with COVID-19 on 25 November. Mild symptoms. Tested negative within two weeks. Patient had significant Alzheimer''s disease, but not life threatening. Other co-morbid conditions that were managed through medication. Facility administered first dose of COVID-19 shortly after Christmas and second dose on 29 January.
Preexisting Conditions: See above. Recommend FDA contact facility for medical records.
Allergies:
Diagnostic Lab Data: Laboratory test on 26 January 2021 showed a creatinine level of 4.0 mg/dL and several other abnormal results.
CDC Split Type:

Write-up: Three days after second COVID-19 vaccine, patient became lethargic. Due to advance directive that instructed that no life saving interventions to take place, patient continued to decline and expired on 29 January 2021.


VAERS ID: 1056972 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-01-29
Onset:2021-02-04
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Biliary dilatation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Gastrointestinal oedema, Hepatic cirrhosis, Imaging procedure, Intestinal angioedema, Intestinal mass, Intracranial mass, Laboratory test, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Peritonitis bacterial, Supraventricular tachycardia, Thrombosis
SMQs:, Torsade de pointes/QT prolongation (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Angioedema (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Torsade de pointes, shock-associated conditions (narrow), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal perforation (narrow), Gastrointestinal haemorrhage (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (broad), Biliary tract disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 23
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction Prolonged Q-T interval on ECG Leukocytosis A-fib Common bile duct dilation Duodenal mass Cirrhosis Small bowel edema Stroke Bleeding esophageal varices SBP (spontaneous bacterial peritonitis) Catastrophic antiphospholipid syndrome
CDC Split Type:

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center. She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.


VAERS ID: 1057082 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-30
Onset:2021-02-08
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Asthenia, Bilevel positive airway pressure, Blood culture negative, Blood gases, COVID-19, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Condition aggravated, Cough, Death, Dyspnoea, Full blood count, Headache, Hypoxia, Inflammatory marker test, Joint swelling, Legionella test, Lung infiltration, Lung opacity, Malaise, Nausea, Oxygen therapy, Parosmia, Productive cough, SARS-CoV-2 test positive, Streptococcus test negative, Taste disorder, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Taste and smell disorders (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Respiratory failure (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: 2021-02-19
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Meds prior to admission: Amiodarone, ASA, Lipitor, Cymbalta, Lasix, Norco, Imdur, Lisinopril, Lopressor, Zofran, Potassium chloride, Xarelto
Current Illness: unknown
Preexisting Conditions: Arthritis, Afib, chronic anticoagulation, chronic back pain, coronary arteriosclerosis, DM, GERD, HLD, HTN, kidney stone, PVD, stroke
Allergies: Pneumococcal vaccine - rash
Diagnostic Lab Data: 2/8/21 - CXR - bilateral pulmonary opacifications. Had numerous CXRs during hospitalization. 2/8/21 - COVID-19 PCR Roche/Liot platform detected 2/9/21 - CTA chest - extensive bilateral groundglass opacities 2/8/21 - Blood cultures negative 2/9/21 - Legionella and Strep pneumo Ag negative Pt had frequent blood work including CBC, ABG, chemistry profiles, and inflammatory markers
CDC Split Type:

Write-up: Pt admitted to Hospital on 2/8/21 with 2-3 days of SOA and cough. His wife was diagnosed with COVID-19 at approximately the same time when the patient received 1st COVID-19 vaccine. Pt had not felt well since receiving the vaccine and had some changes in taste or smell. He became acutely worse 2-3 days p/t admission with DOE, productive cough, H/A, N/V, profound weakness and bilateral infiltrates on CXR. He was hypoxic on room air. During hospitalization, has gone back and forth from BiPAP to HFNC. Unable to prone. Pt and wife discussed goals of care and decided on comfort measure approach. Pt expired on 2/19/21.


VAERS ID: 1057281 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-05
Onset:2021-02-19
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: per husband, stage 4 pancreatic cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient''s husband reported her death that happened after first COVID-19 vaccine


VAERS ID: 1057348 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-26
Onset:2021-01-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318/5/31/21 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dysarthria, Dysstasia, Fatigue, Feeding disorder
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lasik, blood pressure
Current Illness: congestive heart failure
Preexisting Conditions: congestive heart failure
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Extreme Fatigue, slurring speech, unable to stand, eat. Death on 2/5/21


VAERS ID: 1057363 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-13
Onset:2021-02-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L28A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dementia
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: Patient with severe dementia in Hospice Care


VAERS ID: 1057547 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Texas  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

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

Write-up: 86 year old manager received the two doses of the Moderna vaccine and died; A spontaneous report was received from a consumer, concerning an 86-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unspecified date, the patient received their doses of mRNA-1273 (Lot number: unknown) through an unknown route in an unknown arm for prophylaxis of COVID-19 infection. On an unspecified date, it was reported that the patient passed away after receiving both doses. The cause of death was unknown. It was unknown if an autopsy was performed. The patient received both scheduled doses of mRNA-1273 prior to the event; therefore, action taken with the drug in response to the events is not applicable. The outcome of event "86 year old manager received the two doses of the Moderna vaccine and died" was fatal.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. No autopsy report provided. Further information has been requested.; Reported Cause(s) of Death: 86 year old manager received the two doses of the Moderna vaccine and died


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