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From the 1/14/2022 release of VAERS data:

Found 5,438 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died

Government Disclaimer on use of this data



Case Details

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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: DM, HTN, CHF, ESRD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

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


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

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

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

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown. Patient was taking medications for the treatment of the following conditions: hypertension, asthma, congestive heart failure, chronic psoriasis, and possibly a few others. He was definitely taking a blood thinner or was, at least,
Current Illness: Patient was undergoing treatment for a variety of chronic medical conditions, but he was not acutely ill or reported being acutely ill at time of vaccination.
Preexisting Conditions: Patient was undergoing treatment for a variety of chronic medical conditions with documentation with this public health center dating back to 2017. Patient was reported to have the following conditions: hypertension, asthma, congestive heart failure, and chronic psoriasis. He also had a history of alcoholism and obesity, although he had lost a significant amount of weight in the last several years and was considered in recovery from alcoholism.
Allergies: NKA
Diagnostic Lab Data: Unknown. The patient''s body was removed from his home by members of the community as there is no medical care or emergency services provided in this region. He was then transported. It is unclear it the patient was transported straight to the morgue or if he was transported to the facility prior to the morgue.
CDC Split Type:

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lipitor 10 mg tablet 1 tab(s) orally once a day at bedtime Benicar HCT 25 mg-40 mg tablet 1 tab(s) orally once a day metformin 1000 mg tablet 1 tab(s) orally BID Tenormin 50 mg tablet 1 tab(s) orally once a day ASA 81mg enteric
Current Illness: none
Preexisting Conditions: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, obesity, alcohol abuse
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1124383 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-01-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No recent labs 10/20/2020 COVID-19 TEST WAS NEGATIVE 3/19/20 hemoglobin A1C 5.8;CBC and urine WNL, except MCV 96 and urine WBC 6
CDC Split Type:

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


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

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Asthenia, Computerised tomogram abnormal, Death, Dysphagia, General physical health deterioration, Pain, Troponin increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Nadolol, esomeprazole,
Current Illness: Liver cancer
Preexisting Conditions: Liver cancer
Allergies: None
Diagnostic Lab Data: Troponin 7807 Alt 694 AST 248
CDC Split Type:

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


VAERS ID: 1124826 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebral haemorrhage, Cerebrovascular accident, Computerised tomogram head, Death, Magnetic resonance imaging head, Transient ischaemic attack
SMQs:, Haemorrhage terms (excl laboratory terms) (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: 2021-03-01
   Days after onset: 2
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: Mini Stroke (TIA) following 1st vaccine
Other Medications: Plavix, Atenolol 50mg, Rosuvastin Calcium 5mg, Tamsulosin 4mg, and Aspirin 81mg
Current Illness: None
Preexisting Conditions: Taking Atenolol for blood pressure.
Allergies: None
Diagnostic Lab Data: Head CTs and MRIs on January 22nd following the 1st vaccine and again February 28th following the 2nd vaccine.
CDC Split Type:

Write-up: Patient had a mini stroke (TIA) approximately 14 hours after the 1st Moderna COVID vaccine which is when the doctors put him on Plavix, the blood thinner and an aspirin. The patient had a massive stroke with brain hemorrhage within 24 hours of the 2nd Moderna COVID vaccine which resulted in his death.


VAERS ID: 1125070 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Louisiana  
Vaccinated:2021-01-21
Onset:2021-02-28
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 2 RA / 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: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Congestive heart failure; Diabetes; High cholesterol; Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: He past away on 28Feb2021 from a heart attack; A spontaneous report was received from a consumer concerning a 80 year old male patient who received Moderna''s COVID-19 vaccine and the patient died due to heart attack. The patient''s medical history, as provided by the reporter, included diabetes, congestive heart failure, hypertension and high cholesterol. Concomitant product use was not provided by the reporter. The patient received their first of two planned doses of mRNA-1273 (Batch number: 025L20A) intramuscularly in the right arm on 21 Jan 2021. On 26 Feb 2021, the patient received their second of two planned doses of mRNA-1273 (Batch number: 024M20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. On 28 Feb 2021 the patient passed away due to heart attack. No treatment information was provided. The seriousness criteria for the event passed away from a heart attack were death and medically significant. Action taken with mRNA-1273 in response to the event was not applicable. The outcome for the event, he passed away from a heart attack was fatal.; Reporter''s Comments: This case concerns a 80 year old, male patient. who died due to myocardial infarction. Very limited information regarding this event has been provided at this time. The patient''s medical history of diabetes, congestive heart failure, hypertension and high cholesterol remains the risk factor for myocardial infarction. Further information has been requested. The cause of death is Myocardial infarction.; Reported Cause(s) of Death: Heart Attack


VAERS ID: 1125079 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-02
Onset:2021-03-03
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Patient was diagnosed with Covid-19 prior to first dose.); Dehydration (The patient was reported to be dehydrated prior to testing positive for Covid-19)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Patient passed away; Found him non-responsive; A spontaneous report was received from a consumer concerning a male patient of an unknown age who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced unresponsiveness to stimulus. The event was followed by his death. The patient''s medical history included Covid-19 and experienced dehydration prior to testing positive for Covid-19. Concomitant product use was not provided by the reporter. The patient was diagnosed with COVID-19 at the skilled facility after becoming dehydrated. He was transported to Hospital on 23 Dec 2020 then discharged to skilled facility on 03 Jan 2021 for physical therapy. On 02 Feb 2021, the patient received their first of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 02 Mar 2021, the patient received their second of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. The anatomical location were not reported. On 03 Mar 2021, the patient was found non-responsive and the staff at skilled rehabilitation tried to resuscitate. Death was the outcome. Treatment information was not provided. Action taken with mRNA-1273 in response to the event(s) was not applicable. The outcome of the event non responsive to stimuli was fatal. The patient died-on 03 Mar 2021 and the cause of death was not provided. It is not known whether autopsy done on this individual. No results were provided.; Reporter''s Comments: This is a case of death in an unknown aged male subject with unknown medical history of recently recovered covid-19 infection before first dose, who died one day after receiving second dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1125300 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-19
Onset:2021-03-21
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 623MZ0A / 1 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Cardiac pacemaker insertion, Death
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   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: Allopurinol, Eliquis, Furosemide, Imdur, Lisinopril, Crestor, Shingrix, and Tamsulosin.
Current Illness: None.
Preexisting Conditions: Essential hypertension, tachy-brady syndrome, supraventricular tachycardia, atrial flutter, and sinus node dysfunction. He also had a pacemaker implanted on 03/19/2021.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had no known ill effects or complaints directly after receiving his first COVID-19 vaccine on 02/19/2021. However, on 03/21/2021, he was found deceased on his bedroom floor due to a suspected cardiac arrhythmia. It is unknown if there is any correlation.


VAERS ID: 1125469 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-16
Onset:2021-02-28
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: egg, flu vaccine, penicillin
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: PER FAMILY PATIENT PASSED AWAY 2/28/2021


VAERS ID: 1125778 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-03-19
Onset:2021-03-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Albumin globulin ratio decreased, Anion gap decreased, Blood albumin decreased, Blood calcium decreased, Blood creatine increased, Blood glucose normal, Blood urea increased, Blood urea nitrogen/creatinine ratio, Carbon dioxide increased, Death, Full blood count abnormal, Haematocrit decreased, Haemoglobin decreased, Hypopnoea, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Mean platelet volume decreased, Metabolic function test abnormal, Nausea, Protein total decreased, Pulse abnormal, Pulse absent, Red blood cell count decreased, SARS-CoV-2 test negative, Unresponsive to stimuli, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Isosorbide Dinitrate (20mg TID); Lasix ( 40mg- BID); Omeprazole (20mg- Daily); Clonidine (0.1mg-BID); Trazodone (100mg- Daily)- Metoprolo Tartrate (25mg-BID); Norvasc (10mg- Daily); Coreg (6.25mg-BID); Zoloft (100mg- Daily); Cymbalata (30mg
Current Illness: 2/29/21- Acute Exacerbation of HFrEF, Medication non compliance; uncontrolled hypertension 03/05/2021- Bradycardic Arrest ( Resuscitated- intubated)
Preexisting Conditions: Cardiac Arrest, Anasarca, Uncontrolled Hypertension , Acute Chronic HFrEF; Non ischemic Cardiomyopathy, hyperkalemia, Medication non compliance, Type 2 Diabetes, Dysphagia, Adult Failure to Thrive, Cannabis Abuse, CHF Exacerbation, Major Depression Disorders
Allergies: Codeine, Hydralazine, Sulfa , Acetone Solution
Diagnostic Lab Data: 3/17/21- Covid Nasal Swab- negative 3/19/21 CBC & CMP Abnormal results ( RBC-3.17; HGB-8.3; Hct-26.6; MCH-26.1; MCHC-31.1; MPV-6.8; Glucose-136; BUN-43; Creatine-1.93-BUN/Cre-22.0; Co2-33.9; AGAP-4; Calcium lv-8.2- Total Protein-5.8, Albumin-2.55; A/G Ration-0.8
CDC Split Type:

Write-up: 3/20/21 06:22 pm Resident c/o Nausea and feeling full- Tube feeding placed on Hold- Resident started vomiting- Zofran 4 mg given- Positive outcomes. 03/21/2021- 0430 Resident found unresponsive on morning rounds- w/ weak pulse, shallow breathing. O2 via NC increased to 5 L, NP, Family ( Code Status DNR)- Power of attorney ordered to send out- MR notified- Upon arrival no rhythm detected- Death pronounced at 0445


VAERS ID: 1125891 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-11
Onset:2021-03-19
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: An autopsy on the body was denied by the County Coroner.
CDC Split Type:

Write-up: Patient died with an unknown cause. He was found on the kitchen floor with no blood present. We requested an autopsy but because the County Coroner said there was no foul play suspected, that they would not perform an autopsy on the body to determine the cause of death even though the family had requested an autopsy. The Funeral Home stated to us that it had the looks of a heart attack, but he was not qualified to make that determination. He stated that the way the blood had stopped and purpled in his neck, gave him the indication that the heart was unable to pump all the way.


VAERS ID: 1125936 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-20
Onset:2021-03-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cheyne-Stokes respiration, Cough, Dyspnoea, Feeding tube user, Pulmonary congestion, Resuscitation, Ventricular fibrillation, Ventricular tachycardia, Vomiting
SMQs:, Torsade de pointes/QT prolongation (narrow), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   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: Piperacillin-Tazobactam in Dex Solution 3-0.375 GM/50ML Use 3.375 gram intravenously every 8 hours for Staph infection of blood for 13 Days Lovenox Solution (Enoxaparin Sodium) Inject 70 mg subcutaneously one time a day for DVT prevention P
Current Illness: Cough, emesis and chronic health conditions as listed below
Preexisting Conditions: FRACTURE OF UNSPECIFIED PART OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING , ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE, ACUTE RESPIRATORY FAILURE WITH HYPOXIA , UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE, UNSPECIFIED STAPHYLOCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE, DYSPHAGIA, ORAL PHASE, PRESSURE ULCER OF SACRAL REGION, STAGE 4, MUSCLE WEAKNESS (GENERALIZED) , NEED FOR ASSISTANCE WITH PERSONAL CARE, DYSPHAGIA, OROPHARYNGEAL PHASE , COGNITIVE COMMUNICATION DEFICIT, CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED , TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, ESSENTIAL (PRIMARY) HYPERTENSION , MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD, PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED, PRESENCE OF CARDIAC PACEMAKER , LONG TERM (CURRENT) USE OF ANTICOAGULANTS, HYPOTHYROIDISM, UNSPECIFIED
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 3-21-21 at 5:35am - Intermittent coughing during HS. Afebrile. Upper lung fields noted congestion; clearing when coughing/turned repositioned per staff, Afebrile. 3-21-21 at 9:30am - In residents room repositioning him, resident vomited tube feeding. Turned him on his side and swept out his mouth. Tube feeding pump turned off. Breathing became labored. Second nurse placed non-rebreather mask on him. Called 911 to take resident to hospital. 3-21-21 9:45am EMS now at bedside. Pulse palpable, Cheyne Stokes respirations. O2 on per non-rebreather mask. EMS assessed resident- now in VT/VF CPR initiated. Code cart placed outside of door. 3-21-21 10:00am Resident transferred out to Rig with an organized heart rhythm. Dr. ( on call for Dr.) notified of event and transport to hospital.


VAERS ID: 1126004 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-02-22
Onset:2021-03-13
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: NKA
Diagnostic Lab Data: None known
CDC Split Type: Unknown

Write-up: When attempting to schedule dose #2, was advised by the family that the patient passed away on 3/13/2021.


VAERS ID: 1126012 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-10
Onset:2021-03-17
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death within 60 days of vaccination


VAERS ID: 1126015 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-09
Onset:2021-03-13
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Bladder catheterisation, Death, Dyspnoea, Hypotension, Intensive care, Mechanical ventilation, Nail injury, Oxygen saturation decreased, Pneumonia, Sepsis
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: baclofen, citracal with D, Multivitamin, coumadin, folic acid, trazadone, Vitamin B 12 injection, SMX/TMP 800/160 mg, Tylenol, Tums prn, albuterol inhaler prn, Triamcinolone topical prn, a & d ointment prn,
Current Illness: Cellulits with ruled out DVT
Preexisting Conditions: Multiple sclerosis, neurogenic bladder, depression, B12 anemia deficiency, anticoagulant therapy
Allergies: Amoxicillin, oxybutynin, amandadine
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Unknown adverse event from vaccination. 3/14/21 Informed by caregiver that client was sent by ambulance to ER and diagnosed with bilat pneumonia. She developed difficulty breathing on 3/13/21. She was seen at Walk In on 3/12/21 for toenail eviscerated and INR, and had been giving tylenol for pain control for toe. 3/15/21 Informed by caregiver client was in ICU, septic, bilat pneumonia, and low oxygen levels. 3/16/21 Informed by caregiver client not doing well authorized indwelling cath due to low blood pressure and ventilator. Client transfered by med flight to ICU. 3/17/21 Informed by caregiver client death last night.


VAERS ID: 1126060 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-03-05
Onset:2021-03-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: METOPROLOL; METFORMIN; GLIPIZIDE
Current Illness: Diabetes
Preexisting Conditions: Medical History/Concurrent Conditions: Cardiac disorder; Shortness of breath
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: death 2 and half hours after receiving the first Moderna vaccine; A Spontaneous report was received from a health care professional concerning a 61 year old male patient,who received Moderna''s COVID-19 vaccine (mRNA-1273) and reported death. The patient''s medical history as provided by the reporter included diabetes, history of shortness of breath, cardiac history. Concomitant medications included metoprolol, metformin and glipizide. On 05 Mar 2021, prior to the onset of events the patient received his first dose of their two planned doses of mRNA-1273 (Batch N0: 030a21a) intramuscularly for prophylaxis of covid 19 infection. On 05 Mar 2021,it was reported that the patient died 2 and half hours after receiving the first Moderna vaccine. The patient had no symptoms during observation 15 minutes after receiving fist Moderna vaccine.The patient''s PCP ordered an autopsy. Treatment information not included. Action taken with mRNA-1273 in response to the events was not applicable. On 05 Mar 2021, it was reported that the patient died.; Reporter''s Comments: This is a case of sudden death in a 61-year-old male subject with hx of diabetes, history of shortness of breath and cardiac history, who died 2 1/2 hours after receiving first dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1126222 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-04
Onset:2021-03-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Angiogram cerebral, Aphasia, Cerebral haemorrhage, Communication disorder, Computerised tomogram head, Computerised tomogram neck, Hemiplegia, Nervous system disorder
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prozac 40 milligrams PO daily Synthroid 125 micrograms PO daily Protonix 40 milligrams PO daily
Current Illness:
Preexisting Conditions: History of thyroid cancer, hypothyroidism, gastroesophageal reflux. History of cholecystectomy and gastric bypass surgery. History of ATV accident in 2012 with hemopneumothorax, pulmonary contusion, multiple rib fractures and grade 3 splenic laceration.
Allergies: no known allergies
Diagnostic Lab Data: CT head unenhanced CT angiogram head and neck
CDC Split Type:

Write-up: Patient admitted to hospital on 3/6/21 with sudden onset right-sided hemiplegia and aphasia. CT showed acute intraparenchymal brain bleed. Family chose palliative care over neruosurgical intervention due to sever neurologic impairment and inability to communicate. Patient was discharged to home hospice on 3/9/21.


VAERS ID: 1126293 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-03-11
Onset:2021-03-21
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   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: Allopurinol Colcrys
Current Illness:
Preexisting Conditions:
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 10 days after receiving first moderna covid vaccination. Was not told by patients family cause of death, unclear if there is a link between vaccination or not.


VAERS ID: 1126550 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-28
Onset:2021-03-09
   Days after vaccination:40
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Computerised tomogram, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: SARS-CoV-2 test positive
Allergies:
Diagnostic Lab Data: Test Date: 202103; Test Name: CT scan; Result Unstructured Data: lungs were whited out,heavily filled with fluid- could be pulmonary edema
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a 66-year-old, female patient, who received Moderna''s covid-19 vaccine (mRNA-1273) and died. The patient''s medical history included covid-19 infection on 04 Nov 2020. No relevant concomitant medications were mentioned. On 28 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Batch number:unknown) intramuscularly for prophylaxis of COVID-19 infection. On 09 Mar 2021, the patient died. CT was done and did not find any atherosclerosis but found her lungs were whited out,heavily filled with fluid which he described could''ve been pulmonary edema. She had tested Covid positive back on 04 Nov 2020. Treatment information was not provided. Action taken with mRNA-1273 in response to the event was not applicable. The outcome of the event was fatal. The patient died on 09 Mar 2021 and the cause of death was unknown. An autopsy was planned on 11 Mar 2021.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1126609 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-03-17
Onset:2021-03-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Drug screen negative, Haemoglobin normal, Platelet count decreased, Red blood cell count normal, Thrombosis, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: none known by family who showed up at ED.
Current Illness: ETOH ABUSE, TOBACCO ABUSE, DIABETES,
Preexisting Conditions: DIABETES, TOBACCO AND ETOH ABUSE, SOME UNKNOWN LIVER DISEASE BY FAMILY REPORT-ON ONE KNOWS THE NAME OF IT.
Allergies: none known
Diagnostic Lab Data: CBC: WBC 12.8, RBC 4.82, HGB,15.0, HCT 46.0, PLATELETS 29 (LL)-BLOOD WAS CLOTTED, PT WAS DOA. DRUG SCREEN ALL NEGATIVE
CDC Split Type:

Write-up: CARDIOPULMONARY ARREST 2 DAYS AFTER RECIEVING SECOND MODERNA DOSE


VAERS ID: 1126619 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-19
Onset:2021-03-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for Anemia; Lasix Tablet 40 MG Give 1 tablet by mouth one time a day for PLEURAL EFFUSION for 3 days; Losartan Potassium Tablet 50 MG Give 1 tablet by mouth one time a day for HTN
Current Illness: METABOLIC ENCEPHALOPATHY; PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA); AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS; NUTRITIONAL ANEMIA; UNSPECIFIED; UNSPECIFIED ATRIAL FIBRILLATION; ESSENTIAL (PRIMARY) HYPERTENSION; VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE; OTHER ABNORMALITIES OF GAIT AND MOBILITY; MUSCLE WEAKNESS (GENERALIZED); UNSPECIFIED PROTEIN-CALORIE MALNUTRITION; PLEURAL EFFUSION, NOT ELSEWHERE CLASSIFIED; SECONDARY PULMONARY ARTERIAL HYPERTENSION, NONRHEUMATIC MITRAL (VALVE) INSUFFICIENCY; ATHEROSCLEROSIS OF AORTA; CARDIOMEGALY, CONTACT WITH AND (SUSPECTED) EXPOSURE TO COVID-19; DYSPHAGIA FOLLOWING OTHER CEREBROVASCULAR DISEASE, PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2; PRESSURE ULCER OF OTHER SITE, STAGE 2; PRESSURE-INDUCED DEEP TISSUE DAMAGE OF LEFT ANKLE.
Preexisting Conditions:
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: His vitals signs was stable after vaccine was administered, but the resident was expired in 85mins after given 1st dose of Covid Moderna vaccine.


VAERS ID: 1126639 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Apnoea, Unresponsive to stimuli, Vital capacity abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (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: Amantadine HCL 100mg BID, KCL 20 meq q Day, Remeron 30mg Q HS, Hydrocodone 7.5/352mg prn
Current Illness:
Preexisting Conditions: Depression, Parkinsons, HTN, CHF
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: @ 6:50 pm- Resident lying in bed with signs of apnea also has o2 in progress per Nasal cannula. Call bell in reach. v/s 53/20, 12, 101.5, o2 is 92%. Family choice not to send out to hospital bc resident had HX of periods of apnea @ 9:30 pm- resident had no means of life, vitals wasnt reading at this time.


VAERS ID: 1126681 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-20
Onset:2021-02-04
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Multiple Myeloma relapse, CKE stage 3, DM, BPH, liver cirrhosis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Family notified facility of death when we contacted to confirm second dose appointment


VAERS ID: 1126683 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-26
Onset:2021-03-02
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RL / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Afib, back pain, bilateral knee pain, hematuria, diabetes, diverticulosis of colon, dyslipidemia, hypertension, abnormal liver function tests, pancreatic mass, morbid obesity, elevated PSA, urinary retention, hearing loss.
Allergies: Motrin
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death within 60 days of vaccination. Tested positive for COVID-19 2/8/2021, admitted outpatient to Hospital 2/8-2/10 readmitted 2/13-2/14 with transfer to Medical Center in with death on 3/2/2021.


VAERS ID: 1126721 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-18
Onset:2021-03-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Fatigue, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient experienced severe vomiting and fatigue 24 hours after receiving vaccine. This occurred throughout 48 hours after and patient was found d/c on 03/20/2021.


VAERS ID: 1126810 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-03-11
Onset:2021-03-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen 325mg tab, 1 tab 4x per day as needed for leg pain Artificial tears PVA 1.4%/Povidone, 1 drop in both eyes 4x per day as needed for dry eyes Brimonidine 0.2T ophthal. solution, 1 drop in both eyes 3x per day for glaucoma Diclo
Current Illness: RIGHT inguinal hernia with small bowel entrapment/reducible Dementia Anemia Impaired glucose tolerance Cholelithiasis RIGHT ankle pain Glaucoma Dry eye syndrome COPD hyperlipidemia asbestosis
Preexisting Conditions: RIGHT inguinal hernia with small bowel entrapment/reducible Dementia Anemia Impaired glucose tolerance Cholelithiasis RIGHT ankle pain Glaucoma Dry eye syndrome COPD hyperlipidemia asbestosis
Allergies: Codiene
Diagnostic Lab Data: After ED care, patient was on balloon pump until family able to arrive and discuss prognosis. Veteran was admitted to comfort care (hospice) on 3/18/2021 and died on 3/20/2021
CDC Split Type:

Write-up: Patient suffered AMI within 24 hours after dose was administered.


VAERS ID: 1126882 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Cerebrovascular accident, Headache
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: 2021-02-21
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: 3 anti-hypertensives; pain medications and several others
Current Illness: Inflammation in foot
Preexisting Conditions: Hypertension, AFIB, Degenerative Spinal Stenosis
Allergies: Penicillin, apricots, bananas
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s wife states that he reported a bad headache about 3 hours after vaccination, that had improved by the next morning. The afternoon of 1/27/21, within 24 hours of receiving the vaccine, patient suffered from a stroke.


VAERS ID: 1127080 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Decreased appetite, Dialysis, Dyspnoea
SMQs:, Torsade de pointes/QT prolongation (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: pantoprazole, citalopram, metoprol, renal tab Zn+D, aspirin, pravastatin, clopidogrel, amlodipine, trazadone, tramadol
Current Illness:
Preexisting Conditions: kidney failure, year after quad bypass
Allergies: penicillin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: He developed very labored breathing on Tuesday night. By Wednesday morning , upon waking it was severly worse. I would have taken him to the ER had I been home. When I returned home around 11am, he was having a very hard time breathing. I got him a rescue inhaler to use. He had a dailysis treatment that day, during the treatment they kept him on oxygen. I called Dr office to inform them, they ordered a new inhaler and told me if the symptoms did not decrease by 72 hours to inform them. His breathing did get somewhat better but he did not have his enegry levels that he had previously or his appeatite. 12 days after his 2nd dose of the Moderna vaccine he went into cardiac arrest in the home with myself and husband present.


VAERS ID: 1127148 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-02-01
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1127157 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-03-09
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

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

Write-up: Death


VAERS ID: 1127175 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-20
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1127245 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Ohio  
Vaccinated:2020-12-27
Onset:2020-12-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysphagia, Feeding disorder
SMQs:, Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   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: Fluoxetine HCL, Furosemide, Levothyroxine, Linzess, Meloxicam, Polyethylene Glycol, Tramadol, Simvastatin, Divalproex, Lorazepam, Acetaminophem, Polyethylene, Qtussin,
Current Illness: Alzheimers
Preexisting Conditions: High cholesterol, Anxiety, Major depressive disorder
Allergies: No
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine given Dec 27th 2020, patient couldn?t swallow eat or drink the next day, patients family notified Dec 29th 2020 and patient passed away on Dec 30, 2020 at 1 pm EST.


VAERS ID: 1127444 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-12
Onset:2021-03-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes, hypertension, obesity.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden onset of shortness of breath early morning 3/15/2021. EMS called, transported patient to Adventist to ER code blue in asystole. Asystole on arrival, no response to resuscitative efforts, pronounced dead in ER.


VAERS ID: 1127466 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-11
Onset:2021-03-14
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not known
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: No allergies listed on screening form. Denied any allergies
Diagnostic Lab Data: not known
CDC Split Type:

Write-up: Received call from his exwife that patient had passed away. Death Certificate states date of death as March 14, 2021. Causes of death are listed a. Cardiac Pulmonary Arrest. b. Myocardial Infarction


VAERS ID: 1127468 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-11
Onset:2021-03-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Acute kidney injury, Blood test normal, Confusional state, Death, Decreased appetite, Dizziness, Echocardiogram normal, Lethargy, Malaise, Nausea, Retinal vascular thrombosis, Somnolence, Ultrasound kidney normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Retinal disorders (narrow), Vestibular disorders (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: LOSARTAN 100 MG HYDRALAZINE 50 MG LOVASTATIN 20 MG METFORMIN 1000 MG OMEPRAZOLE 20 MG FUROSEMIDE 20 MG INSULIN GLARGINE 100 UNIT/ML
Current Illness: NONE
Preexisting Conditions: DIABETES HIGH BLOOD PRESSURE POSTHERPETIC NEURALGIA SCIATICA
Allergies: NONE
Diagnostic Lab Data: She had just had a heart ultrasound and kidney ultrasound and blood work less than a month before her vaccine and they both showed normal function. She went into complete renal failure in a less than a week.
CDC Split Type:

Write-up: Severe lethargy after receiving the shot. Constant sleepiness and malaise, nausea, confusion, loss of appetite, dizziness, Blood vessels/clots formed in her eyes. Acute renal failure and eventually death on March 18, 2021.


VAERS ID: 1127653 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-01
Onset:2021-01-20
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: METOPROLOL SUCC ER 25 MG HYDROCHLOROTHIAZADINE 12.5 MG HYDRALAZINE 50 MG L-THROXINE 100 MCG 800/ULTRA D TAB SENNA-S Docusate Sodium 50 MG/Sennosides 8.6 MG
Current Illness: N/A
Preexisting Conditions: Hypertension
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death by Hemorrhagic Stroke


VAERS ID: 1127847 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-15
Onset:2021-01-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, COVID-19, Cognitive disorder, Cough, Death, Deep vein thrombosis, Dyspnoea, Endotracheal intubation, Flushing, Full blood count, Hyperkalaemia, Hypoxia, Metabolic function test, Multiple organ dysfunction syndrome, Myalgia, Paralysis, Polyuria, Pyrexia, Respiratory failure, Sepsis, Unresponsive to stimuli, X-ray
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 39
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 36 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: see attached
Current Illness: COPD. DM HTN, sinusitis obesity, h/o stroke, hyperlipidemia,
Preexisting Conditions: broken nose, COPD, Diabetes Mellitus II, seasonal allergies with rhiniits, cervical degenerative disease
Allergies: NKDA
Diagnostic Lab Data: 1/20/21 x-rays, CBC. CMP --refer to hospital notes.
CDC Split Type:

Write-up: Participant felt flushed, feverish, fatigued with general aches and dry cough over the weekend after receiving injection, took acetaminophen and cough syrup on Monday. He became short of breath on 1/20/2021 and was hypoxic on oximeter check, was sent to the ER. He was intubated in ER and went into respiratory failure with sepsis due to COVID19. He was treated with tocilzumab, became paralyzed and DVT in left lower extremity was found. HE required pressors and diuresis, he developed AKI and hyperkalemia. On 2/21 he was in multi-organ failure. His level of cognition decreased until he was no longer responsive and he died on 2/24/2021.


VAERS ID: 1127860 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-17
Onset:2021-02-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cerebrovascular accident, General physical health deterioration, Illness, Influenza, Influenza B virus test positive, Neurological symptom, Organ failure, Pneumonia, Pulmonary mass, Respiratory failure, SARS-CoV-2 test negative, Sepsis, Transient ischaemic attack, Tremor, Urinary tract infection
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: blood pressure medicine, a-fib medicine, thyroid
Current Illness: None.
Preexisting Conditions: None.
Allergies: None
Diagnostic Lab Data: None. He died at the hospital.
CDC Split Type:

Write-up: Not sure if covid vaccine caused this, but this is what happened - Received covid vaccine. two days later had violent shakes in the night. Immediately went to get a covid test out of precaution. Tested negative for covid, but positive for "flu b". Went home to treat flu with fluids and rest. Got no better. Went to heart doctor out of precaution, full work up...everything checked out great. Went home, got no better. Went to primary care physician, full work up...found a "spot" on left lung. Was given antibiotics and steroids, go home and in a few days will be getting better. 3 days later became incapacitated and had to be rushed to ER. Was admitted into hospital for 6 days to treat "pneumonia". Also possible UTI and sepsis. Also while in hospital found out that a mini stroke had happened. Treatment went well, oxygen levels were good. Was released with glowing reports. 24 hours later at home had to be rushed to ER again after becoming incapacitated.. Was admitted again 7 more days. During this time everything took a nose dive in succession. Lungs were failing, multiple unexplained strokes were happening (while on blood thinners, had been on blood thinner 15 years...after first stroke they changed to another blood thinner...only more strokes). After so many strokes and compounding of strokes, his neuro function started failing. He was put on life support. While on life support his organs started failing. He had to be put on comfort mode and was dead within 8 hours. A perfectly healthy 77 year old man who had never been sick a day in his life (literally) got his 2nd covid shot, two days later he fell ill. From that point on his health spiraled out of control until his death on March 19th. Every doctor (pulmonologist, cardiologist, neurologist, and all attending doctors said that it was "atypical and abnormal" what was happening. It should not have happened. 180 degrees from normal.


VAERS ID: 1128052 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Feeling abnormal, Vaccination site pain, Vomiting
SMQs:, Acute pancreatitis (broad), Dementia (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Chest pain; felt really bad; Death; Vomited that night; Sore arm and pain in both arms; A spontaneous report was received from a consumer concerning a 83-years-old, male patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sore arm and pain in both arm /pain in extremity, felt really bad/feeling abnormal, chest pain and the patient died. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 03 Mar 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Lot number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 04 Mar 2021, patient experienced sore arm and felt bad. The patient vomited that night. On an unknown date patient reported chest pain and pain in both arms. On 05 Mar 2021, at 12:46pm the patient died. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on 05 Mar 2021. The cause of death was reported as unknown. Plans for an autopsy were unknown.; Reporter''s Comments: This is a case of death in an 83-year-old male subject with unknown medical history, who died 2 days after receiving first dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1129005 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-13
Onset:2021-03-20
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1129117 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-03-15
Onset:2021-03-23
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   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: Norco 325 mg-7.5 mg tablet 1 tab(s) orally TID prn, Notes: given by Pain clinic Methotrexate Sodium 2.5 mg tablet 3 tabs orally once a week folic acid 1 mg tablet 1 tab(s) orally once a day Periactin 4 mg 1 tab Oral bid for a
Current Illness:
Preexisting Conditions: Systemic lupus erythematosus, Rheumatoid arthritis
Allergies: cefdinir
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away in her sleep 8 days after receiving 2nd dose of Moderna vaccine. Patient''s family reports they believe it was a massive heart attack. They do not believe this was related to the vaccine.


VAERS ID: 1129805 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-03
Onset:2021-03-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Blood pressure measurement, Death, Depressed level of consciousness, Dizziness, Hypotension, Loss of consciousness
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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   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: LEVOTHYROXINE; ISOSORBIDE; ASPIRIN ACTAVIS -low dose aspirin; METOPROLOL; LASIX [FUROSEMIDE SODIUM]; WARFARIN
Current Illness: Heart disorder
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210308; Test Name: Blood Pressure; Result Unstructured Data: Low
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; unconscious; in and out of consciousness; weak, very weak; blood pressure was very low; little light headed; A spontaneous report was received from consumer concerning a 88 years old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced a little light headed/ dizziness, weak, very weak/asthenia, blood pressure was very low/ hypotension, in and out of consciousness/depressed level of consciousness, unconscious/ loss of consciousness and passed away. The patient''s medical history was reported as heart issues. Concomitant medications taken by the patient included levothyroxine, isosorbide, acetylsalicylic acid, metoprolol, furosemide, warfarin, antibiotics. On 3 Mar 2021, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 (Lot number: 015M20A) intramuscularly in the right arm for prophylaxis of COVID-19 infection. On 3 Mar 2021, when the patient got home the night, after getting the shot, patient was a little lightheaded, she seemed to be okay on 04 Mar 2021 and 05 Mar 2021. Patient had complained of being weak and her blood pressure was very low on 08 Mar 2021. She was progressively started getting weaker. On 09 Mar 2021, she was very weak and was in and out of consciousness. Patient was taken to the hospital, and she became unconscious and then passed away. Patient passed away on 09 Mar 2021. The patient died on 09 Mar 2021. The cause of death was unknown. Plans for an autopsy were unknown. Treatment activities for event was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of events, unconscious, a little light headed, weak, very weak, blood pressure was very low, in and out of consciousness was unknown. The outcome was considered fatal.; Reporter''s Comments: This is a case of sudden death in a 88-year-old female patient with a history of heart issues, who died 6 days after receiving first dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1129838 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-16
Onset:2021-03-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide, Glipizide, BP and cholesterol meds, aspirin
Current Illness: No acute illnesses
Preexisting Conditions: CKD stage 3, CAD, Diabetes, HTN
Allergies: none
Diagnostic Lab Data: None - dead on arrival to ED
CDC Split Type:

Write-up: chest pain, vomiting, death


VAERS ID: 1129860 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-19
Onset:2021-01-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: Died January 21 after she received an mRNA shot; A spontaneous report was received from a consumer via social media concerning a 28-year-old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and died two days later (death). The patient''s medical history was not provided. No relevant concomitant medications were reported. On 19 Jan 2021, per social media post, the patient received one of their two planned doses of mRNA-1273 (Batch number not provided) intramuscularly for prophylaxis of COVID-19 infection. The reporter stated that the patient was dead on 21 Jan 2021. Treatment information was not provided. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on 21 Jan 2021. The cause of death was reported as unknown. An autopsy was done. The reporter stated that the autopsy showed no other red flags, otherwise, no additional autopsy results were reported.; Reporter''s Comments: Very limited information regarding this event has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1129951 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-02
Onset:2021-03-21
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   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: Lisinopril 20mg Amlodipine 10mg Lasix 40 mg Lopressor 25mg ASA 325 mg
Current Illness: COVID- NOT POSTIVE AT TIME OF VACCINATON, ALTHOUGH DID NOT DISCLOSE HE HAD BEEN TESTED FOR COVID ON 2/27/21
Preexisting Conditions: HTN, Aortic Valve Replacement, venous stasis, CAD, AAA, and s/p squamous cell carcinoma in 2019
Allergies: NKDA
Diagnostic Lab Data: Positive COVID test on 3/2/2021 3/6 ? patient presents to ED in severe respiratory distress, DX of Covid-19 pneumonia & transferred to ICU
CDC Split Type:

Write-up: 72 y/o with hx of HTN, Aortic valve replacement, venous stasis and venous insufficiency of both lower extremities, CAD, AAA, and s/p squamous cell carcinoma excision in 2019 Upon reviewing the history, here is what we found. 1. 2/27 -- Received send-out covid swabbing/testing- Patient did not disclose this information when screened for his covid vaccination at the clinic. 2. 3/2, 10:00 AM ? Presented to Covid Vaccination Clinic and received 1st dose of Moderna. Results of pending covid test were not back at this time, nor did he disclose this information when screened by nurse prior to vaccination. 3. 3/2, 10:30 PM ? Covid result came back to lab as positive SARS Co-V 2019 4. 3/3 ? patient called and notified of result per ED nurse 5. 3/3 ? Pharmacy recommended patient for mAB infusion (patient did not receive it) 6. 3/6 ? patient presents to ED in severe respiratory distress, DX of Covid-19 pneumonia & transferred to ICU 7. 3/21 ? patient dies after 15 day hospitalization in ICU (pt. had received convalescent plasma x 2 and remdesivir there)


VAERS ID: 1129993 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-03-11
Onset:2021-03-23
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   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: Unsure
Current Illness: Family stated she felt fine after the shot. Complained of upset stomach and took tums at bedtime. Died in her sleep.
Preexisting Conditions: Unsure
Allergies: Nka
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Family stated she felt fine after shot. Had upset stomach night before her death. Took tums. Died in sleep.


VAERS ID: 1130105 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-01
Onset:2021-02-24
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol Synthroid Azithromycin Buspirone Eliquis Lasix Lipitor Miralax Inhaler Remeron Sertraline Sim ethic on pen
Current Illness: Cellulitis
Preexisting Conditions: Hypothyroidism Type 2 diabetic Acute respiratory failure Arthritis Muscle weakness Depression
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Kidney failure and death. Patient heart labs were good.


VAERS ID: 1130110 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-02-21
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Incomplete course of vaccination
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away unrelated to covid vaccination Narrative: The patient had diabetes, hypertension and coronary atherosclerosis. Patient received his first dose of Moderna on 1/7/2021. Patient elected to not receive 2nd dose vaccination following clinical discussion with provider. Patient was diagnosed with pancreatic cancer and ws place on hospice care. Patient passed away on 2/21.No indication that death was related to COVID 19 vaccination.


VAERS ID: 1130111 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-02-08
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away unrelated to covid vaccine Narrative: The patient received his first dose of Moderna on 1/14 and he was rushed to the hospital at 4 am on 1/15. The patient tested positive for COVID and is hospitalized in the hospital. The patient passed away on 2/8. Cause of death not documented, possibly due to COVID complication. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1130112 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-09
Onset:2021-02-16
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 - / IM

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

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

Write-up: Patient passed away unrelated to covid vaccination Narrative: The patient had COPD and history of prostate cancer. Patient was placed on hospice care. Patient received his first dose Moderna on 2/9. Patient passed away on 2/16. Cause of death not documented. No indication that death was related to COVID 19 vaccination.


VAERS ID: 1130148 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Missouri  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Liver disorder
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: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: something wrong with the liver; A spontaneous report was received from a consumer concerning patients of unspecified age and gender who received Moderna''s COVID-19 vaccine (mRNA-1273) and were dying after second shot and something wrong with the liver (liver disorder). The patients'' medical histories were not provided. No relevant concomitant medications were reported. Dates of vaccination were not reported. The reported heard on the news that "people are dying after the second shot" and apparently one of the patients had something wrong with the liver after getting the shot. The reporter said the patients received Moderna''s mRNA-vaccine. On an unknown date, the patient experienced the event(s) people are dying after second shot, No treatment information was provided. The action taken with the vaccine in response to the events was not applicable. The cause of death for "one of the patients was had something wrong with the liver".; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested; Reported Cause(s) of Death: liver disorder; death unknown cause


VAERS ID: 1130250 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-17
Onset:2021-03-16
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   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: Abilify, ASA, Breo Ellipta, Clonidine, Cymbalta, Furosemide, Hydralazine, Incruse Ellipta, Isosorbide Mononitrite, Labetalol, Levothyroxine, Nifedipine, Potassium Chloride, Pravastatin, Pro Air
Current Illness: None. Patient went into hospital with SOB on 3/16/21 and was diagnosed with COVID.
Preexisting Conditions: HTN, COPD, Chronic Kidney Disease Stage 4, Hypothyroidism
Allergies: HCTZ, Hydrocortisone and Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient tested positive for Covid on 3/12/21 per hospital admission notes. Patient was admitted to the hospital on 3/16/2021 with Covid pneumonia. She passed away on 3/22/21.


VAERS ID: 1130251 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-03-03
Onset:2021-03-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036A21A / 2 UN / IM

Administered by: Senior Living       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: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Insuline, Synthroid, Omeprazole
Current Illness: No
Preexisting Conditions: Diabetes, hypothyroidism
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-66-21

Write-up: Sister reports that she was fine, the day before I took her to the dentist. Sister on 5/3/2021 called her and did not answer, so she goes to the nursing home where she resides. She finds her sister cold in the apartment''s furniture. Massive heart attack


VAERS ID: 1130306 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-29
Onset:2021-02-03
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure fluctuation, Dyspnoea, Oxygen saturation decreased, Respiratory failure, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Furosemide 40mg, Plavix 75 mg, Aspirin 81 mg, Atorvastatin 40 mg, Norvasc 5m
Current Illness: No
Preexisting Conditions: CVA/ patient was in terminal stage
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-67-21

Write-up: It began on 2/3/2021 to present low saturation, pressures rose and fell (unstable). They gave him therapy, since he could not breathe. On 02/04/2021, POC reports that caregivers took their rounds and he was without vital signs. Doctor certifies that it was due to respiratory failure.


VAERS ID: 1130327 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: b12, vitamin d, sodium bicarb, metoprolol, furosemide, doxazosin
Current Illness:
Preexisting Conditions: obese, arthritis, hip replacement
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: died in sleep


VAERS ID: 1130340 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-12
Onset:2021-02-25
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   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: Buspiron,Norvasc,Lipitor,Melatonina,Temazepam,Keppra, Vasotec, Zintroi,Omeprazole
Current Illness: None reported
Preexisting Conditions: Down syndrome / patient with PEG, Foli, Hypertensive, Thyroid, Alzheimer''s, Anxiety, Insomnia
Allergies: None reported
Diagnostic Lab Data: Tested for aspiration pneumonia and the result was negative
CDC Split Type: PR-68-21

Write-up: 2/25/2021 She was taken to the hospital for aspiration. 03/09/2021 was discharged, but relatives were informed that she was unwell. 3/13/2021 When they went to take the rounds she was without signs, she was sleeping. He refers that the patient died of Aspiration Pneumonia and was tested at the Hospital with negative results. They certify death due to cardiovascular arrest


VAERS ID: 1130386 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-24
Onset:2021-03-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Coronary artery occlusion, Death, Syncope, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Medication NovoLIN 70/30 subcutaneous suspension 75 unit(s) subcutaneous 2 times a day hydroCHLOROthiazide 12.5 mg oral tablet 1 tab(s) orally once a day amLODIPine 5 mg oral tablet 1 tab(s) orally once a day atorvastatin 40 mg oral ta
Current Illness:
Preexisting Conditions: mild intellectual disability, HTN, pancreatitis s/t hypertriglyceridemia and uncontrolled IDDM
Allergies: Penicillin, Meropenem, motrin
Diagnostic Lab Data:
CDC Split Type:

Write-up: syncopal event. 911 was then called. Once EMS arrived he was found unresponsive and was in V fib.; transferred to the cath lab where he was found to have a proximal LAD occlusion deceased 3/17/2021


VAERS ID: 1130616 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-03-16
Onset:2021-03-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Myocardial infarction, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (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: 2021-03-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Community partner reported that they found her unresponsive on the 17th (so she may have died on the 16th) from what they believe was a heart attack. The family has requested an autopsy.


VAERS ID: 1131280 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-03
Onset:2021-03-22
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 29K21A / 2 - / -

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Chills, Death, Malaise, Pulse absent, Pyrexia, Respiratory arrest, Unresponsive to stimuli, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   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: Trulicity, and a few others.
Current Illness: None
Preexisting Conditions: Type 2 Diabetes, Hypertension
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 3/23/2021, Patient became ill, vomiting uncontrollably, throughout the day. On 3/24/2021, he continued his vomiting episodes, and developed a fever with chills. At about 2100 hrs, patient was extremely weak, he went to the bathroom, urinated, and attempted to crawl back to his bedroom, less than 10 steps away. His wife, called 911, and went down stairs to allow entry for the fire department, The fire department, found patient unresponsive, not breathing, and no pulse. He was pronounced dead in his home.


VAERS ID: 1131556 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-02-23
Onset:2021-03-10
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Immune thrombocytopenia, Platelet count decreased
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Mobic Atorvastatin Sulfasalazine
Current Illness:
Preexisting Conditions: Sjorgens
Allergies:
Diagnostic Lab Data: Platelets under 10,0000
CDC Split Type:

Write-up: Diagnosis?s with TTP on March 12. Passes away on March 19 2021


VAERS ID: 1131617 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anxiety, Asthenia, Death, Dyspnoea, Heart rate abnormal, Malaise, Pain in extremity
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 43
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: B-12 1000 mcg tablet 1 tablets orally once a day for vitamin 01/22/21 Bactrim DS 800 mg-160 mg tablet 1 tablets orally every 12 hours x 7 Days for Other Instructions: With H2O 03/07/21 biotin 5000 mcg tablet, disintegrating 1 tablets orally
Current Illness: Diastolic Heart Failure, NYHA Class IV Co Morbid Dx Atrial Fib, Murmor, HTN, Anemia, Kidney Failure Secondary type 2 Diabetes
Preexisting Conditions: Diastolic Heart Failure, NYHA Class IV Co Morbid Dx Atrial Fib, Murmor, HTN, Anemia, Kidney Failure Secondary type 2 Diabetes
Allergies: Codeine, hydromorphone, cipro
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt c/o of left arm pain after injection and for several days after. Pt was in bed for 2 days after injection c/o generalized malaise and weakness. Pt c/o of feeling of funny heart rhythms and feeling of constant anxious feeling. Pt started having episodes of SOB and was very labored doing simple tasks such as using the toilet. Pt started using o2 for the first time and had to recover for any activity for several minutes. Different medications were tried to help control symptoms such as Morphine for SOB and ativan for anxious feelings. Symptoms were never well managed after vaccine. Pt eventually died from worsening symptoms on 3/20


VAERS ID: 1132062 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-18
Onset:2021-03-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ativan and Morphine- per Hospice orders
Current Illness: Patient had been admitted to Hospice prior to her first dose of the vaccine. She had been decompensating for many months prior.
Preexisting Conditions: COPD, Emphysema, hypertension, seizure disorder, anemia, schizoaffective disorder, bordeline personality disorder,
Allergies: Lithium
Diagnostic Lab Data:
CDC Split Type:

Write-up: Had multiple hospitalizations for COPD prior to COVID-19 infection in December 2020. Had been admitted to Hospice for further decompensation after COVID diagnosis. Limited oral intake and hospice began using morphine and Ativan. Was on comfort medications only prior to 1/26/2021


VAERS ID: 1132090 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Illinois  
Vaccinated:0000-00-00
Onset:2021-03-09
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Fibrin D dimer increased, SARS-CoV-2 test positive, Ultrasound scan
SMQs:, Haemorrhage laboratory terms (broad), 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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Afib, CKD stage 3, Mycardial infarction, Pacemaker, Anemia, hyperlipidemia, DM2, hypothyoidism, GERD, heart failure
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reportedly received COVID vaccine doses on 1/23 and 2/15, but we are unsure of which manufacterer or lot number. Patient admitted to our hospital on 3/9/2021. Patient presented with elevated D-dimer with concern for septic shock. Ultrasound of patient revealed no VTEs. COVID test on 3/10 resulted POSITIVE. Patient was going to require vasopressors but patient requested to go on comfort measures only. Patient ordered comfort measures on 3/10 and pronounced deceased on 3/18.


VAERS ID: 1132159 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-23
Onset:2021-03-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-24
   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: unknown
Current Illness: None Reported
Preexisting Conditions: Diabetes, CHF, COPD
Allergies: None reported
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death, adverse event occurred outside of the hospital and outside of observation window. Event was reported via employee to hospital.


VAERS ID: 1132299 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-03-06
Onset:2021-03-18
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Trapadone 50mg / ASA 81mg / Amiodipine 2.5mg / Levothyroxine 25mg, Silvadene 1% cream / Ipratroprilem Bromide 0.2% / Acetaminophen every 6 hrs / Cepalexin 250mg / Gabapentin 100mg twice a day but not given since March 16, 2021.
Current Illness: None reported
Preexisting Conditions: Alzheimer''s, Thyroid, Gastro Patient
Allergies: None reportes
Diagnostic Lab Data: None reported
CDC Split Type: PR-69-21

Write-up: Unstable vitals


VAERS ID: 1132313 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-03-23
Onset:2021-03-01
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Body temperature increased, Death, Headache, Pain, Scan normal, Urinary tract infection
SMQs:, Neuroleptic malignant syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-24
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown. Patient was only at our site for COVID 19 vaccine. Patient denied taking a blood thinner or taking medications suppress the immune system
Current Illness: Patient reported history of type 2 diabetes. Patient had been positive for COVID 19 2/4/21.. On 2/23/21 pt was at our office (post quarantine) for 1st dose of COVID 19 vaccine. Pt denied any symptoms of illness at that time.
Preexisting Conditions: DM II is all that I am aware of
Allergies: Patient had reported no known allergies
Diagnostic Lab Data: pt was treated at Hospital
CDC Split Type:

Write-up: Patient got vaccine dose #2 on 3/23/21 (Tues) approx 10am. Per family reports patient went to hospital 3/24/21 (Wed) for unspecified pain and temp of 102f. Family states a "scan" was done and came back with nothing. P was treated for UTI and sent home. Patient was reportedly laying down at home about 8:15 or 8:30am complaining of a bad headache. Patient was found later that am deceased in her bed.


VAERS ID: 1132327 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-03-01
Onset:2021-03-19
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Larbidora 100 mg, Ramipril 5mg, Atorvastatin Calcium 20mg, Amantadine Hydrochloride 100 mg, Furosemide 20 mg, Omeprazole 20 mg, Cevothyroxine 0.025 mg, Tizadine HcL 2mg, Janymet XR 100 mg/1000 mg, Montelukast sodium 10mg, Gabapentin 600 mg
Current Illness: None reported
Preexisting Conditions: Alzheimer''s, respiratory problems (oxygen dependent), cardiovascular conditions, diabetes, hospice, hypertensive
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-70-21

Write-up: They proceed to take the round and at that moment they realize that she was not breathing, she was already compromised . He dies of heart failure.


VAERS ID: 1132360 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-27
Onset:2021-02-02
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, Vital functions abnormal
SMQs:

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: Irbesantan 300 MG, Metoprolol 50 mg
Current Illness: None reported
Preexisting Conditions: Diabetes, Hypertension, Alzheimer''s, Renal Failure
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-71-21

Write-up: She was being treated for kidney failure, at one point her body was not responding to the treatments and they put her in Hospice. She was in hospice for some 5 days. She had been dying for days and in one of the rounds around 6 am on 2/2/2021, the caregivers accompanied her until she no longer had vital signs.


VAERS ID: 1132458 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-04
Onset:2021-03-14
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Folic Acid, Melatonin 3 mg, Rosuvastatin 40 mg, Docusate 100 mg, Tamsulosin, Finasteride
Current Illness: None reported
Preexisting Conditions: Alzheimer''s and Prostate Cancer
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-72-21

Write-up: He was in Hospice. He died as a veteran. He had a constant lack of appetite. Has no additional information


VAERS ID: 1132667 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-04
Onset:2021-03-04
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac failure, Death, Hypotension
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Cardiomyopathy (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin 20 mg, Buspirone 10 mg, Clonazepam 2 times a day, Docusate, Donepezil 10 mg, Lisinopril 2.5 mg, trazondone 50 mg, Venlafaxine 75 mg, Risperidone 0.5 mg, Levothyroxine 100 microgram
Current Illness: None reported
Preexisting Conditions: Renal failure, Hypertension, Diabetes, High cholesterol, Hyperthyroidism, Anemia
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-74-21

Write-up: She was transferred to the hospital on 3/4/2021 due to low blood pressure, she understands that due to heart failure. The death certification information is unknown.


VAERS ID: 1132713 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-02
Onset:2021-02-16
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043220A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypotension, Pneumonia, Resuscitation
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   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: Thorazin 200 mg, Flurazepam, Depakote,
Current Illness: None reported
Preexisting Conditions: Severe Intellectual Disability, Poor Impulse Control, Epilepsy, Gastritis, Vascular Dementia, Hypertensive
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-74-21

Write-up: 2/16/2021 He was transferred to the Regional Hospital of due to low pressure (systole), received CPR in the ambulance on the way to the hospital. He died on 2/19/2021 due to various complications, including pneumonia.


VAERS ID: 1133010 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-03-09
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Cardiac failure, Chest discomfort, Confusional state, Dizziness, Dyspnoea, Respiratory failure
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Bee sting hypersensitivity; Bipolar disorder; Hypertension; Obesity
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: shortness of breath; weakness; diffuse chest tightness; confusion; dizziness; cardiac failure; pulmonary failure; A spontaneous report was received from a consumer concerning a 51-year-old, male patient who developed cardiac failure, pulmonary failure/respiratory failure and died. The patient''s medical history included hypertension, obesity, bee allergy and bipolar disorder. Concomitant product use was not provided by the reporter. Patient received first dose of vaccine prior to two weeks to his death (died on 09 Mar 2021). A week prior to his vaccination as shortness of breath, weakness, diffuse chest tightness, confusion, and dizziness. These symptoms progressed following his vaccination and he was hospitalzed for two days prior to his death on 09 Mar 2021. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 09 Mar 2021 The cause of death was reported as cardio/pulmonary failure with secondary and tertiary causes of hypertension and obesity. Plans for an autopsy were not provided. The outcome of the events, cardiac failure and pulmonary failure were fatal.; Reporter''s Comments: This is a case of death in a 51-year-old male subject with a medical history of HTN, obesity, bee allergy and bipolar disorder,who died 7 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: cardiac failure; pulmonary failure


VAERS ID: 1133564 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-02
Onset:2021-02-12
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043220A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypotension, Respiratory arrest
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin 40 mg, Lisinopril 20 mg, Metfomin 100 mg, Aldactone 25, Aspirina 81, Dilantin 100 , cogentin 1 mg, Activan 1mg, Seroquel
Current Illness: None reported
Preexisting Conditions: Hypertension, Diabetes, Epilepsy, Severe Intellectual Disability
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-76-21

Write-up: It was sent for low pressure on 02/12/2021 to the Hospital Medical Center. He died of respiratory arrest.


VAERS ID: 1133604 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-26
Onset:2021-03-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Restoril, Ketopine
Current Illness: None reported
Preexisting Conditions: Alzheimer
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-77-21

Write-up: She was taken to hospital 03/02/2021 where she died at 4 am from a heart attack.


VAERS ID: 1133712 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-22
Onset:2021-03-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21-2A / UNK LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiomegaly, Death, Headache, Hepatomegaly
SMQs:, Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-24
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: only reported allergy was to black walnuts
Diagnostic Lab Data:
CDC Split Type:

Write-up: reported bad headaches on the day following the vaccine--did not see the doctor--later died. the coroner reported that the preliminary autopsy showed an enlarged heart and liver


VAERS ID: 1133747 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-03-14
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anaemia, Chronic obstructive pulmonary disease, Coronary artery disease, Death, Dementia
SMQs:, Haematopoietic erythropenia (broad), Dementia (narrow), Noninfectious encephalopathy/delirium (broad), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2010-03-14
   Days after onset: 4018
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: died on hospice Narrative: Patient died on hospice, it is my clinical recommendation that death was r/t chronic anema, advanced dementia, COPD, CAD, and not related to prior administration of COVID-19 vaccination


VAERS ID: 1133940 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-02-12
Onset:2021-02-20
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol tartrate, diltiazem ER, furosemide, Xarelto, levothyroxine, morphine sulfate ER, hydrocodone-apap, trazodone, pregabalin, vitamin D
Current Illness: None
Preexisting Conditions: CVA with right-sided weakness, hypertension, atrial fibrillation, chronic pain, bilateral leg swelling
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found deceased at home on 2/20/2021, 8 days after receiving the 1st dose of COVID-19 vaccine.


VAERS ID: 1134021 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-09
Onset:2021-03-11
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 - / -

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

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

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


VAERS ID: 1134054 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-11
   Days after onset: 80
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 17 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalization within 6 weeks after receiving vaccine


VAERS ID: 1134070 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-29
Onset:2021-03-13
   Days after vaccination:43
Submitted: 0000-00-00
Entered: 2021-03-25
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: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1134376 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-03-25
   Days after vaccination:49
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiogenic shock, Coronary artery bypass, Death
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   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: 05/04/2017 Glucagon Emergency Kit (human-recomb) 1 mg injection 05/19/2020 FreeStyle Freedom kit 05/19/2020 Novolog Flexpen U-100 Insulin aspart 100 unit/mL (3 mL) subcutaneous 05/19/2020 Glucophage XR 500 mg tablet,extended release 05/19/2
Current Illness: HFrEF, CAD, HTN, DM
Preexisting Conditions: CAD, HTN, HLD, DM, HF
Allergies: Ibuprofen
Diagnostic Lab Data: hospitalized, had multiple tests
CDC Split Type:

Write-up: Patient passed away from cardiogenic shock after a CABG


VAERS ID: 1134432 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-23
Onset:2021-03-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-24
   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: Lasix, Sotolol, Amlodipine, Simvastatin, Eliquis, Flomax, Gabapentin
Current Illness: Chronic kidney disease, bilateral lower extremity edema, A-Flutter/A-fib
Preexisting Conditions: A-Fib, Chronic kidney disease, Hypertension, history of right renal mass, hypothyroidism
Allergies: NKA
Diagnostic Lab Data: N/A. This is not a suspected allergic reaction to the COVID vaccine at this time.
CDC Split Type:

Write-up: Pt went unresponsive at home per wife, was transported to hospital by EMS and died after getting to the hospital. This is not a suspected allergic reaction to the COVID Moderna vaccine at this time.


VAERS ID: 1134647 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-06
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Memory impairment
SMQs:, Anaphylactic reaction (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 81 y/o male patient was vaccinated 3/3/21 and died 3/6/21. Patient''s wife reported he was having "some trouble breathing" but could not remember whether this problem started before or after being vaccinated.


VAERS ID: 1135281 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-21
Onset:2021-01-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT: 011L20A EX / 1 LA / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; A spontaneous report was received from a Healthcare Professional concerning a 57-years-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away/death. The patient''s medical history was not provided. However, the patient had some serious chronic health condition. No relevant concomitant medications were reported. On 21 Jan 2021, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 (lot/batch: LOT: 011L20A Exp: 03July2021) intramuscularly in the left deltoid for prophylaxis of COVID-19 infection. He did not experience any symptoms right away and nothing within the next 15 mins under observation. On 22 Jan 2021, the patient passed away. Treatment details was not reported. Action taken with mRNA-1273 in response to the event passed away, was not applicable. On 22 Jan 2021, the patient died. It was unknown if an autopsy was performed.; Reporter''s Comments: Very limited information regarding the event of death has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Passed away


VAERS ID: 1135292 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-02-11
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

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

Write-up: Stroke shortly after the first dose; A spontaneous report was received from a consumer concerning an 81 year old, male patient who experienced stroke shortly after the first dose (cerebrovascular accident). The patient''s medical history was not provided. No relevant concomitant medications were reported. On 11 FEB 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 for prophylaxis of COVID-19 infection. It was reported that the patient experienced stroke shortly after the first dose. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not reported. The outcome of the event of stroke shortly after the first dose (cerebrovascular accident) was considered unknown.; Reporter''s Comments: This is a case of sudden death in a 93-year-old female subject with no medical hx reported who suffered a stroke (unspecified days) after receiving first dose of vaccine. Very limited information has been provided at this time. Further information will be pursued..


VAERS ID: 1135351 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-01-13
Onset:2021-02-03
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Testicular failure
SMQs:, Fertility disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Glipizide, atorvastatin, chlorpheniramine, terazosin, aspirin, gabapentin, ondansetron, mometasone, medical marijuana
Current Illness:
Preexisting Conditions: metastatic prostate cancer, diabetes mellitus 2, hypertension, nicotine dependence, hyperlipidemia, chronic kidney disease stage 3 associated with DM, GERD, osteoarthritis, age-related macular degeneration, rheumatoid arthritis, COPD, environmental allergy, chronic pain, history of TIA, history of Hepatitis C, testicular hypofunction, diabetic neuropathy, hypermetropia, astigmatism, presbyopia, combine form of senile cataract, chronic pain
Allergies: Metformin, NSAIDS
Diagnostic Lab Data: none.
CDC Split Type:

Write-up: 2/03/2021 Death. No treatment. Deceased.


VAERS ID: 1136004 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-15
Onset:2021-03-25
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   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: unknown
Current Illness: none known
Preexisting Conditions: Pulmonary Fibrosis, Atrial Fibrillation , Rheumatoid Arthritis
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patients representative notified pharmacy today to cancel patients second appointment as the patient had died this morning due to a staff infection in hospital. Representative did state they did not believe it was related to vaccination as patient has been having difficult time with underlying conditions (pulmonary fibrosis and atrial fibrillation).


VAERS ID: 1135730 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-11
Onset:2021-03-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: IRON SULFATE; FLUTICASONE; GABAPENTIN; LAMOTRIGINE; METHOCARBAMOL; PROPRANOLOL HYDROCHLORIDE
Current Illness: Bipolar disorder; Hypertension; Polyps; Tremor
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Patient found dead two days after vaccination; A spontaneous report was received from a healthcare provider concerning 48-year-old, male patient who received Moderna''s COVID-19 vaccine (mrna-1273) and died. The patient''s medical history includes bipolar disorder, colon polyps, hypertension, benign tremors & other Comorbidities. Concomitant product like iron sulfate, Fluticasone, Gabapentin, Lamotrigine, Methocarbamol, Propranolol hydrochloride was reported by the reporter . On 11 mar 2021, approximately 2 days prior to the event, the patient received their first dose of two planned doses of mRNA-1273 (Batch number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 13 Mar 2021, the patient died. No other details were reported. Treatment information was unknown. The patient died on 13 Mar 2021. The cause of death was not provided. Plans for an autopsy were unknown.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1135778 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-08
Onset:2021-03-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 2
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: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Breathing issues; Death; A spontaneous report was received from a consumer concerning a 78 years old, female patient who experienced breathing issues/dyspnoea. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. On 08 Mar 2021, prior to the onset of the symptoms, the patient received their first of two planned doses of mRNA-1273 (Batch number not provided) intramuscularly in an unknown arm for prophylaxis of COVID-19 infection. The patient experienced breathing difficulty on 12 Mar 2021. The patient died on 12 Mar 2021. Treatment information was not provided. Action taken with the drug in response to the events is not applicable. The patient died on 12 Mar 2021. The cause of death was not reported. The reporter wanted to conduct a autopsy to find out if the death was caused by the vaccine.; Reporter''s Comments: This is a case of death in a 78-year-old female subject with unknown medical history, who died 4 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: Unknown cause of death


VAERS ID: 1136547 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-19
Onset:2021-03-14
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 070M20A / 2 - / -

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

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

Write-up: 92 y/o - Severe dementia. Hospice


VAERS ID: 1136657 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-02-26
Onset:2021-03-20
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA 74 y/o several comorbidities. Stroke


VAERS ID: 1136716 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-12
Onset:2021-03-03
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Death, Dementia Alzheimer's type, Diabetes mellitus, Ulcer
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Dementia (narrow), Gastrointestinal ulceration (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Percoset, Preprotein, Insuline Humulin N
Current Illness: Non reported
Preexisting Conditions: Ongoing pain / patient received hospice services Hypertension, Diabetes, Diabetic neuropathy, Arthritis, Alzheimer''s
Allergies: Non reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-78-21

Write-up: The patient referred that has no symptoms. POC was with her, until she died. She died of Alzheimer''s, diabetes and a sacral ulcer that she brought when she was admitted.


VAERS ID: 1136862 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-09
Onset:2021-03-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Reported by brother, says he had two stents and was on blood thinners.
Current Illness: None.
Preexisting Conditions: Two stents placed, recent cardiology visit was ok.
Allergies: None.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Had his vaccine, he had some reaction but not aware of what it was. On 3/20/21 they found him slumped over the toilet where he had died. His brother had spoken with him the day before and was supposed to see him on Saturday. Brother is not aware if he had taken anything for his symptoms, probably just took some Tylenol.


VAERS ID: 1136867 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-27
Onset:2021-02-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M2OA / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Headache, Malaise, Pain
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: vomiting and diarrhea from 1st Moderna shot
Other Medications: unknown
Current Illness: Rheumatoid Arthritis, Osteoarthritis, AMD
Preexisting Conditions: Rheumatoid Arthritis, Osteoarthritis, AMD
Allergies: Clindamycin, ID Agents, Nexium, Penicillin, Tetracyclines, Omeprazole, Tetracine
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: headache started about 12 noon on day of, texted a friend at 5:47pm to say wasn''t feeling well, hurting all over mostly in chest, shoulders and head.


VAERS ID: 1137286 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-05
Onset:2021-03-11
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M2OA / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Aphasia, Arthralgia, Back pain, Blood creatine phosphokinase increased, Blood culture positive, Blood gases abnormal, Body temperature increased, C-reactive protein increased, CSF cell count increased, CSF glucose increased, CSF lymphocyte count, CSF neutrophil count increased, CSF protein increased, Chills, Computerised tomogram abnormal, Delirium, Echocardiogram, Echocardiogram abnormal, Endocarditis, Haematocrit decreased, Haemoglobin decreased, Hyperhidrosis, Hyperthermia, Immature granulocyte count increased, Joint range of motion decreased, Lymphocyte count decreased, Magnetic resonance imaging head abnormal, Mean platelet volume increased, Mental status changes, Mobility decreased, Myalgia, Neutrophil count increased, Platelet count decreased, Platelet morphology abnormal, Pseudohyponatraemia, Pyrexia, Red blood cell count decreased, Red blood cell sedimentation rate increased, Respiratory rate increased, Sepsis, Septic embolus, Somnolence, Staphylococcal infection, Tachycardia, Toxic encephalopathy, Toxicologic test abnormal, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Accidents and injuries (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Arthritis (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 3
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: No known OTC medications
Current Illness:
Preexisting Conditions: Gout, very poorly controlled diabetes mellitus, high cholesterol, tox screen positive for cannabinoids and cocaine. Recent MVA where hit the R shoulder, has been on PT since then (date of MVA not documented). Recent dental procedure 4 months ago, crown placement and high burden of caries.
Allergies: No known allergies
Diagnostic Lab Data: 3/11: Family started noticed patient was unable to answer questions, somnolent. Endorsed myalgias resembled post exercise soreness sensation. On ED, noted hyperthermia, Tmax in 105, associated with slight tachycardia, and increased respiratory rate, hyperactive delirium. Elevated BG 280, pseudohyponatremia, and mild AKI. WBC 9, PLT 123. CPK 400. PCT 8. CT with evidenced nasal septum perforation, and periapical lucency on Left First maxillary molar. Delirium episodes wax and waned seemed in relation to temperature fluctuations. LP performed at ED, with a cell count of 77 cells, 89% PMN. Protein 101, Glucose 144 (SBG 300), and tox screen positive for cannabinoids and cocaine. 3/12/21: exam concerning for limited mobility at R shoulder, significant back pain limiting ability to sit up or turn to side and hemorrhagic lesions on fingers concerning for embolic phenomena. No appreciable murmur, but later on rounds, a 1.8 x 1.5 cm vegetation was noted on the ventricular side of the aortic valve cusps. TEE has been ordered. He presented with fever and AMS, prompting an LP with 77 nucleated cells (89% PMNs), protein 101 and glucose ~ 50% of serum. WBC normal, low RBC (4.26), hemoglobin (12.6), hematocrit (38.6), platelet count (103), elevated MPV (12.2). Neutrophil bands 39% (high), lymphocytes 7% (low), absolute neutrophil count 9.51 (high), platelet estimate: decreased, platelet morphology: large platelets seen, Platelet clumps: rare. ESR (sed rate) high at 100 (ref range: 0-20), CPK 925, CRP 255 3/13/21: 1. MRSA Aortic valve infective endocarditis: complicated with brain septic emboli. 2. Suspected Lumbar vertebrae osteomyelitis/parameningeal involvement. Able to palpate entire spine, exquisite tenderness in L1-L2. Second set of BCx (03/12 9AM, 1/2) remained positive. First set with Vancomycin MIC <2 (susceptible). Noted results from MRI brain with shower like distribution of septic emboli. TTE with vegetative lesion in aortic valve. Labs: WBC elevated (12.10), low rbc (4.03), H/H (11.9/35.7), platelets (102), elevated MPV (12.7), neutrophils relative percent (87.2), immature granulocytes (0.7), neutrophils absolute count (10.55), decreased lymphocytes absolute count (0.63), elevated absolute immature granulocytes (0.09), low lymphocytes (5.2) 3/14/21: elevated WBC (12.96), low RBC (3.86), H/H (11.4/34.5), platelets (139), elevated MPV (12.0), neutrophils relative percent (85.9), immature granulocytes (1.5), neutrophils absolute count (11.14), decreased lymphocytes absolute count (0.81), increased absolute immature granulocytes (0.20), decreased lymphocytes (6.3), increased ESR (sed rate: 86), CPK (708), CRP (127) 3/15/21: -TTE positive for 1.8cm x 1.5cm mobile vegetation on the ventricular side of aortic valve cusps -LP with elevated protein, glucose/ serum ratio of 0.5 -Large amount of nucleated cells on cell count concerning for possible early meningitis or infection near the meninges
CDC Split Type:

Write-up: Brought in from ED, family concerned for altered mental status, hyperthermia, Tmax in 105. The patient stated that after the covid-19 vaccine on Friday, he experienced acute onset of R shoulder pain, constant, associated with decreased ROM. On PM Monday, he noticed first episode of chills, that lasted a few minutes, accompanied with sweating. This episode recurred 4 times over the week, then the family started noticed the patient was unable to answer questions and was somnolent. Blood Cultures in the ED were positive for MRSA 2:2. He was positive for endocarditis (previous dental work). Acute metabolic encephalopathy due to severe sepsis most likely 2/2 MRSA bacteremia complicated by NSTEMI and AKI in setting of newly diagnosed aortic valve endocarditis complicated by septic emboli to the bilateral cerebral hemispheres


VAERS ID: 1137449 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-11
Onset:2021-03-07
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardio-respiratory 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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xarelto 15 mg, Fero sulfato 45 mg, Mirtazapine 30 mg, Simvastin 20 mg, Divalproex 50 mg, Quetiapine 25 mg, Verapamil 80 mg, Trazodone 100mg, Sertraline 50 mg.
Current Illness: Unknown.
Preexisting Conditions: Alzheimer, cholesterol, high pressure.
Allergies: Unknown.
Diagnostic Lab Data:
CDC Split Type:

Write-up: He returned from the hospital through a PEG tube, he was stable. On 7/3/2021, caregivers give a round of vitals at 7:30 am, he was stable, when he was going to receive food he was without vital signs. Cause of death respiratory cardiac arrest.


VAERS ID: 1137461 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-25
Onset:2021-03-25
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Hypoxia, Intensive care
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), 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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol, amiodarone, atorvastatin, bumetanide, cholecalciferol, cinacalcet, diltiazem, ferrous sulfate, fluticasone-salmeterol, ipratropium-albuterol, levothyroxine, metolazone, metoprolol, multivitamin, nystatin cream, omeprazole, warf
Current Illness:
Preexisting Conditions: COPD, hyperlipidemia, hypertension, paroxysmal afib, gastric ulcer, CKD stage 4, gout, hyperparathyroidism, spinal stenosis (lumbar), hypothyroidism.
Allergies: Latex (itching/rash), environmental
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received first Moderna COVID shot 2/25/2021. Pt developed acute on chronic respiratory failure with hypoxia, presented to local hospital ED on 3/25 and transferred to our facility for higher level of care. Currently in ICU with covid related hypoxia and pneumonia.


VAERS ID: 1137529 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-19
Onset:2021-02-08
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Public       Purchased by: ?
Symptoms: Cardiac failure, Death, Dyspnoea, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Aspirina, Plavix, Indur 30 mg, Levothyroxine, Zyprexa 15mg, Prozac 20 mg, Xanax 1mg.
Current Illness: Unknown.
Preexisting Conditions: Hypertensive, cva, schizophrenia, depression.
Allergies: Unknown.
Diagnostic Lab Data:
CDC Split Type:

Write-up: See started having shortness of breath on the night of 8/2/2021. He sends her to do tests, and she was taken to the hospital. She died in the hospital due to kidney and heart failure.


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