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

Found 17,128 cases where Vaccine is COVID19 and Patient Died



Case Details

This is page 14 out of 172

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VAERS ID: 1066107 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Unknown  
Location: Pennsylvania  
Vaccinated:2021-01-21
Onset:2021-02-22
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 2 AR / IM

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

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

Write-up: death


VAERS ID: 1066118 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Death, Pulseless electrical activity, Resuscitation, Shock
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), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin Dulaglutide Glipizide Loratadine Losartan Metformin
Current Illness: None
Preexisting Conditions: Type 2 Diabetes Hypertriglyceridemia Hypertension Recurrent pancreatitis Obesity Nicotine dependence
Allergies: Apple, cherry, pear, pollen - throat swelling and itching
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had an unwitnessed cardiac arrest while outside walking his dog. AED in the field initially advised shock and was shocked 3 times without effect. At the time EMS ALS arrived, patient was in PEA arrest. He was transferred to Hospital with CPR in progress. Time of death called at 1857.


VAERS ID: 1066126 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-21
Onset:2021-01-26
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1066178 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-10
Onset:2021-02-15
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, General physical health deterioration, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CAD, HTN, Basal Cell CA, cancerous appendix removed 1 month ago
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Caller is nephew of patient. Patient was admitted to Hospital on 2/15/21 with Covid like symptoms and decreased O2 sat. He tested positive for Covid 2/15/21. Treated with Remdesivir. Patient status continued to decline and he passed away in hospital 2/22/21 0612.


VAERS ID: 1066199 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-08
Onset:2021-03-01
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 15M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Anion gap increased, Aspartate aminotransferase increased, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood calcium increased, Blood chloride normal, Blood creatine phosphokinase MB, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase increased, Blood glucose increased, Blood potassium normal, Blood sodium normal, Blood urea increased, Bradycardia, Carbon dioxide decreased, Death, Epinephrine, Full blood count, Globulins increased, Glomerular filtration rate decreased, Laboratory test, Malaise, Metabolic function test, Mydriasis, Myocardial necrosis marker, Myoglobin blood increased, Protein total normal, Pulse absent, Pupil fixed, Resuscitation, Syncope, Troponin I increased, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (narrow), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (narrow), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Multiple Vitamins(multivitamin) tablet 1 tablet by mouth once a day aspirin(aspirin) 81 mg tablet,delayed release (DR/EC) 1 tablet once a day ibuprofen(ibuprofen) 200 mg capsule 1-2 capsule by mouth at bedtime as needed carvedilol(carvedi
Current Illness: Per EMS report patient had been having diarrhea and vomiting for the last 3 to 4 days.
Preexisting Conditions: Hyperlipidemia (disorder) Generalized osteoarthritis (disorder) Hypothyroidism (disorder) Tinnitus (finding) Benign essential hypertension (disorder)
Allergies: LIPITOR
Diagnostic Lab Data: TROPONIN I 0.478 HH ng/mL 0.000 - 0.056 LG2 03/01/2021 15:47 CKMB 6.7 HH ng/mL 0.0 - 3.6 LG2 03/01/2021 15:47 MYOGLOBIN 4467 H ng/mL 10 - 92 LG2 03/01/2021 15:47 CK (CREATINE KINASE) 470 HH unit(s)/L 39 - 308 LG2 03/01/2021 15:47 SODIUM 142 N mmol/L 136 - 145 CLH 03/01/2021 15:19 POTASSIUM 4.8 N mmol/L 3.5 - 5.1 CLH 03/01/2021 15:19 CHLORIDE 100 N mmol/L 98 - 107 CLH 03/01/2021 15:19 CARBON DIOXIDE 20.0 L mmol/L 21.0 - 32.0 CLH 03/01/2021 15:19 ANION GAP 22 H mmol/L 4 - 15 CLH 03/01/2021 15:19 GLUCOSE 152 H mg/dL 65 - 99 CLH 03/01/2021 15:19 CALCIUM 10.7 H mg/dL 8.5 - 10.1 CLH 03/01/2021 15:19 AST (SGOT) 87 H U/L 0 - 37 LG2 03/01/2021 15:47 ALT (SGPT) 84 H U/L 0 - 65 LG2 03/01/2021 15:47 ALK PHOSPHATASE 105 N U/L 46 - 116 LG2 03/01/2021 15:47 BILIRUBIN, TOTAL 1.8 H mg/dL 0.2 - 1.3 LG2 03/01/2021 15:47 PROTEIN, TOTAL 7.3 N g/dL 6.4 - 8.2 LG2 03/01/2021 15:47 ALBUMIN 3.2 L g/dL 3.4 - 5.0 LG2 03/01/2021 15:47 GLOBULIN 4.1 N g/dL 1.4 - 4.8 LG2 03/01/2021 15:47 BUN (BLOOD UREA NITROGEN) 48 H mg/dL 8 - 23 CLH 03/01/2021 15:19 CREATININE 3.86 H mg/dL 0.70 - 1.30 CLH 03/01/2021 15:19 BUN/CREAT RATIO 12 N RATIO 10 - 20 CLH 03/01/2021 15:19 GFR, FEMALE (CREAT $g0.7) 10 mL/min/1.73m^2 CLH 03/01/2021 15:19 GFR, MALE (CREAT $g0.9) 14 mL/min/1.73m^2 CLH 03/01/2021 15:19 GFR, FEMALE (CREA <=0.7) 47 mL/min/1.73m^2 CLH 03/01/2021 15:19 GFR, MALE (CREAT <=0.9) 44 mL/min/1.73m^2 CLH 03/01/2021 15:19
CDC Split Type:

Write-up: Patient had gotten up to the bathroom and collapsed in the hallway after using the restroom. Patient was unresponsive upon EMS arrival with vomitus coming out of the mouth per the report when they rolled patient over onto his side the emesis was pouring out of his mouth. ER course: Examination. Epinephrine 1 mg IO x4 CBC, CMP, cardiac panel MDM: 1447 patient arrival, per EMS report patient had been sick and vomiting all morning. Bradycardia noted at arrival with rates in the 30s, CPR was initiated patient had received 3 rounds of epi prior to arrival. 1450 CPR continues via the Lucas device, 1 mg epinephrine given IV push 1451 CPR pause rhythm check. CPR resumes 1453 CPR paused for rhythm check. No central pulses, CPR resumed, glucose of 99 per fingerstick 1454 King tube removed. Oral airway placed respirations by BVM. 1 mg epinephrine IV push 1455 CPR pause for both pulse and rhythm check. No central pulses noted. CPR resumes via Lucas 1456 pupils are fixed and dilated bilaterally 1457 CPR pause for pulse and rhythm check. No central pulses noted. CPR resumed via Lucas. 1 mg epinephrine IV push 1459 warm blankets applied. CPR pause for pulse and rhythm check. No central pulses noted. CPR resumed 1501 CPR pause for pulse and rhythm check. No central pulses. CPR resumes 1502 1 mg epinephrine given IV push 1503 CPR pause for pulse and rhythm check. No central pulses noted. CPR resumed via the Lucas device 1506 resuscitation is ceased at this time. Time of death recorded at 1506


VAERS ID: 1066209 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2020-12-30
Onset:2021-01-18
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Aphasia, Bulbar palsy, Cognitive disorder, Coordination abnormal, Death, Demyelination, Dysarthria, Dysphagia, Electromyogram abnormal, Endotracheal intubation, Guillain-Barre syndrome, Immunoglobulin therapy, Intensive care, Magnetic resonance imaging brain normal, Magnetic resonance imaging neck, Muscular weakness, Nervous system disorder, Progressive bulbar palsy, Spinal osteoarthritis
SMQs:, Rhabdomyolysis/myopathy (broad), Angioedema (broad), Peripheral neuropathy (narrow), Anticholinergic syndrome (broad), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Optic nerve disorders (broad), Demyelination (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Arthritis (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of CLL and possible CSF involvement, also hx of Rheumatoid arthritis.
Allergies:
Diagnostic Lab Data: MRI BRAIN, 20-Feb-2021, No stroke; EMG, 25-Jan-2021, Loss of f-waves
CDC Split Type:

Write-up: [COVID-19 Vaccine] treatment under Emergency Use Authorization(EUA): He presented 10 days after first COVID-19 Vaccine with Progressive neurological deficits with bulbar manifestations - dysarthria, dysphagia and bilateral arm weakness and incoordiantion, worse on right. MRI brain was negative for acute stroke and MRI cervical, showed degenerative changes. Transferred from community hospital to tertiary center where the diagnosis was made of AIDP. He was intubated at that time in Neuro ICU. Given Steroids and IVIG but no improvement and was either will need to have Trach and PEG vs CMP and family honored the patient''s wishes and made him CMO. signs of severe demyelination and AIDP was diagnosed.


VAERS ID: 1066274 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-21
Onset:2021-01-23
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: 1066289 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Unknown  
Location: Pennsylvania  
Vaccinated:2021-01-21
Onset:2021-02-08
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 AR / IM

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

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

Write-up: death


VAERS ID: 1066291 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-14
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J204 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: nitroglycerin, asa,crestor,lantus,gabapentin,clopidogrel isosorbide, metformin,metoprolol, furosemide, ramipril, pantoprazole, albuterol, ondansetron, methocarbamol, norco, diclofenac Patient was given influenza vaccine by an outside provid
Current Illness: none
Preexisting Conditions: Type 2 diabetes, heart failure, hyperlipidemia, claudication, left hip and knee pain
Allergies: Aspirin, pneumococccal vaccine
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient administered vaccine on 1/14/21 with no reactions noted after 15 minutes. Patient seen for wellness visit on 1/20/21 with no complaints regarding vaccine. Patient died on 1/30/21


VAERS ID: 1066307 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-27
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 RA / IM

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

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

Write-up: Patient is not a patient of our clinic. When called to confirm appointment for second dose, we were notified patient was deceased.


VAERS ID: 1066322 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-15
Onset:2021-02-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aortic aneurysm rupture, Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

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

Write-up: Patient was vaccinated approx 9a. Later that evening, patient was having trouble breathing so they called son who lives down the road to come, 20 mins after the call the patient has passed. Per medical examiner, pt died due to possible PE, MI, or his aortic aneurysm ruptured.


VAERS ID: 1066332 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Unknown  
Location: Pennsylvania  
Vaccinated:2021-01-21
Onset:2021-01-25
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1066344 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-01-28
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

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

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

Write-up: This not a patient of our clinic. When called to confirm his second dose vaccine, is when we learned patient is deceased. Unable to reach anyone regarding date of death.


VAERS ID: 1066484 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac disorder, Death, Diabetes mellitus, End stage renal disease, Fall, Hypertension, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: In-center meds: Doxercalciferol, Cinacalet,Mircera, LiquaCel. Home medication: Amlodipine 5mg 1 daily, ASA 81mg. 1 daily, Atorvastatin 40mg 1 at night, Auryxia 210mg 1 three times a day, Daily Multi-vitamin 1 daily, 6.25mg 2 tablets every
Current Illness: Same as listed in # 12.
Preexisting Conditions: Hypertnesion, Cardiovascular disease, Diabetes Type 2, End Stage Renal Disease, Amputee,
Allergies: Morphine Xarelto
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received vaccination at 14:20 2/26/21. Was observed until discharged at 15:15. Discharged per wheel chair to lobby in alert/stable condition, to wait on bus to take him home. At 18:00 his neighbor heard him fall, could not get patient to answer phone, found him unresponsive. Neighbor called 9-1-1, ambulance personnel could not revive patient. Coroner''s office ruled his death as Natural Causes due to Hypertension, Cardiac disease, Diabetes, ESRD. There were no indication of anaphylactic reaction noted when I questioned the coroner''s office. The Coroner''s office/EMS were aware the patient had received the Moderna COVID 19 vaccination that day.


VAERS ID: 1066715 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-29
Onset:2021-01-21
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Epistaxis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

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: mvi, albuterol, invanz, macrobid, flomax, metoprolol, enalapril,
Current Illness: copd, prostate ca
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: epistaxis.


VAERS ID: 1066770 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lasix, seroquel, kcl, coreg, eliquis, vasotec,omeprazole, tylenol, rocephin
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: died


VAERS ID: 1066829 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-25
Onset:2021-03-02
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6198 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: atorvastatin, amlodipine, clopidogrel, metoprolol, losartan,
Current Illness:
Preexisting Conditions: Atherosclerosis, PAD, CKD, Hypertension, Hyperlipidemia, Systolic Murmur, Hyperplasia fatty tissue, HX prostate cancer
Allergies: Aspirin
Diagnostic Lab Data: None known
CDC Split Type:

Write-up: Patient passed away in his sleep that evening after he recieved his COVI vaccine. Patient had not been ill. No other information is known.


VAERS ID: 1066852 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-24
Onset:2021-02-28
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 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: Steroids
Current Illness: None
Preexisting Conditions: Terminal cancer- Hospice care started 1/2021
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: History of terminal cancer, entered hospice care 1/2021, expired 2/28/2021. No reported adverse events from patient or family after receiving vaccine


VAERS ID: 1066906 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: New York  
Vaccinated:2020-12-30
Onset:2021-02-01
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Axonal and demyelinating polyneuropathy, COVID-19, Computerised tomogram spine, Death, Electromyogram abnormal, Guillain-Barre syndrome, Immunoglobulin therapy, Magnetic resonance imaging brain normal, Mental status changes, Mobility decreased, Movement disorder, Polyneuropathy, Spinal myelogram normal, Urinary tract infection
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (narrow), Dementia (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Demyelination (narrow), Tendinopathies and ligament disorders (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations: Influenza Vaccine
Other Medications: ACETAMINOPHEN 325 MG TABLET (.) TWO TAB(S) by mouth every 6 hours prn MAXIMUM OF 3.90 GRAMS (3900MG) OF ACETAMINOPHEN PER DAY . *12 TABLETS* dx pain, ACETAMINOPHEN 325 MG TABLET (.) TWO TAB(S) by mouth two times per day (09:00, 17:00) M
Current Illness: Dementia with behavioral disturbances.
Preexisting Conditions: 1. CAD 2. Leg edema 3. BPH 4. Vascular dementia 5. MDD/behavioral disturbances 6. Sleep wake disturbance 7. Hx BCC posterior neck 8. B/L hips and right knee OA 9. Hyponatremia
Allergies: No known allergies.
Diagnostic Lab Data: See history above.
CDC Split Type:

Write-up: 92 year-old male with PMHx of vascular dementia, BPH, MDD, sleep disturbance , basal cell carcinoma of neck, osteoarthritis, BLE edema, Guillain-Barre syndrome 30 years prior, s/p COVID positive on 1/11/21 and received IV Bamlanivimab. Sent to hospital on 2/2/21 for altered mental status, generalized weakness with inability to lift bilateral UE and difficulty moving his BLE. He was treated for UTI with 7 days of Cefepime for Morganella Morganii. He was followed by neurology with MRI of the brain and CT of the spine without acute findings. Lumbar puncture unable to be obtained. He received 5 day course of IVIG for presumed Guillain-Barre . EMG showed generalized sensory motor polyneuropathy both axon loss and demyelinating type severe in degree. However, he did not recover from his GBS symptoms, was transferred back to the nursing home and died on 2/15/2021.


VAERS ID: 1067036 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen saturation decreased, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Patient was discharged from the hospital to a home on 2/25/21 after a complicated 25 day hospitalization.
Preexisting Conditions: history of hypertension, diabetes mellitus, history of chronic AFib, on anticoagulation, history of MI with a stent, history of BPH, history of dementia, chronic kidney disease, GERD and benign essential tremor, who was at a nursing home
Allergies: lisinopril, metoprolol
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received dose 1 of Moderna Vaccine on 1/14/21 administered by pharmacy. Patient was hospitalized on 1/31/21 due to shortness of breath and diminished O2 sats down to 88%. Patient was in atrial fibrillation. Patient discharged from hospital on 2/25/21 to home. Patient received dose 2 of Moderna Vaccine on 2/25/21 prior to discharge from hospital. Last hospital note stated that patient was pleasant and cooperative with good motivation. Patient passed away after discharge from the hospital on 2/26/21. Patient''s son called the hospital to report his passing.


VAERS ID: 1067090 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute pulmonary oedema, Aortic stenosis, Chest X-ray, Chills, Computerised tomogram, Condition aggravated, Confusional state, Dyspnoea, Echocardiogram, Intensive care, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: metoprolol nifedipine asa vitamin d preservision eye vitamin escitalopram 5 mg latanoprost eye drop qhs to left eye
Current Illness: aortic stenosis severe mild hypertension peripheral vascular disease stable
Preexisting Conditions: aortic stenosis glaucoma macular degeneration mild hypertension senile dementia
Allergies: none
Diagnostic Lab Data: chest x ray, CAT scan, cardiac echo,
CDC Split Type:

Write-up: within 24 hours after her second injection she developed chills, had a syncopal episode and had, difficulty breathing. this progressed over the next day when she had a second syncopal episode and her dyspnea and confusion worsened EMT was called and she was brought to the hospital. she was in flash pulmonary edema and with her history of severe aortic stenosis she was admitted to the cardiac icu. she had no prior history up to that time of pulmonary edema and was functioning without distress in her home. she had a history of covid in early april, manifesting primarily as severe confusion, from which she recovered.


VAERS ID: 1067125 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / UNK - / IM

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

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

Write-up: was reported to staff at Health Department that client passed away hours after receiving Moderna vaccine, also reported that client had multiple health conditions.


VAERS ID: 1067177 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-02-20
Onset:2021-02-27
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Dizziness, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: diabetes, hypertension, hypothyroidism, osteoporosis, chronic kidney disease
Allergies: actonel, aspirin, bextra, celebrex, iodine, novacaine, penicillin, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had sudden death 1 week after 2nd COVID vaccine. Had complained of dizziness throughout the week leading up to it.


VAERS ID: 1067358 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-23
Onset:2021-01-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, COVID-19, COVID-19 pneumonia, Cough, Dyspnoea, Emotional distress, Malaise, Pneumonia, Rales, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Depression (excl suicide and self injury) (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tessalon Perles 100 mg Tivicay 50mg ibuprofen 400mg cimduo 300mg peridex 0.12% mouthwash augmentin 500mg-125mg zyrtec 10mg Flonase allergy relief 50mcg diclofenac 1% topical gel
Current Illness: Mild respiratory symptoms with cough
Preexisting Conditions: HIV Obesity
Allergies: Acetaminophen
Diagnostic Lab Data: 1-29-2021- SARS-CoV02 viral RNA COVID-19 test 2/01/2021- test result positive
CDC Split Type:

Write-up: 1-25-2021- Phone call: pt had cold and cough prior to vaccine. cough worsened 1-28-2021 Phone call: pt requesting provider visit, cough is same and taking tessalon pearls 1-29-2021 Provider in office visit: pt complain of cough and SOB for 6 days. Getting worse. Temp 101.2, pulse ox 87%, BP 128/70. level of distress- leaning forward to breath. appeared ill. diffuse rales throughout both lung fields, more at bases. Diagnosis Pneumonia due to COVID 19 virus. Sent to ER


VAERS ID: 1068743 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Tennessee  
Vaccinated:0000-00-00
Onset:2021-02-09
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: 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: 2021-02-09
   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: Bamlanivimab; Aspirin; Lumigan; Citracal + D3; Chondroitin sulfate a; gabapentin; ipratropium; levothyroxine; losartan; metoprolol; multivitamin; nitroglycerin; fish oil; ranolazine; viagra; simvastatin; maxzide
Current Illness:
Preexisting Conditions: allergic to iodine and naproxen. past medical history including hypertension, type 2 diabetes, bladder cancer, hypothyroidism, coronary artery disease, 2 heart attacks, prostrate cancer, and vitamin d deficiency.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Bamlanivimab treatment under Emergency Use Authorization(EUA): Bamlanivimab treatment under Emergency Use Authorization(EUA). Patient received 1st dose of COVID vaccine on 01/28/2021, but he began to have COVID symptoms on 02/04/2021 and tested positive on 02/05/2021. The patient was treated with banlanivimab on 02/08/2021, and he passed away on 02/09/2021.


VAERS ID: 1068761 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-02-06
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

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

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

Write-up: DEATH Narrative: patient was placed on hospice care following vaccine, unclear cause of death, not documented


VAERS ID: 1068762 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-03-02
   Days after vaccination:50
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: DEATH Narrative: patient''s wife reported he had gone in an outside hospital, had held his brilinta as advised anticipating shoulder surgery "and he threw a big clot and died."


VAERS ID: 1068882 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-29
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

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

Write-up: DEATH Narrative: Son stated that patient was doing well, still working and driving places. He stated that he called his son and stated that he wasn''t feeling well and died shortly after that.


VAERS ID: 1068883 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-31
Onset:2021-02-05
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: DEATH Narrative: PATIENT PASSED AWAY WHILE ON HOSPICE CARE


VAERS ID: 1068884 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-08
Onset:2021-02-22
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardioversion, Death, Dyspnoea, Endotracheal intubation, Hypotension, Intensive care, Pulseless electrical activity, Respiratory distress, Resuscitation, Sepsis
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

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

Write-up: DEATH Narrative: Presented to ED via EMS c/o increasing shortness of breath, O2 sat mid to high 80s on 4L. When EMS arrived , pt was in distress, intubated by EMS and transported to ED. Pt had a PEA arrest en route but resuscitated w/ return of spontaneous circulation after receiving a dose of epinephrine and chest compressions. Pt was hypotensive on arrival to ED. He was started on sepsis protocol , volume resuscitation and empiric antibiotics. Once stabilized, he was admitted to icu at hospital. Removed from respirator 2/22/21


VAERS ID: 1068885 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-15
Onset:2021-02-17
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Decreased appetite, Fatigue, Illness, Incomplete course of vaccination, Insomnia, Lethargy, Malaise, Nocturia, Pollakiuria
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Medication errors (narrow), Hypoglycaemia (broad)

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

Write-up: DEATH Narrative: PRIOR TO DEATH, spoke with pt''s daughter and she reported that pt is unable to keep his appt for the second Covid vaccine appt because is sick today. Per daughter, pt has been lethargic, not enough sleep last night because of frequent urination at least every 30 to 45 minutes looks exhausted and with poor appetite. Pt has not been drinking fluids at least 6 to 8 glasses a day and daughjter tries to make sure pt drinks fluids, the best he can. Per daughter, pt''s vitals signs are as follows: BP: 93/48mmhg PR: 93/min. Temp: 98.1 F and O2 sat: 95%.


VAERS ID: 1068886 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-01-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute myocardial infarction, Arrhythmia, Chest discomfort, Chills, Death, Deep vein thrombosis, Dyspnoea, Intensive care, Pain, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: DEATH Narrative: Pt he reports he developed chills SOB body aches the same night as receiving the COVID vaccine on 1.26.2021-pt is currently reporting CheSt tightness and SOB Admitted to hosp: ICU with Bilateral Pulmonary Emboli, LLE DVT, NSTEMI, Arrhythmia.


VAERS ID: 1068887 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-02-13
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

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

Write-up: DEATH Narrative: UNSURE DETAILS OF EVENT, NO DOCUMENTATION IN PROGRESS NOTES


VAERS ID: 1068888 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: DEATH


VAERS ID: 1068295 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Oklahoma  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Illness, Malaise, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Lupus syndrome
Allergies:
Diagnostic Lab Data: Test Name: COVID-19; Test Result: Negative ; Comments: tested negative 2 times over the following 10 day while deteriorating.; Test Name: COVID-19; Test Result: Negative ; Comments: tested negative 2 times over the following 10 day while deteriorating.; Test Name: COVID-19; Test Result: Positive ; Comments: Was admitted and tested positive and put on ventilator
CDC Split Type: USPFIZER INC2021201566

Write-up: Was admitted and tested positive and put on ventilator; She felt slightly ill the day of vaccine; 2 days later patient become ill; tested negative 2 times over the following 10 day while deteriorating; Patient died 10 days later; This is a spontaneous report from a contactable consumer via Pfizer Sales Representative. This consumer (daughter) was reported for a female patient (mother). A 76-year-old female patient received first dose of bnt162b2 (Pfizer), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. Medical history included lupus from an unknown date and unknown if ongoing. The patient''s concomitant medications were not reported. The patient with lupus received 1st dose of vaccine. She felt slightly ill the day of vaccine. 2 days later patient become ill, tested negative 2 times over the following 10 day while deteriorating. Was admitted and tested positive and put on ventilator. Patient died 10 days later. Daughter thought she had COVID before vaccination. Event took place after use of product. The patient underwent lab tests and procedures which included COVID-19: negative (tested negative 2 times over the following 10 day while deteriorating), COVID-19: positive (Was admitted and tested positive and put on ventilator) all on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. The outcome of other events was unknown. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Patient died 10 days later


VAERS ID: 1068304 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Connecticut  
Vaccinated:2021-02-10
Onset:2021-02-17
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Bacterial infection (Patient was being treated for bacterial infection and had spent 1 week in hospital within one month prior to being dosed with vaccine.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021209258

Write-up: died; This is a spontaneous report from a contactable consumer reporting for a patient. An 86-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), on 10Feb2021 at single dose for COVID-19 immunization. Concomitant medications were not reported. Relevant medical history included bacterial infection, the patient was being treated for bacterial infection and had spent 1 week in hospital within one month prior to being dosed with vaccine. On 17Feb2021 the patient died. The cause of death was unknown. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: death


VAERS ID: 1068306 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-18
Onset:2021-02-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Blue toe syndrome, Body temperature, Death, Feeling cold, Heart rate, Heart rate increased, Myocardial infarction, Nasopharyngitis, Peripheral swelling, Pneumothorax, Pyrexia, Skin discolouration, Tremor
SMQs:, Cardiac failure (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications:
Current Illness: Magnesium low (went to the hospital on 17Feb2021)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: Body temperature; Result Unstructured Data: Test Result:normal; Test Date: 20210218; Test Name: Body temperature; Result Unstructured Data: Test Result:low grade fever; Test Date: 20210219; Test Name: Body temperature; Result Unstructured Data: Test Result:fever increased; Test Date: 20210219; Test Name: Heart rate; Result Unstructured Data: Test Result:130/140 seconds
CDC Split Type: USPFIZER INC2021211484

Write-up: heart attacks; Collapse of lung; pulse was in the 130s/140s; passed away; nose and fingers turned gray and were cold to the touch; nose and fingers turned gray and were cold to the touch; his big toe had turned gray; his right foot was swollen; low grade fever; Shaking; extremely cold; This is a spontaneous report from a contactable consumer. An elderly male patient received the 2nd dose of bnt162b2 (BNT162B2, Manufacturer Pfizer-BioNTech), via an unspecified route of administration, on 18Feb2021, at single dose, for COVID-19 immunisation. Medical history included ongoing blood magnesium decreased (went to the hospital on 17Feb2021). Concomitant medications were not reported. Previously the patient received the 1st dose of bnt162b2 (BNT162B2, Manufacturer Pfizer-BioNTech), on 27Jan2021, for COVID-19 immunisation and experienced arm soreness. The patient experienced passed away (death, hospitalization, medically significant) on 23Feb2021, heart attacks (caused hospitalization, medically significant) on 20Feb2021 with outcome of unknown, collapse of lung (caused hospitalization) on 20Feb2021 with outcome of unknown, pulse was in the 130s/140s (caused hospitalization) on 19Feb2021 with outcome of unknown, low grade fever on 18Feb2021 with outcome of recovered on 23Feb2021, shaking on 18Feb2021 with outcome of unknown, extremely cold on 18Feb2021 with outcome of unknown, nose and fingers turned gray and were cold to the touch on 19Feb2021 with outcome of unknown, his big toe had turned gray on 19Feb2021 with outcome of unknown, his right foot was swollen on 19Feb2021 with outcome of unknown. The events his big toe had turned gray and his right foot was swollen required physician visit on 19Feb2021. They were reported as a result of the magnesium deficiency. On 19Feb2021 evening his fever increased and his nose and fingers turned gray and were cold to the touch. On 20Feb2021 he collapsed at home and was taken to the hospital by ambulance. He had several heart attacks prior to the collapse. They decided to put him in a medically induced coma and reduce his body temperature that evening and started dialysis on 21Feb2021. They returned his body to normal temperature on 23Feb2021, his pulse was in the 130s/140s. They were starting to reduce the sedatives on 23Feb2021. The patient passed away on 23Feb2021. It was not reported if an autopsy was performed. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: passed away


VAERS ID: 1068307 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021213418

Write-up: died; bled out; This is a spontaneous report from a contactable nurse. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on an unspecified date at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. The patient had bled out on an unspecified date with outcome of unknown. The patient died on an unspecified date. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: The limited information provided precludes a full clinical assessment of the case. As a cautionary measure and for reporting purposes, and assuming a drug-event temporal association, the Company cannot completely exclude a causal association between the reported events ''bled out'' and ''died'' (death of unknown cause) and BNT162B2 administration, until sufficient information becomes available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees, and Investigators, as appropriate.,Linked Report(s) : US-PFIZER INC-2021210582 Same reporter/drug, different patient; Reported Cause(s) of Death: died


VAERS ID: 1068308 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-03
Onset:2021-02-13
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3428 / 1 LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal discomfort, Cardiac arrest, Computerised tomogram, Condition aggravated, Headache, Loss of consciousness, Malaise, Pericardial effusion, Pyrexia, SARS-CoV-2 antibody test, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: AMITRIPTYLINE HYDROCHLORIDE; ATORVASTATIN; DUTASTERIDE; LINZESS; GABAPENTIN; MONTELUKAST; RAMIPRIL; TRESIBA; VICTOZA
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Type 2 diabetes mellitus
Allergies:
Diagnostic Lab Data: Test Name: CT scan; Result Unstructured Data: Test Result:covid like pneumonia and pericardial effusion; Comments: CT scan results that came back after death showed covid like pneumonia and pericardial effusion.; Test Date: 20210211; Test Name: Nasal Swab; Result Unstructured Data: Test Result:Negative; Comments: Nasal Swab; Test Date: 20210221; Test Name: Nasal Swab; Result Unstructured Data: Test Result:Negative; Comments: Nasal Swab
CDC Split Type: USPFIZER INC2021214034

Write-up: cardiac arrest due to pericardial effusion; cardiac arrest due to pericardial effusion; On 21Feb he went to the ER after vomiting and passing out; On 21Feb he went to the ER after vomiting and passing out; On 19Feb, he began to feel ill again with a fever. He felt worse on 20Feb; On 19Feb, he began to feel ill again with a fever. He felt worse on 20Feb; fever; headache; stomach upset; This is a spontaneous report from a contactable consumer reporting for the father: A 75-year-old male patient received the 1st dose of bnt162b2 (BNT162B2, Lot # EL3428) at single dose at left arm on 03Feb2021 for Covid-19 immunisation. Medical history included type 2 diabetes mellitus. No known allergies. The patient had not experienced Covid-19 prior vaccination. Concomitant medication in 2 weeks included amitriptyline hydrochloride (manufacturer unknown) 10 mg, atorvastatin (manufacturer unknown) 20 mg, dutasteride (manufacturer unknown) 0.5 mg, linaclotide (LINZESS) 290 mcg, gabapentin (manufacturer unknown) 300 mg, montelukast (manufacturer unknown) 10 mg, ramipril (manufacturer unknown) 5 mg, insulin degludec (TRESIBA) 100 unit/ml, liraglutide (VICTOZA) 18 mg/3ml solution. No other vaccine in 4 weeks. The patient experienced cardiac arrest due to pericardial effusion on 21Feb2021 14:15, fever on 13Feb2021, headache on 13Feb2021, stomach upset on 13Feb2021, on 19feb, he began to feel ill again with a fever, he felt worse on 20feb on 19Feb2021, on 21feb he went to the ER after vomiting and passing out on 21Feb2021. Events resulted in Emergency room/department or urgent care. Therapeutic measures were taken as a result of cardiac arrest due to pericardial effusion. Course of events: In Feb2021, 10 days after his 1st injection, the patient developed fever, headache, and stomach upset. He went for a rapid Covid-19 test (nasal swab) and it was negative on 11Feb2021. The doctor told him he might be having a delayed reaction to the vaccination. After a couple of days, he improved. On 19Feb2021, he began to feel ill again with a fever. He felt worse on 20Feb2021. On 21Feb2021 he went to the ER after vomiting and passing out and received treatment: IV fluids, diagnostic testing at ER. Rapid Covid test (nasal swab) at ER came back negative again on 21Feb2021. His heart arrested suddenly and he could not be resuscitated. CT scan results, that came back after death, showed Covid like pneumonia and pericardial effusion. The patient died on 21Feb2021 14:15. Cause of death was cardiac arrest due to pericardial effusion. An autopsy was not performed. The outcome of cardiac arrest due to pericardial effusion was fatal, of fever, headache, stomach upset was recovering, of he began to feel ill again with a fever, he felt worse was not recovered, of he went to the ER after vomiting and passing out was unknown.; Reported Cause(s) of Death: cardiac arrest due to pericardial effusion; cardiac arrest due to pericardial effusion


VAERS ID: 1068357 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-13
Onset:2021-02-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood pressure measurement, Cardiac arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension
Preexisting Conditions: Medical History/Concurrent Conditions: Prostate cancer
Allergies:
Diagnostic Lab Data: Test Date: 20210119; Test Name: Blood pressure; Test Result: Inconclusive ; Result Unstructured Data: 133/84 mmHG
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: No pulse and no heart beat; couldn''t wake him up; passed away; A spontaneous report was received from a daughter concerning a 84-year old, male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) experienced no pulse or heartbeat, couldn''t wake him up and passed away. The patient''s medical history, as provided by the reporter, included high blood pressure and prostate cancer. No relevant concomitant medications were reported. On 19 Jan 2021, the patient had a blood pressure reading of 133/84 at a cardiology visit. On 13 Feb 2021, approximately 3 hours prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (batch number 031M20A) intramuscularly for prophylaxis of COVID-19 infection. On 13 Feb 2021 at 3:30 pm, the patient could not be woken up and was found with no pulse or heartbeat. Action taken with the drug in response to the events was not applicable. The outcome of the events, no pulse or heartbeat and couldn''t wake him up, were not provided. The patient died on 13 Feb 2021. The cause of death was unknown.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. The patient''s medical history of high blood pressure and prostate cancer remains the risk factors. The cause of death was unknown. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1068549 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-10
Onset:2021-02-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 13
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: Obesity, Lung disease, DM type 2, spinal stenosis, OA, essential tremor, sleep apnea, glaucoma, Hashimoto thyroid disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/13/21 Patient had covid like symptoms 2/15/21 Patient admitted to Hospital with covid like sx and decreased O2 sat; tested positive for Covid on 2/15/21; treated with Remdesivir and convalesent Plasma. Sx worsened and patient died 2/26/21..


VAERS ID: 1068564 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-26
Onset:2021-02-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac death, Death, Myocardial infarction
SMQs:, Torsade de pointes/QT prolongation (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)

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: amoxicillin 500mg-potassium clavulanate 125mg tablet; aspirin 81mg; atorvastatin 40mg; carvedilol 12.5mg; clopidogrel 75mg; enalapril maleate 20mg tablet; furosemide 40mg tablet; mupirocin 2% topical ointment; pantoprazole 20mg tablet; pota
Current Illness: unknown
Preexisting Conditions: chronic kidney disease stage 3; congestive heart failure; diabetes; hypertension; hyperlipidemia; morbid obesity; bilateral paresis of lower extremity; peripheral edema; sleep apnea; stented artery; history of malignant neoplasm of prostate
Allergies: nkda
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: On 3/2/2021, clinic was notified by patient''s family that patient had deceased on 2/28/2021 from a heart attack. Unsure of any relation to the Moderna vaccine but reporting for due diligence.


VAERS ID: 1068700 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Known pneumothorax w/ chest tube placement after percutaneous lung biopsy;
Preexisting Conditions: current smoker; severe emphysema ; enlarging lung nodules w/ avidity; IA Lung CA with right lower lobectomy;
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away 24 hours after receipt of 1st Dose Pfizer vaccine. Provider does not feel death was due to vaccination. but underlying conditions. No immediate side effects noted from vaccination.


VAERS ID: 1068814 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-16
Onset:2021-02-25
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007NCOA / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol; gemfibrosil; indomethacin; lisinopril
Current Illness: none
Preexisting Conditions: Gout
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: 9 days after vaccination, the patient was found deceased in his home, sitting on his couch. Determined to be due to pulmonary embolism.


VAERS ID: 1068850 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Calcitriol 0.25 mg daily, Carvedilol 25 mg BID, (Cont.) Ergocalciferol 50,000 units weekly, Epoetin alfa, Furosemide, Hydrocodone/acetaminophen 10/325 mg Q6H PRN, Mycophenolate sodium 360 mg BID, Prednisone 10 mg daily, Sevelamer carbonate
Current Illness:
Preexisting Conditions: Cardiomegaly, Hypertension, BK virus nephropathy, Acute Kidney Inj., Chronic pain, Kidney Transplant, (cont.) Anemia of chronic disease, Immunosuppression, Arthritis, Depression, Spinal stenosis, cytomegalovirus infection, degenerative joint disease.
Allergies: Vancomycin (itching)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pfizer-BioNTech COVID- 19 Vaccine EUA: Wife of patient called Primary Care Physician to inform that patient had received dose #2 of Pfizer COVID vaccine, and later that evening experienced a seizure and expired.


VAERS ID: 1068889 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-29
Onset:2021-01-25
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: death Narrative: no other details available, as nothing documented in record


VAERS ID: 1068890 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-02-11
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Spinal operation
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: death Narrative: unclear of details, s/p spine surgery on 2/2/21 and discharged on 2/6/21


VAERS ID: 1068901 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-30
Onset:2021-02-21
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Aortic dissection, Aortitis, Arteritis coronary, Cardioversion, Chest pain, Computerised tomogram, Computerised tomogram normal, Death, Echocardiogram, Electrocardiogram, Electrocardiogram normal, Fatigue, Inflammation, Laboratory test, Pain in jaw, Pulse absent, Red blood cell sedimentation rate normal, Respiratory arrest, Syncope
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 (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vasculitis (narrow), Osteonecrosis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prednisone BP medication
Current Illness: COVID prior to vaccination - still having symptoms SOB, Tired, foggy head -thinking
Preexisting Conditions: GCA Arthritis
Allergies:
Diagnostic Lab Data: 2/17-2/19 hospital admit Medical Center Labs, CT, Echo 2/21 EMTs conducted EKGs
CDC Split Type:

Write-up: ER admit for CP and Jaw pain, exhaustion, Aortic arteritis normal SED rate found on CT scan hospital admit IV medications required Solumedrol and Actemra questionable how much medications received d/t IV''s not working. Released from care on 2/19 with prednisone . Symptoms still present off and on. 2/21 922pm CP Jaw Pain severe EMT''s called EKG done reported no heart attack, pain better, EMTs left. 10/15 severe Pain collapsed with no pulse and no breathing, EMTs returned unable to obtain a shock-able rhythm time of death pronounced. reason for death on certificate Aortitis - hospitalist thinks aortic dissection d/t severe inflammation


VAERS ID: 1068931 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-02-17
Onset:2021-02-28
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Death, Haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (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: Bymetanide (1MG tablet) 1x daily Lisinopril (10MG tablet) 1x daily Terazosin (10MG tablet) 1x daily
Current Illness: No other illnesses. He spent six days at a nearby hospital last week. Came home Thursday, February 25, 2021, as his blood work indicated that he had stopped bleeding and was stable. Per family, "he was in good spirits Friday and Saturday which started to change Sunday morning." He passed way in his sleep sometime late Sunday night or very early Monday morning. I believe his date of death will be 3/1/2021.
Preexisting Conditions: Diverticulitis Spinal Stenosis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Case passed away on 2/28/21. During post vaccination monitoring, case did not have any adverse reactions. When writer spoke to him on 2/26/21 to schedule his second dose, he sounded well.


VAERS ID: 1068963 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Conversion disorder, Death, Dysphagia, Fatigue, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cranberry Tablet, Ferrous Sulfate, Levothyroxine, Metoprolol, Mirtazapine, Omeprazole, Risperidone, Vitamin C, Vitamin D3, Asprin, Alprazolam, Vitamin B Complex, B 12 injections
Current Illness: Adenocarcinoma of colon, hypothyroidism, Alzheimer''s dementia with behaviors disturbance, Anxiety, A Fib, GERD, recurrent UTI, Vitamin B 12 deficiency.
Preexisting Conditions: See Item 11
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: approximately 24 hours post vaccine Patient developed a low grade fever of 99.5 and had increased fatigue. 48 hours later she had decreased neurological functioning. 02/23 she had difficulty swallowing. 02/23 She was admitted to hospice services. 02/26 she passed just before 10 am.


VAERS ID: 1068993 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-01-23
Onset:2021-02-20
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Hypertension, morbid obesity
Allergies: Unknown
Diagnostic Lab Data: Autopsy performed 3/1/2021
CDC Split Type:

Write-up: Spontaneous intracerebral hemorrhage and death on 2/20/2021


VAERS ID: 1069009 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Axillary vein thrombosis, Chest X-ray abnormal, Erythema, Pleural effusion, Pneumonia
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Embolic and thrombotic events, venous (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: None
Current Illness: Swollen hands
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Chest X ray
CDC Split Type: PR-46-21

Write-up: Several days after vaccination his left arm turned red. He was taken to the hospital where he was evaluated and admitted with a diagnosis of left axillary vein thrombosis. A chest X-ray was taken and he presented bibasilar atelectasis and pneumonia with pleural effusions.


VAERS ID: 1069026 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-02-26
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EL3247 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, Endotracheal intubation, Mechanical ventilation
SMQs:, Angioedema (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Patient admitted with severe COVID on 2/12. Prolonged hospital course requiring intubation. Treated with mechanical ventilation, proning therapy, as well as medical therapy to no avail. Other "significant conditions contributing to death" but not resulting in the underlying cause given in PART I: HTN, T2DM, ESRD, CAD
CDC Split Type:

Write-up: Death Narrative: Family was able to be present at bedside shortly after patient was extubated. Fentanyl bolus given 10-15 minutes prior. Patient passed away soon after endotracheal tube removed. Time of death 10:14am.


VAERS ID: 1069118 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-25
Onset:2021-03-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: albuterol sulfate, Aspir-81, bethanechol chloride, Bevespi, Aerosphere, cholestyramine (with sugar), citalopram, clopidogrel, duloxetine, famotidine, gabapentin, lisinopril, magnesium oxide, megestrol, metoprolol tartrate, mupirocin, nitrog
Current Illness: First covid vaccine received 1/28/2021 without incident. Had been hospitalized prior to vaccination for intractable vomiting.
Preexisting Conditions: history of acute respiratory failure, carotid artery stenosis, chronic back pain, chronic esophagitis, chronic hyperglycemia, chronic obstructive lung disease, chronic sinusitis, coronary arteriosclerosis, depressive disorder, exposure to SARS-CoV-2, history of polyp of colon, hyperlipidemia, hypertensive disorder, hypoxia, nicotine dependence, non-small cell lung cancer, osteoarthritis, peripheral nerve disease, peripheral vascular disease, tremor
Allergies: codeine, Zithromax
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Within 10 minutes following the second vaccination, patient reported dizziness and nausea, had an episode of vomiting but recovered within 30 minutes. It was reported to our clinic that the patient was found deceased on March 1, 2021 at approximately 10 pm. Cause of death is not determined at this time.


VAERS ID: 1069140 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bacofleno, Agrenox, Synthroid, Fenofibrate, Busoiron, Lasix, Lipthol, Amiodarone, Clonopin
Current Illness: None reported
Preexisting Conditions: Hypertension, stroke, pacemaker
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-47-21

Write-up: The day after the administration of the vaccine, the fever began, the patient claim that he had no blood pressure problems. He was given acetaminophen every 4 hrs. and vitamin C and D. On February 11, he was stabilized, he had his regular meals without any problem but in the afternoon his temperature rose again and they put him to bed. The patient died that same afternoon around 4:00 pm


VAERS ID: 1069235 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-01-07
Onset:2021-02-28
   Days after vaccination:52
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: Morphine, Lorazepam, Haloperidol, Loperamide, Ondansetron
Current Illness: Dementia, Anxiety, Hypokalemia, Peripheral Vascular disease, HTN, Absence of part of Lung Z90.2, BPH, Hypomagnesemia,
Preexisting Conditions: Dementia, Anxiety, Hypokalemia, Peripheral Vascular disease, HTN, Absence of part of Lung Z90.2, BPH, Hypomagnesemia,
Allergies: Amoxicillin, Azithromycin, Notriptyline, Augmentin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death


VAERS ID: 1069263 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-11
Onset:2021-02-16
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

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

Write-up: DIED


VAERS ID: 1069316 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-12
Onset:2021-02-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: death


VAERS ID: 1069560 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-15
Onset:2021-01-31
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, Blood lactic acid increased, COVID-19, Cardiac failure, Chest X-ray abnormal, Cyanosis, Death, Dyspnoea, Electrocardiogram abnormal, Electrocardiogram normal, Endotracheal intubation, Fibrin D dimer increased, Intensive care, Lung infiltration, Myocardial ischaemia, Pneumonia, Pulmonary embolism, Respiratory arrest, SARS-CoV-2 test positive, Skin discolouration, Troponin increased, Urine electrolytes normal
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (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: 2021-02-20
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol MDI Robitussin DM TheraFlu cough & cold
Current Illness: Ankle fracture
Preexisting Conditions: Past medical history Ankle fracture, left 12/30/2020 Asthma Diabetes mellitus Hypertension Obesity 104.3kg; Height 5?6?
Allergies: Iodine ? hives Shellfish - hives
Diagnostic Lab Data: Per patient ? tested positive for COVID-19 on 1/26/21
CDC Split Type:

Write-up: Hospital course 1/31 ? 2/20/21 1/31 in ED pt was at home when children noticed his lips were blue, ems arrived and found him to be 50% on RA, on Non-rebreather pt got to 78%, covid on 01/26 Shortness of Breath 61-year-old male presents with EMS for evaluation of shortness of breath hypoxia. History is limited due to the patient''s current clinical condition and so is primarily obtained from EMS. EMS reports that he tested positive for COVID-19 5 days ago. He began developing shortness of breath yesterday and his family called because his lips and fingers were blue today and he appeared short of breath. On EMS arrival he had a room air saturation of less than 50% so he was placed on nonrebreather with improvement in his saturation to 70% and he was transported to the emergency department. Patient does admit to shortness of breath. He denies any chest pain. He is noted to have a cast on his left ankle and said that he broke his left ankle on 23 December but has not had surgery. He denies any new pain or swelling of the leg. In the ED he was placed on 15L nasal cannula and NRB mask with improvement in SPO2 to low 90s. Additional work up revealed troponin of 1.35, lactic acid 5.8, and d-dimer 14.4. He received dexamethasone and was placed on heparin gtt. 1/31 admitted to ICU Acute hypoxic respiratory failure due to COVID-19 vs heart failure vs PE. CXR with bilateral hazy infiltrates more pronounced in the bases and left periphery and suspected multifocal pneumonia. At risk for PE given LLE immobility in the setting of COVID-19 with significantly elevated d-dimer. RISK of CTA outweighs benefit given AKI and iodine allergy. Continue with empiric treatment with heparin gtt. Admitted to ICU with SO2 in 60s-70s on 15L and NRB. Attempted 50L 95% FIO2 high flow and nasal cannula. Given lasix 40mg IV with good diuresis however SPO2 still remained low 80s with RR 40s and PO2 42 so the decision was made to intubate. Oxygenation improved following intubation, with further improvement following recruitment maneuver and increase in PEEP. FIO2 weaned to 90% with SPO2 remaining in mid 90s. Will continue to wean FIO2 as able. ARDS net protocol as much as possible. Consider prone ventilation and/or epoprostenol if unable to improve . VAP Bundle: HOB $g30 degrees; Oral care per nursing standard and on DVT/PPI prophylaxis Sedation: Target Richmond Agitation and Sedation Scale (RASS) of 0 to -2 with propofol and fentanyl. Check baseline TG levels. COVID - 19: Convalescent plasma: Not indicated Steroids: Dexamethasone 6 mg / day for 10 days Remdesivir: Not indicated d/t AKI IL-6 inhibitor: Meets criteria for tocilizumab Systemic AC: Heparin gtt. No signs of bleeding (Platelets and Hb stable). Antibiotics: Start 3 and 7 day course of azithromycin and ceftriaxone, respectively. Elevated troponin Suspect demand ischemia d/t hypoxia; EKG does not show any ischemic changes AKI: Suspect d/t hypoxia in the setting of COVID infection. Urine output and electrolytes acceptable. Closed fracture of left ankle Suffered fracture following a fall on ice in December. Cast was placed on 12/30 by SOS. He was due to be re-evaluated this week for possible cast removal. Inhaled epoprostenol started Considered for ECMO but not initiated due to not a candidate Vasopressors required at times Antihypertensive infusion required at times severe hypoxia with position changes switched from heparin drip to enoxaparin prophylaxis 2/20 discharge summary 61 y/o male admitted to Hospital on 1/31 with hypoxia. He was diagnosed with COVID 19 5 days prior to admission, and had worsening respiratory status. He was intubated after arrival, and was on ventilator for the entire intervening time, until he was extubated on 2/20 at the time of transition to Comfort measures only. Prior to developing COVID 19, he had received his first dose of the Pfizer vaccine, as a member of the school system. He had a fractured L ankle after a fall on 12/31/20, and had a cast in place at the time of admission. He received Tocilizumab on 1/31, and underwent several cycles of prone positioning, beginning on 2/2. He completed a course of Decadron, he received Ceftriaxone and azithromycin beginning on admission, and completed a course of these. Anticoagulation with enoxaparin was utilized due to coagulopathy associated with COVID 19. Vasopressor support was required at times, as well as diuresis for fluid management. He required high levels of sedation to maintain ventilator synchrony, and high levels of ventilator support with high oxygen levels throughout his stay. Tracheostomy was being considered, but family decided that since he was not going to have good recovery, withdrawal of support, and allowing death was the appropriate choice for the patient and for them. He was extubated at 2100 on 2/20/2021. Death was pronounced at 2123 on 2/20/2021. Children were at bedside.


VAERS ID: 1069647 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-19
Onset:2021-02-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Chills, Condition aggravated, Death, Decreased appetite, Depressed level of consciousness, Fatigue, Lethargy, Loss of consciousness, Pyrexia, Respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (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: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide, Midodrine, Amiodarone, Escitalopram, Aspirin, Finasteride, Tamsulosin, Rosuvastatin, Potassium Chloride, Oxycodone, Budesonide, Albuterol, Alprazolan
Current Illness: s/p CABG with valve replacement (1/28/21) with slow recovery (in ICU 2 weeks)
Preexisting Conditions: COPD, prostatitis, Celiac disease, arthritis, LBP
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Beginning in the evening 2/19/21, fever/chills/fatigue; worsening of symptoms 2/20/21 with lethargy/lack of appetite/weakness; unable to arouse on 2/21/21 then breathing stopped, patient''s spouse called 911 performed CPR, EMS continued for 15 min then while in ambulance to hospital where he was pronounced dead. Official time of death 2:20pm


VAERS ID: 1069685 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Death, Dyspnoea, Hypopnoea, Pallor
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (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: allopurinol, duloxetine, glipizide, melatonin, torsem
Current Illness: COVID 19
Preexisting Conditions: heart failure, stage 4 KD, SOB, malnutrition, dysphagia, muscle weakness, unsteady, GERD, metabolic encephalopathy
Allergies: Morphine
Diagnostic Lab Data: none, resident was a DNR/DNI
CDC Split Type:

Write-up: 3/2/21 became SOB, treated with oxygen and head of bed up in bed, only at dessert and drank supplement, for evening meal, no pain noted. 3/3/21 staff helped get her up in morning, went to weight room to take her weight, she then appeared to be struggling to breath, she was brough back to her room and the aides summoned nurse for assessment, was put back into bed, nurse noted poor color and shallow breathing, resident passed away shortly after that.


VAERS ID: 1069728 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-02
Onset:2021-03-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dizziness, Loss of consciousness, Resuscitation, Seizure like phenomena, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), 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)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Everything was done in ED in the hospital on early morning of 3/3/2021
CDC Split Type:

Write-up: Patient Started having dizziness, feeling faint at around midnight on 3/3/2021. He then lost consciousness, had seizure-like activity and was taken to hospital via EMS. In the hospital patient was unresponsive and received resuscitation attempts unsuccessfully. Per family, after about 45 minutes, code was called and patient expired.


VAERS ID: 1069743 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none reported
Preexisting Conditions: A-fib, DM
Allergies: none
Diagnostic Lab Data: Squad called by wife on 2/26/2021, wife found patient in full cardiac arrest, patient was transported to Hospital for treatment, please see records for additional information
CDC Split Type:

Write-up: Cardiac arrest- death


VAERS ID: 1069830 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-08
Onset:2021-01-25
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Basophil count normal, Basophil percentage, Brain herniation, Cerebral haemorrhage, Cerebral mass effect, Computerised tomogram head abnormal, Death, Encephalitis, Eosinophil count increased, Eosinophil percentage, Granulocyte count, Granulocyte percentage, Haematocrit decreased, Haemoglobin decreased, Imaging procedure artifact, Lymphocyte count, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Meningioma, Monocyte count increased, Monocyte percentage abnormal, Neutrophil count increased, Neutrophil percentage, Platelet count normal, Red blood cell count decreased, Red cell distribution width normal, Subdural haemorrhage, Vasogenic cerebral oedema, White blood cell count increased
SMQs:, Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Noninfectious encephalitis (narrow), Accidents and injuries (broad), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin 81 mg daily; Tylenol arthritis 650 mg daily; calcium and vit d; meclizine 12.5 mg daily; Fosamax 70 mg every 7 days; Toprol 50 mg ext release daily; cozaar 50 mg daily; levothyroxine 100 mcg daily; crestor 10 mg MWF; plaquenil 400
Current Illness:
Preexisting Conditions: arthritis, osteoporosis, prior heart stent
Allergies: NSAIDS
Diagnostic Lab Data: ED visit with labs: Abnormal Result Collected: 1/25/2021 19:41 Last updated: 1/25/2021 19:58 Status: Final result WBC: 13.4 K/uL [Ref Range: 4.8 - 10.8] RBC: 3.65 M/uL [Ref Range: 4.20 - 5.40] HEMOGLOBIN: 11.3 g/dL [Ref Range: 12.0 - 16.0] HEMATOCRIT: 34.6 % [Ref Range: 36.0 - 46.0] MCV: 94.8 fL [Ref Range: 84.0 - 103.0] MCH: 31.0 pg [Ref Range: 27.0 - 34.0] MCHC: 32.7 g/dL [Ref Range: 30.0 - 35.0] RDW: 11.9 % [Ref Range: 11.0 - 14.5] RDW-STDEV: 41.1 fL [Ref Range: 37.0 - 54.0] PLATELETS: 230 K/uL [Ref Range: 140 - 440] MPV: 8.8 fL [Ref Range: 8.9 - 12.8] NEUTROPHILS: 70 % [Ref Range: 42 - 75] LYMPHOCYTES: 12 % [Ref Range: 24 - 44] MONOCYTES: 9 % [Ref Range: 2 - 10] EOSINOPHILS: 7 % [Ref Range: 0 - 7] BASOPHILS: 1 % [Ref Range: 0 - 1] IMMATURE GRANULOCYTES: 0 % [Ref Range: 0 - 2] NEUTROPHIL ABSOLUTE: 9.47 K/uL [Ref Range: 2.00 - 8.00] LYMPHOCYTE ABSOLUTE: 1.56 K/uL [Ref Range: 1.20 - 4.00] MONOCYTE ABSOLUTE: 1.23 K/uL [Ref Range: 0.10 - 0.60] EOSINOPHIL ABSOLUTE: 0.99 K/uL [Ref Range: 0.00 - 0.70] BASOPHILS ABSOLUTE: 0.13 K/uL [Ref Range: 0.00 - 0.20] IMMATURE GRANULOCYTES ABSOLUTE: 0.06 K/uL [Ref Range: 0.00 - 0.10]
CDC Split Type:

Write-up: From CT Scan in ED at 7:40 pm on 1/25/2021 -- There is a large intraparenchymal hemorrhage with Surrounding vasogenic edema within the left occipital lobe. There is additional subdural hemorrhage layering along the left frontal, temporal and parietal convexity which may be decompressing from the area of intraparenchymal hematoma. No visualized intraventricular hemorrhage.There is some trace hemorrhage layering along the left tentorium cerebelli. Severe associated mass effect with left-to-right midline shift of 2.1 cm. There is subfalcine and downward transtentorial herniation with complete effacement of the basilar cisterns. Evaluation of the craniocervical junction is limited due to beam hardening artifact. Near-complete effacement of the left lateral ventricle. No head trauma or fall. Deceased 1/26/2021


VAERS ID: 1069876 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-02-20
Onset:2021-02-22
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Agitation, Arrhythmia, Death, Hernia repair, Hypotension, Incarcerated hernia, Mental status changes, Sinus arrhythmia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Disorders of sinus node function (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: Albuterol , Budesonide, Clotrimazole, Levothyroxine, Lorazepam, Methadone, Nicotine 2mg gum , Polyethylene glycol, Potassium chloride, Sennosides, Tamsulosin, Tiotropium, Torsemide
Current Illness: Incarcerated ventral/incisional hernia
Preexisting Conditions: CAD, Hep C wiht cirrhosis, CKD, CHF, COPD, HTN, chronic pain, hypothyroidism
Allergies: NKDA
Diagnostic Lab Data: Too numerous to list
CDC Split Type:

Write-up: Vaccinated 2/20. At that time, had symptoms of incarcerated hernia, went to ED for evaluation. Not felt to warrant hospital admission. Returned two days later with agitation, altered mental status, and incarceration. Went to OR, uncomplicated hernia repair. Postoperatively, did not recover mental status. Went into arrythmias POD 4, hypotension ensued, had multiple interventions and evaluations without satisfying answers for clinical course.


VAERS ID: 1069938 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-04
Onset:2021-02-20
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown blood thinner
Current Illness: unknown, none listed on pre checklist
Preexisting Conditions: unknown, takes blood thinner
Allergies: nkma
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: expired at Hospital


VAERS ID: 1070005 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-07
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 AR / IM

Administered by: Private       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: 2021-02-03
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension, CAD, Hypothyroidism, Hypercholesterolemia
Preexisting Conditions: Hypertension, CAD, Hypothyroidism, Hypercholesterolemia
Allergies: NKA
Diagnostic Lab Data: Positive Covid Test
CDC Split Type:

Write-up: Patient contracted Covid some period of time after receiving the vaccine.


VAERS ID: 1070038 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-01-14
Onset:2021-01-22
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix Aspirin Lisinopril Diazepam Morphine Sulfate Lyrica Spiriva Respinate Proair Air
Current Illness: COPD
Preexisting Conditions: COPD Vascular Disease Chronic Pain Opioid Dependence HTN
Allergies: No known allergies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Client passed away 8 days after being vaccinated. It is unknown if it occurred from the vaccine or other comorbidities.


VAERS ID: 1070040 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-10
Onset:2021-02-22
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Duloxetine, LIsinopril/Hctz, Oxycodone 10/325, Gabapentine 600
Current Illness: Thyroid nodule
Preexisting Conditions: Diabetes, HTN, Depression, chronic pain
Allergies: Morphine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital 2/22/21


VAERS ID: 1070051 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-06
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 AR / IM

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin, Pennsaid, Carbidopa-Levodopa
Current Illness: HTN, Aortic Valve Disorder, Coronary Atherosclerosis of Native Coronary Artery, Hyperlipidemia, Aortic aneurysm
Preexisting Conditions: HTN, Aortic Valve Disorder, Coronary Atherosclerosis of Native Coronary Artery, Hyperlipidemia, Aortic aneurysm
Allergies: Unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown


VAERS ID: 1070562 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-01
Onset:2021-03-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Relatively severe aortic valve stenosis, bradycardia, orthostatic hypotension and Parkinson''s disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The coroner called Dr. on 3.2.2021 to advise that he had a witnessed collapse and Mr. was taken to the ED where he was pronounced.


VAERS ID: 1070765 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021215418

Write-up: died 2 days after the second vaccine; This is a spontaneous report from a contactable consumer reporting for his/her father. An 87-year-old male patient received the second dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number unknown) via unspecified route of administration on an unspecified date at single dose for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. The patient previously received the first dose of BNT162B2 on an unspecified date for COVID-19 immunisation and was fine. The patient died 2 days after the second vaccine. The reporter stated patient death due to the Pfizer Covid vaccine. The patient had autopsy. The outcome of event was fatal. Information about lot/batch number has been requested.; Reported Cause(s) of Death: died 2 days after the second vaccine


VAERS ID: 1070769 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Diabetes; Heart disorder; Hospitalization; Pacemaker insertion (cardiac)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021224736

Write-up: then died within 24 hours afterwards; This is a spontaneous report from a contactable consumer. This consumer reported that a 74-year-old female patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; Lot number unknown), via an unspecified route of administration an unspecified date at single dose for COVID-19 immunization. Concomitant medications were not reported. The patient with a host of health issues (heart issues/had a pace maker, diabetes, among others) was in a rehabilitation center following a hospital stay and was given the second dose of vaccine. It was reported that the patient died within 24 hours afterwards. It was not reported if an autopsy was performed. Information on batch/lot number was requested.; Reported Cause(s) of Death: then died within 24 hours afterwards


VAERS ID: 1070770 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Texas  
Vaccinated:2021-02-04
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 - / OT

Administered by: Public       Purchased by: ?
Symptoms: Foetal heart rate abnormal, Heart rate, Maternal exposure during pregnancy, Ultrasound scan
SMQs:, Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow), Foetal disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: VIT D; FOLATE; PRENATAL VITAMINS [ASCORBIC ACID;BETACAROTENE;CALCIUM SULFATE;COLECALCIFEROL;CYANOCOBALAMIN;FERROUS ; ZOLOFT
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210203; Test Name: heartbeat; Result Unstructured Data: Test Result:152 bpm; Test Date: 20210220; Test Name: heartbeat; Result Unstructured Data: Test Result:no heartbeat; Test Date: 20210203; Test Name: ultrasound; Result Unstructured Data: Test Result:no abnormalities; Test Date: 20210220; Test Name: ultrasound; Result Unstructured Data: Test Result:fetus stopped growing
CDC Split Type: USPFIZER INC2021225027

Write-up: Maternal exposure during pregnancy; Fetus stopped growing on 09Feb21 (8w4d); no heartbeat detected; This is a spontaneous report from a contactable consumer (parent). This consumer reported information for both mother and fetus. This is a fetus report. A patient of unspecified age and gender (fetus) received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL9269), transplacental on 04Feb2021 at 14:00 at single dose for COVID-19 immunisation. The patient medical history was not reported. Concomitant medication included ergocalciferol (VIT D), folic acid (FOLATE), ascorbic acid/betacarotene/calcium sulfate/colecalciferol/cyanocobalamin/ferrous fumarate/folic acid/ nicotinamide/pyridoxine hydrochloride/retinol acetate/riboflavin/thiamine mononitrate/tocopheryl acetate/zinc oxide (PRENATAL VITAMINS) and sertraline hydrochloride (ZOLOFT) at 25 mg, all transplacental. It was reported that OB exam on 03Feb21 showed healthy baby at 7weeks 5days heartbeat detected 152 bpm; no abnormalities identified via ultrasound; labs and hormone levels all within normal ranges. No issues detected. Mother received 1st dose of vaccine on 04Feb2021. Per ultrasound on 20Feb2021, fetus stopped growing on 09Feb2021 (8 weeks 4 days); no heartbeat detected. Miscarriage occurred on 22Feb2021. The fetus died on 22Feb2021. It was not reported if an autopsy was performed.; Sender''s Comments: Linked Report(s) : US-PFIZER INC-2021204433 same drug and reporter, different patient and event; Reported Cause(s) of Death: Fetus stopped growing on 09Feb21 (8w4d); no heartbeat detected; Mother received 1st dose of vaccine 04Feb21. Per ultrasound on 20Feb21, fetus stopped growing on 09Feb21 (8w4d); no heartbeat detected. Miscarriage occurred 22Feb21.


VAERS ID: 1070937 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-18
Onset:2021-03-03
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

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

Write-up: Unwitnessed Cardiac arrest. ACLS protocols were performed. Cessation of resuscitation was called in the field by Dr.


VAERS ID: 1071117 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-01-31
Onset:2021-02-07
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Haemorrhage, International normalised ratio, Urinary tract infection, Urine analysis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ANTICOAGULATION
Current Illness: Anticoagulant therapy (Long term history of anticoagulation therapy.)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210210; Test Name: INR; Test Date: 20210210; Test Name: urine analysis; Result Unstructured Data: diagnosed with a UTI
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; UTI; Abnormal bleeding; A spontaneous report was received from a healthcare professional concerning a patient who received the Moderna COVID-19 Vaccine (mRNA-1273) and experienced abnormal bleeding, UTI, and passed away. The patient''s medical history included a long term history of anticoagulation therapy. Concomitant product use included anticoagulation therapy. On 31Jan2021 prior to the onset of the events the patient recieved their first dose of mRNA-1273 (Lot number:not reported) intramuscularly for prophylaxis of COVID-19 infection. On 07Feb2021, the patient complained of abnormal bleeding. Patient was seen at clinic on 10Feb2021 and was diagnosed with a UTI and given antibiotics. An INR was also completed that day due to patient having a long term history of anticoagulation therapy. Results of that showed the INR to be 12. Prior to vaccination, patient''s INR was normal and no changes to medications and diet were made after vaccination and prior to complaint starting. On 12Feb2021 the patient passed away. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 12Feb2021. The cause of death was unknown. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns an 82 year old male patient, with history of long term anticoagulation therapy (unknown indication), who experienced a fatal event of death and abnormal hemorrhage, 13 days after receiving second dose of mRNA- 1273 (Lot# Unknown). 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: 1071120 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-02-12
Onset:2021-02-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Atrial fibrillation, Atrial flutter, Heart rate increased
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: TRAVATAN
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: Atrial fibrillation; Feeling fluttery; Heart rate was racing and was increasing, went up to 175 just sitting; A spontaneous report was received from a consumer concerning a 64-year-old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced atrial fibrillation, feeling fluttery, and heart rate was racing and was increasing, went up to 175 just sitting. The patient''s medical history was not provided. Concomitant medications included Travatan for glaucoma. On 12 Feb 2021, prior to the onset of the events, the patient received the first of two planned doses of mRNA-1273 (lot/batch: 030M20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. On 12 Feb 2021, five hours after vaccination, the patient experienced a fluttery feeling, heart rate was racing and was increasing, heart rate went up to 175 just sitting. She took an EKG on her watch and it was atrial fibrillation. When she was sleeping, her heart rate was at 102 or the 90s, normally it would be in the 60s. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not reported. At the time of this report, the outcome of the events, atrial fibrillation, feeling fluttery, and heart rate was racing and was increasing, went up to 175 just sitting, was unknown.; Reporter''s Comments: This case concerns a 64 year old female patient, who was on hospice care experienced a fatal event of death, 1 day after receiving second dose of mRNA- 1273 (Lot# 030M20A). Very limited information regarding this event has been provided at this time. Further information has been requested.


VAERS ID: 1071128 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2021-01-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unresponsive; A spontaneous report was received from Pfizer concerning a 32-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 28 DEC 2020, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 04 JAN 2021, at 7:20 am, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 04 Jan 2021. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: This case concerns a 32-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The cause of death was unknown. Plans for an autopsy were not provided. 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: 1071129 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-01-09
   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: No adverse event (no reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unresponsive; A spontaneous report was received from Pfizer concerning a 43-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 08 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 09 JAN 2021, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 08 Jan 2021. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; 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: 1071130 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: Unresponsive; A spontaneous report was received from Pfizer concerning a 45-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 28 Dec 2020, approximately 24 hours prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 29 Dec 2020, the patient was found deceased at home. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 29 Dec 2020. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; 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: 1071131 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-31
Onset:2020-12-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: Unresponsive; A spontaneous report was received from Pfizer concerning a 50-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 31 Dec 2020, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) intramuscular for prophylaxis of COVID-19 infection. On 31 Dec 2020, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 31 Dec 2020. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: This case concerns a 51 year old, female patient, who experienced an unexpected event of Death, after receiving 1st dose of mRNA- 1273 (Lot# unknown). Very limited information regarding this event has been provided at this time. There is no contact information and no further follow up information is expected.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071132 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
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: chronic hypoxia respiratory failure; Unresponsive; A spontaneous report was received from Pfizer concerning a 51-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had developed hypoxia a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 07 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 07 Jan 2021, around 6:00 pm, the patient became increasingly hypoxic. He was transported to the hospital for acute on chronic hypoxia respiratory failure. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 12 Jan 2021 at 11:25pm. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071133 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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: Unresponsive; A spontaneous report was received from Pfizer concerning a 52-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 08 Jan 2021, approximately 2 hours prior to the onset of event, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient was monitored for the appropriate amount of time by nursing staff, following vaccination. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 08 Jan 2021 at 2:15pm. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: This case concerns a 52-year old, female patient, who experienced a sudden death 1 day after administration of first dose of mRNA-1273. The cause of death was not provided. Plans for an autopsy were unknown. 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: 1071134 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-23
Onset:2021-01-08
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (no reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a reporter concerning a 56-year old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and had experienced death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 23 Dec 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 08 Jan 2021. The cause of death was not provided. Plans for an autopsy were not provided.; 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: 1071135 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   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: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unresponsive; A spontaneous report was received from Pfizer concerning a 56-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 08 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 09 Jan 2021, the patient was found deceased in her home. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 09 Jan 2021. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; 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: 1071136 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-04
Onset:2021-01-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Pyrexia, Respiratory failure, Sepsis, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? 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: sepsis; respiratory failure; Fever; Unresponsive; A spontaneous report was received from Pfizer concerning a 56-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced respiratory failure, sepsis, fever and sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 04 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 11 Jan 2021, the patient began to have a fever. She was sent to the emergency room for evaluation. That evening, she died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 11 Jan 2021. The cause of death was reported as respiratory failure and sepsis. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: This is a case of 56-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sepsis, fever, respiratory failure and sudden death. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Respirtory Failure; Sepsis


VAERS ID: 1071137 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-30
Onset:2021-01-04
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-01-04
   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: Medical History/Concurrent Conditions: No adverse event (No Reported Medical History)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unresponsive; A spontaneous report was received from Pfizer concerning a 58-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 30 Dec 2020, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 04 Jan 2021, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 04 Jan 2021. The cause of death was unknown/not reported. Plans for an autopsy were unknown/not provided.; 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: 1071138 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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: Sudden death; A spontaneous report was received from Pfizer concerning a 60-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 05 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 08 Jan 2021. The cause of death was unknown/not reported. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: Very limited information regarding the event has been provided at this time and is insufficient for causality assessment. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071139 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (no reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Sudden death; A spontaneous report was received from Pfizer concerning a 60-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 12 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 13 Jan 2021, the patient was found to be deceased at 3:00 am. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 13 Jan 2021. The cause of death was unknown/not reported. Plans for an autopsy were unknown/not provided. .; 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: 1071300 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-04
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: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died; A spontaneous report, was received from a consumer on a social media, concerning a 38-years-old female patient, unknown race and ethnicity, who was administered Moderna''s COVID-19 vaccine (mRNA-1273), and died. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unknown date, prior to the onset of the event, the patient received dose of mRNA-1273 (Lot number: unknown), for the prophylaxis of COVID-19 infection. On 17-Feb-2021, social media interaction was posted concerning a death of a patient on an unknown date after receiving Moderna vaccine. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on an unknown date. The cause of death was not provided. Plans for autopsy were not provided.; Reporter''s Comments: Very limited information regarding the event of death has been provided at this time. No further information will be available.; Sender''s Comments: MODERNA, INC.-MOD-2021-018380:Same reporter; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1071367 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-11
Onset:2021-02-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood pressure measurement, Cardiac failure, Death, Electrocardiogram, Fatigue, Feeling cold, Hyperhidrosis, Hypersomnia, Hypotension, Illness, Mobility decreased, Tremor
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: COUMADIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Heart failure, congestive
Allergies:
Diagnostic Lab Data: Test Date: 202101; Test Name: Blood Pressure; Result Unstructured Data: Low; Test Date: 202101; Test Name: EKG; Result Unstructured Data: Normal
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Blood pressure went down until he died; Couldn''t hear his heartbeat; neck was sweating; He was cold; Couldn''t get up; Death; Sick; immediately very tired; he was tired; Hands were shaking; Slept for too long; A spontaneous report was received on 18 Feb 2021 from a consumer concerning a 81-years-old, male patient who received Moderna''s COVID-19 vaccine and developed immediately very tired, hands were shaking, neck was sweating, was cold, sick, couldn''t get up, couldn''t hear his heartbeat and blood pressure went down until he died. Patients'' medical history, as provided by patient''s spouse, was emergency room(ER) admission in November 2020 because he had a congested chest (he had fluid around his heart). At that time, they gave him pills for kidney function. Other concomitant medication reported was Coumadin, blood thinner. Two weeks before receiving the vaccine, patient''s EKG was normal. On 11 Feb 2021, in the morning, patient received their first of two planned doses of mRNA-1273(BATCH/LOT # 007M20A) probably in the right arm for the prophylaxis of COVID-19 infection. On 11 Feb 2021, approximately after 15 minutes of receiving vaccine, they left and patient was immediately very tired, his hands were shaking. So, patient''s spouse made them down sleep for too long. On Friday, 12 Feb 2021 she tried to pick him up, but he was tired, exhausted, and sick. On Saturday, 13 Feb 2021, she brought him a coffee and he couldn''t hold it because his hands were shaking, so she gave him the coffee and then made him pee on the bed because he couldn''t get up. At lunch time she made him eat something and he fell sleep again. His wife was hanging around him all day and around 7:30pm she realized that he was cold, and his neck was sweating, she couldn''t hear his heartbeat. So, she called emergency services and when they arrived, her husband''s blood pressure went down until he died. Treatment for the events were not provided. Action taken with mRNA-1273 was not applicable. Patient was pronounced dead on 13 Feb 2021 20:00. The cause of death was not provided. The plans for an autopsy were not provided. The events of blood pressure went down until he died and couldn''t hear his heartbeat were fatal. The outcome for the remaining events were unknown.; Reporter''s Comments: This case concerns an 81 year old, male patient, who experienced a serious event of death among others, 2 days after receiving mRNA- 1273 (Lot# 007M20A). 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: 1071618 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Chills, Death, Fatigue, Flatulence, Headache
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: dupixent, furosemide, klor-con m10, levothyroxine, atenolol,
Current Illness: none
Preexisting Conditions: irregular heart beat
Allergies: biaxin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chills; headache; extreme fatigue; gas or chest pain that was thought to be gas and went away Died 4 days later


VAERS ID: 1071741 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-24
Onset:2021-02-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abnormal faeces, Breath sounds abnormal, Crepitations, Death, Discoloured vomit, Haematemesis, Vomiting, Wheezing
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Biliary system related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Noninfectious diarrhoea (broad), Respiratory failure (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: glimepiride 1mg Glucophage levothyroxine lisinopril Tylenol 3 with codeine fenofibrate cyclobenzaprine omeprazole
Current Illness: No
Preexisting Conditions: High Blood Pressure Prostate cancer in the past Non-insulin diabetic Coronary Artery Disease Aortic Stenosis
Allergies: No
Diagnostic Lab Data: no. no autopsy.
CDC Split Type:

Write-up: He started vomiting 2 days later. we suspect he was having stool issues as well. he vomited blood at some point over the weekend. there was black vomit right before he passed. from 2am-6am he was wheezing and rattling and then he passed at approximately 6am 3/1/2021 at home. EMS did come and try to revive him and were unsuccessful.


VAERS ID: 1071863 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-04
Onset:2021-01-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL 0140 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysphagia, General physical health deterioration, Pain
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: 2021-01-09
   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: Ativan, Lisinopril, lasix
Current Illness: Dementia, health decline
Preexisting Conditions: chronic gout, renal impairment, ischemic cardiomyopathy
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient, age 101, was having a period of declining health prior to vaccine administration. This continued after the vaccine to include increased pain, inability to swallow and ultimately Patient passed away on 1/9/2021. The physician does not believe this is due to vaccine administration, however family asked that this information be reported for record keeping.


VAERS ID: 1071903 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-02-26
Onset:2021-02-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: School       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: reported none at time of vaccination
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: reported none at time of vaccination
Diagnostic Lab Data: none known
CDC Split Type:

Write-up: No reported adverse effects after vaccine was administered. Someone reported to our clinic that patient was found dead at home on Sunday


VAERS ID: 1071935 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-03
Onset:2021-03-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Dizziness, Fall, Headache, Malaise, Weight increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Vestibular disorders (broad), Respiratory failure (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: Metoprolol ER 50 mg qHS, Trazodone 50 mg qHS, Lisinopril 40 mg daily, HCTZ 25 mg daily, Topiramate 25 mg qHS, Melatonin 1 tab qHS, Bupropion 300 mg daily
Current Illness: HTN, sleep apnea
Preexisting Conditions: HTN, sleep apnea, hx of MRSA wound infection in groin
Allergies: Penicillin
Diagnostic Lab Data: Wt = 201 kg (443 lbs), No specific labs were drawn when he presented to ED coding.
CDC Split Type:

Write-up: Patient received the vaccine around 11 am. He hadn''t been feeling well (headache, dizziness) per report and initially called in to work. He then decided to come to work and was found down in a patient bathroom during his shift on our Facility while taking care of a patient (he was a nurse aid). Patient was coded and the team and was transferred to our Facility ED. He expired 3/3 2112


VAERS ID: 1072113 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-02-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1072156 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-22
Onset:2021-02-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Anxiety, Blood culture negative, Cardiac disorder, Cardiac failure, Cellulitis, Culture urine negative, Culture wound negative, Depression, Echocardiogram, Haemodynamic instability, Intensive care, Mental status changes, Postoperative wound infection, Pyrexia, Septic shock, Sleep apnoea syndrome, White blood cell count increased
SMQs:, Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: allopurinol 300mg daily aripiprazole 5mg daily cephalexin 500mg q12h cholecalciferol 2000 units daily hydroxychloroquine 200mg 2x daily levothyroxine 125mcg daily presnisone 5mg daily ruxolitinib 15mg 2x daily sertraline 100mg daily valacyc
Current Illness: erythema of face consistent with mild cellulitis recent MOS procedure for skin cancer
Preexisting Conditions: myelofibrosis History of aortic valve replacement in 2014 hx of depression, anxiety
Allergies: amiodarone, doxycycline, penicillin
Diagnostic Lab Data: Blood cultures, wound culture, urine culture - no growth WBC 16.1 on admission ECHO - no vegetation seen on aortic valve
CDC Split Type:

Write-up: Vaccine manufacturer and lot number unknown, vaccine given at alternate location. 2/23/21 8:27 PM: The patient is a 68-year-old male comes to the emergency department by paramedic ambulance for altered mental status that, began at around noon in association fever temp 102.9. PMH of myelofibrosis (on Jakafi and hydroxychloroquine), depression, anxiety, OSA, and history of AVR. Given history of myelodysplasia and Jak inhibitor predisposing to some opportunistic infections most notably viral reactivation with history of HSV and possible bacterial endocarditis he was admitted to the ICU for further monitoring and pressors. Patient has a MOS procedure 14 days prior - Status post MOSs procedure with large wound deficit on forehead -- Does not appear to be overtly infected at the time of admission. ED physician indicated mild facial cellulitis. 2/23/21- WBC 16.1 on admission. ECHO 2/26 indicated - no vegetation visualized. Of note second COVID vaccine 2 days prior to admission. Dr. felt incident was possible cardiogenic shock secondary to COVID vaccine. He did not feel the patient has a source of infection upon admission. Questionable given wounds on forehead Dr. (CMO) review of case- his impression was septic shock with and underlying case of chronic cardiac compromise making the hemodynamics worse


VAERS ID: 1072166 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Vermont  
Vaccinated:2021-02-09
Onset:2021-03-02
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Pneumonia
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amlodipine, atorvastatin, betamethasone topical, carvedilol, clobetasol topical, furosemide, losartan, mycophenolate mofetil, nitroglycerin, pantoprazole, potassium chloride, rivaroxaban, tamsulosin, triamcinolone topical
Current Illness: paraviral pneumonia
Preexisting Conditions: atrial fibrillation, bladder cancer, aortic dissection, hypertension, spinal cord stroke
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient hospitalized with shortness of breath and pneumonia (from 2/15/2021 to 2/21/2021) and patient died at another facility on 3/2/2021.


VAERS ID: 1072218 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Vermont  
Vaccinated:2021-02-13
Onset:2021-02-21
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Public       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: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin, atorvastatin, clotrimazole topical, gabapentin, lisinopril, metoprolol, docusate, multivitamin, nitroglycerin, omeprazole, probenecid, triamcinolone topical, zolpidem
Current Illness:
Preexisting Conditions: angina pectoris, coronary artery disease, epistaxis, gout, hyperlipidemia, hypertension, idiopathic pulmonary fibrosis, lymphoma
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient hospitalized for NSTEMI (from 2/18/2021 to 2/20/2021) and discharged on hospice/comfort care. Patient died 2/21/2021.


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