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From the 11/19/2021 release of VAERS data:

Found 4,746 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died

Government Disclaimer on use of this data



Case Details

This is page 16 out of 48

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VAERS ID: 1204429 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-10
Onset:2021-03-15
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A 02/10/2 / 2 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test, Computerised tomogram head, Computerised tomogram kidney, Condition aggravated, Death, Dementia, General physical health deterioration, Urine analysis
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 16
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: Atorvastatin 40mg take 1 by mouth daily--cetirizine 10mg take 1 by mouth daily--- b-12 500mg take 1 daily---folic acid 400mcg take 1 by mouth daily---fosinopril 10mg take 1 by mouth daily---memantine 10mg take 1 by mouth 2 times daily--- Om
Current Illness: Dimentia with lewey bodies
Preexisting Conditions: Dimentia diagnosed 03/2017
Allergies: Penicillian Ancef Septra
Diagnostic Lab Data: ct scan of head 03/17/21 ct scan of kidneys 03/18/21 ct scan of head 03/19/21 urinalisys/ and blood work appropiate to determine sudden decline.
CDC Split Type:

Write-up: From golfing on 02/23/2021 to dimentia suddenly going into overdrive and death on 03/31/2021 All tests and care was taken to understand rapid/ unexplained decline.


VAERS ID: 1204502 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-03
Onset:2021-03-30
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized and died within 60 days of receiving a COVID vaccine series


VAERS ID: 1204680 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-03-26
Onset:2021-03-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / UNK - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, 81mg 1x day Carvedilol, 12.5 mg, 1 Tab twice daily Glimepride, 2mg, Take 1 tablet twice daily Losartan Potassium, 50 mg, Take 1 Tablet Daily Metformin HCI - 1000 mg, Take 1 Tablet twice daily Pioglitazone HCI, 30 mg, Take one table
Current Illness: Type II diabetes High Blood Pressure Interstitial Lung Disease
Preexisting Conditions: Type II diabetes Hypertension Interstitial Lung Disease
Allergies: Sensitive to Eggplant (food) No drug allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Suddent Death approximately 75 hours after second dose of Moderna Vaccine


VAERS ID: 1204876 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-08
Onset:2021-03-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Depakote
Current Illness: Dementia/Alzheimer?s Disease
Preexisting Conditions: Dementia/Alzheimer?s Disease
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1205036 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-03-19
Onset:2021-03-30
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 LA / -

Administered by: Private       Purchased by: ?
Symptoms: Anticoagulant therapy, Biopsy bone marrow, Blood test, Dyspnoea exertional, Electrocardiogram, Headache, Hypotension, Intensive care, Intracardiac thrombus, Platelet count decreased, Pulmonary embolism, SARS-CoV-2 test negative, Thrombosis
SMQs:, Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Pulmonary hypertension (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Blood work EKG Oxygen Bone Marrow Tested
CDC Split Type:

Write-up: On March 30th started with headaches then progressed to shortness of breath while moving. Then on April 4th transport to hospital via EMT was tested for Covid 19 results was negative. It was determined that blood clots where found in Right leg & Left leg and both lungs and now blood clot was found in heart. PT has low platelets, low blood pressure. While in the hospital pt was given herapin . Patient has remained in ICU since the 4th to present time.


VAERS ID: 1205305 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 RA / IM

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

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

Write-up: 3-11 didn''t feel well, passed away later that day


VAERS ID: 1205392 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Idaho  
Vaccinated:2021-02-16
Onset:2021-02-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen saturation decreased, Pulmonary embolism, Thrombosis
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: metformin and water pill
Current Illness: chest cold 2/1-2/7, told almost had pneumonia on 2/7 and given Zpack and inhaler. Improved some by 2/14. Returned to work on 2/16 after 2 weeks off sick and got 2nd vaccine shot because it was the last day to get it or would have to restart. Became hard to breathe again on 2/19 and hospitalized from lack of oxygen on 2/21. Blood clots discovered 2/22, died 2/24 from pulmonary embolism
Preexisting Conditions: diabetes, high blood pressure and varicose viens.
Allergies: none
Diagnostic Lab Data: Would have to ask ICU
CDC Split Type:

Write-up: blood clots in left leg and both lungs diagnosed on 2/22, died 2/24


VAERS ID: 1205421 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-04-08
Onset:2021-04-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, No adverse event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: alprazolam 1mg, metformin 1000mg, pantoprazole 40mg, clopidogrel 75mg, venlafaxine 75mg, tamsulosin 0.4mg, potassium 20meq, gabapentin 600mg, fludrocortisone 0.1mg, furosemide 40mg, famotidine 40mg, levemir flextouch 65 units qhs, finasteri
Current Illness: Unknown
Preexisting Conditions: Diabetes, and other unknown complications of diabetes.
Allergies: latex, adhesive tape, thimerosal
Diagnostic Lab Data:
CDC Split Type:

Write-up: On April 8, 2021 patient received his second dose of Moderna COVID-19 vaccine at pharmacy at 1:08pm. Patient waited the appropriate 15 minutes, and then left pharmacy. He reported no adverse reactions to our staff during that time, and did not call afterward to report any adverse reactions. At approximately 4:30pm on April 10, 2021, I received notification that patient was found DOA at his residence. No other information is available at this time.


VAERS ID: 1205518 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-09
Onset:2021-04-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031B21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cold sweat, Death, Dehydration, Malaise, Pyrexia
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   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: none known
Current Illness: none known
Preexisting Conditions: none known
Allergies: none known
Diagnostic Lab Data: none known
CDC Split Type:

Write-up: Resident was inoculated on 04/09. According to family members, he began to feel unwell that evening, cold sweats, high fever, dehydration. According to family members, he refused to get medical attention. After not hearing from him for a few days, family members called for a wellfare check on 04/12 at which time he was found deceased.


VAERS ID: 1205714 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-04-08
Onset:2021-04-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: valsartan
Current Illness: hypertension syncopal episodes glaucoma
Preexisting Conditions: hypertension glaucoma cataracts
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: She was found unresponsive by her husband on 4/11/2021 and pronounced dead at the scene. She had been to the emergency room for recurrent syncope several weeks prior to any vaccinations. No cause was determined.


VAERS ID: 1205863 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-09
Onset:2021-02-05
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20 / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Chest pain, Death, Fibrin D dimer increased, Full blood count, Platelet count, Pulmonary embolism, Resuscitation, Thrombocytopenia, Troponin normal
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Embolic and thrombotic events, venous (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin D, Vitamin B, Zinc, 81mg Aspirin.
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: 2/5/2021 - D-Dimer, Troponin, CBC with platelets.
CDC Split Type:

Write-up: Died from Pulmonary Embolism. No leg pain, no leg swelling to indicate DVT in leg. Also was thrombocytopenic at the time of emergency/ER visit/treatment. He suddenly complained of very bad chest pain, could hardly speak to tell symptoms. Immediate resuscitation was started by family member and 911 was called. Ambulance detected tech, tried to electroconvert, but was not successful. Chest compression and bagging was done until patient got the hospital. There full resuscitation effort. Unsuccessful. Troponin normal, D-dimer sky high.


VAERS ID: 1205982 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-26
Onset:2021-03-05
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 14M20A / 2 AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arthralgia, Death, Pulmonary embolism, Unresponsive to stimuli, X-ray limb normal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Unknown
Current Illness: None
Preexisting Conditions: High Blood Pressure
Allergies: None
Diagnostic Lab Data: 2 Doctor''s visits as described above with one x-ray. I do not know all of tests that were run in the emergency room. I know that they scanned her head and it was clear.
CDC Split Type:

Write-up: On 1-27-21 my mother received her first dose of the Moderna COVID-19 vaccine (031L2A). The next day she felt something in the back of her left knee. The following day (2 days) after the injection she saw her primary care physician for the discomfort in the back of her knee. She was treated for what was believed to be a soft tissue injury. She received her second dose of the Moderna COVID-19 (14M20A) vaccine on Friday 2-26-21. The next day the back of her knee started to bother her again. She saw her doctor on Monday3-1-21 and had an x-ray. On Tuesday the doctor''s office called and said her x-ray was clear. Friday morning, 3-5-21 my father heard a loud noise (thud) and found my mother unresponsive on the bathroom floor at approximately 8:30am. He called 911. She was transported to the hospital via ambulance. The emergency room physicians worked on her for over an hour and were unable to get her back. Her time of death was 10:12am. The primary cause of death listed on her death certificate is pulmonary embolism.


VAERS ID: 1206085 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal discomfort, Cardiac failure, Death, Decreased appetite, Fatigue, Hepatic failure, Illness, Lethargy, Neck pain, Pain in extremity, Pulseless electrical activity, Renal failure, Shock
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Arthritis (broad), Tumour lysis syndrome (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Eliquest Motoporal Synthroid/Levothyroxine Losartan (A heart Medication, I''ll have to find the name and update)
Current Illness: Some kidney and heart problems pre-existing, but under control with medications.
Preexisting Conditions: Some kidney and heart problems
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: She got sick, pain in the arm and neck the day after the vaccine. I called her doctors office on the 19th of Feb and I did not get a call back. She was sick to her stomach, really tired and lost her appetite. On the 22nd I called her doctor again... no response, on the 23 I called again. On the 24th finally someone spoke to me.. they stated they had called my mom and spoke with her. They are suppose to call me, my mom could not remember by the time she would hang up. They said to let her rest and give her electrolytes and Vit. B6. On the 26th when I called the doctor and said she is lethargic they said to take her to the ER. She flat lined at the hospital and her body went into shock. She ended up having Kidney, Heart and Liver Failure. She was still driving and doing all of her cooking, banking, shopping, showering, walking every day on Feb 18th. She died on March 5th.


VAERS ID: 1206330 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-04-11
Onset:2021-04-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019B21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Cardiomegaly
Allergies:
Diagnostic Lab Data: Autopsy
CDC Split Type:

Write-up: Death


VAERS ID: 1207097 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-04-02
Onset:2021-04-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Electrocardiogram abnormal, 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: 2021-04-04
   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: N/A
Current Illness: Hypercoaguable state
Preexisting Conditions: Hypercoaguable state, CAD, MI in 2018, Status post right femoral fracture in 2018, Lower extremity edema, Hyperlipidemia, RA, HTN, Diastolic Dysfunction, Aortic Stenosis, Osteoarthritis
Allergies: Banana, Benadryl, Iodine, Kidney beans, Milk Containing Products, Mushroom, oats, Penicillins, Remicade, Seafood/ saltwater fish, Sulfa
Diagnostic Lab Data: EKG
CDC Split Type:

Write-up: According to hospital records, patient presented to the ER in full cardiac arrest with ongoing CPR in progress.


VAERS ID: 1207198 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-11
Onset:2021-04-08
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EN6199 / 2 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Blood lactic acid increased, Chronic kidney disease, Death, Gastrointestinal haemorrhage, Spinal compression fracture
SMQs:, Rhabdomyolysis/myopathy (broad), Haematopoietic erythropenia (broad), Lactic acidosis (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Gastrointestinal haemorrhage (narrow), Accidents and injuries (narrow), Ischaemic colitis (broad), Osteoporosis/osteopenia (broad), Chronic kidney disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Anemia GI bleed Lactate blood increased CKD (chronic kidney disease) Jefferson fracture


VAERS ID: 1207372 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-13
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Probiotics and Omeprazole
Current Illness: None reported
Preexisting Conditions: Respiratory problems, in hospice
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: On 1/21/2021 Caregivers proceed to go on rounds taking vitals and found she was with low blood pressure. They call Hospice and they certify that she had passed away.


VAERS ID: 1207395 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-13
Onset:2021-01-24
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, Labetalol, Mecobalamin, Amlodipine, Fenofibrate, Aspirina, Zolpidem, Pravastatin
Current Illness: None reported
Preexisting Conditions: Thyroid, Circulation Problems, Vascular Problems
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: On 1/24/2021 the patient was discharged from the hospital due to swelling in the body, when they proceeded to infuse medications. She herself had passed away.


VAERS ID: 1207428 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-04-06
Onset:2021-04-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: No Known Drug Allergies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient declared deceased the day after receiving second Moderna COVID vaccine. not her regular pharmacy to our knowledge. Have attempted to contact last known PCP with no response. Son notified pharmacy of patient passing away.


VAERS ID: 1207687 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-03-12
Onset:2021-03-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 5 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Feeling cold, Illness, Influenza like illness, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinipril, Digoxin, Metopralol, xarel,Doztiazem
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: He was given a stint
CDC Split Type:

Write-up: My husband became very sick the day after recieving the shot. He was freezing cold. No matter what he did he could not get warm. He experienced flu like symptons for about 24 hours. This was on Saturday. On Tuesday he died. They said it was a heart attack. He was in excellent health. We had gone to the gym 3 days a week for years. He was doing Cardio on the bike and treadmill for over an hour each time. He never experienced shortness of breath and before the shot was 100 % healthy


VAERS ID: 1207773 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-26
Onset:2021-03-15
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20 A / 2 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Confusional state, Death, Dyspnoea, Gait disturbance, Intensive care, Mechanical ventilation, Pneumonia, Pulmonary embolism, Renal disorder, Sedation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Embolic and thrombotic events, venous (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Rivastigmine 13.3mg patch, losartan 25 mg, furosemide 20mg tab, aspirin 81mg, glipizide 5mg, Insulin Aspart 100UN/ML Novo flexpen 3ml sliding scale,, meclizine hcl 25mg, buspirone hcl 10mg, Olanzapine 5mg, Topiramate 100mg, duloxetine hcl 6
Current Illness: Diabetes, Alzheimers, Pacemaker,
Preexisting Conditions: Diabetes, Alzheimers, Pacemaker
Allergies:
Diagnostic Lab Data: 03/15/2021
CDC Split Type:

Write-up: 2nd maderna vaccine was given to my dad on 02/26/2021 and on 03/15/2021 my dad was visiting me all day and he acted fine and normal. At the end of our visit between 8 & 9 pm we went to the store where he started to gasp for breath. He had to keep stopping and said he couldn''t breath. I had him sit several times because I didn''t know how bad it was. By the time we reached the doors to leave after a short trip he almost fell over and he became confused and said he couldn''t breath. I had another customer get my dad a wheel chair close by while I called 911. The ambulance came quickly but at the hospital my dad went into cardiac arrest and his heart stopped 2 or 3 times and it had to be restarted. When I was able to get to the hospital my dad was on a ventilator and sedated. They had put him on medicine to blast the blood clots they had found. They said he had 2 very large blood clots with one on each lung. Later his kidneys started failing him and they said he would need to go on dialysis as soon as the next day. Later that night they told me my dads heart was shutting down and he had developed pneumonia. My dad died that night and I had to watch him take his last breath. If you want further information please contact Medical center would be the ones to contact for all information and my dad was in the critical care unit.


VAERS ID: 1207822 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-04-06
Onset:2021-04-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydromorphone, Cyclobenzaprine, Lisinopril, Duloxetine, Sildenafil, Trazodone, Amoxicillin, Sulfate Thoxazole, Buspirone, Metformin, Omeprazole, Carvedilol, Ibuprofen, Pregabalin, Tamsulosin, Gabapentin
Current Illness: back surgery 5 days prior
Preexisting Conditions: Intervertebral disc. disorders with radiculopathy, hypoxemia, atelectasis, type 2 diabetes, essential hypertension, chronic obstructive pulmonary disease, alcohol dependence, major depressive disorder, benign prostatic hyperplasia, gastro-esophageal reflux disease, nicotine dependence, spinal stenosis-lumbar region, syncope and collapse
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse symptoms from vaccination. Decedent died day after 2nd vaccination, death not related to vaccination


VAERS ID: 1207863 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-18
Onset:2021-03-28
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1207869 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-03-05
Onset:2021-03-19
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Cardiac arrest, Cardiac failure, Chest X-ray abnormal, Death, Dyspnoea, Electrocardiogram, Endotracheal intubation, Life support, Lung infiltration, Oxygen saturation decreased, Pulseless electrical activity
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Interstitial lung disease (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Carvedilol, cyclobenzaprine, Eliquis, furosemide, Rosuvastatin, spronolactone
Current Illness: Abdominal pain, cramps, bloating.
Preexisting Conditions: Atrial Fibrillation, Heart Failure, Hyperlipidemia, Chronic Kidney Disease Stage 2, Nicotine Dependence, BMI 29, Pacemaker status.
Allergies: Lisinopril
Diagnostic Lab Data: EKG, HR 60, paced rhythm; chest xray: right lower lobe infiltrate. CT contraindicated due to renal insufficiency.
CDC Split Type:

Write-up: Presented to the ER on 3/19 at 23:57 with 2 days of worsening shortness of breath. HR 60, Pulse Ox: 85% on Room air. Placed on BiPAP. could not maintain oxygen, intubated. The patient rapidly decompensated and went into cardiac arrest with PEA. ACLS performed for 35 minutes without the ability to reverse. Patient expired at 0222 on 3/20/21.


VAERS ID: 1207928 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-01-04
Onset:2021-02-11
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Antoprasole, Pantoprazole, Quetiapine
Current Illness: None reported
Preexisting Conditions: Alzheimer
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: Shortness of breath


VAERS ID: 1207989 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-04-12
Onset:2021-04-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Dyspepsia, Loss of consciousness, Pain in extremity, Respiratory arrest
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), Gastrointestinal nonspecific dysfunction (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Not Reported/Unknown
Current Illness: Indigestion; Arm Soreness
Preexisting Conditions: Cardiac History; Strokes (Multiple); Hypertension; Ventricular Fibrillation; Hyperlipidemia; Diabetes Mellitus; Lyme''s Disease
Allergies: Not Reported/Unknown
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: The decedent was last seen alive at approximately 0130 when the decedent''s next of kin (NOK) heard the decedent walking around the residence. The decedent complained of arm soreness and indigestion; the decedent received a second COVID-19 vaccination (Moderna) on 04/12/2021. The decedent went to the living room to sleep on the couch due to the health and soreness complaints. At approximately 0750, NOK entered the living room and found the decedent unconscious and not breathing.


VAERS ID: 1208248 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-02-04
Onset:2021-02-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Dysphagia
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: 2021-03-18
   Days after onset: 40
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Apixaban, Digoxin, Omeprazole, colchicine, prednisone, Senna Multi vitamin, Vitamin B, Magnesium
Current Illness:
Preexisting Conditions: Parkinson?s Disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Had a general over all weakness especially affected his swallowing.


VAERS ID: 1208360 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-03
Onset:2021-02-12
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   Days after onset: 54
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized X 5 and died within 60 days of receiving a COVID vaccine


VAERS ID: 1208477 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-03-19
Onset:2021-03-30
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac failure, Death, General physical health deterioration
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 14
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: Received Moderna vaccine on 2/29/21 and 3/19/2021. Health began declining 2 weeks later and died on 4/13/2021 (26 days post vaccination) with heart failure listed as cause of death.


VAERS ID: 1208579 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-31
Onset:2021-02-03
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Blood test, Brain stem thrombosis, Computerised tomogram head abnormal, Death, Intracardiac thrombus, Magnetic resonance imaging head abnormal, Magnetic resonance imaging heart, Thrombosis
SMQs:, Supraventricular tachyarrhythmias (narrow), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clopidogrel 75mg, Metoprolol 125mg, Montelukast 10mg, Simvastatin 40mg, Synthroid 50mcg, Vitamin D3 50mcg, Biotin 5000mcg
Current Illness: None
Preexisting Conditions: COPD, Hypothyroid, TIA 10 years ago
Allergies: Codeine, Shellfish
Diagnostic Lab Data: Multiple CT scans, MRIs and blood work between 2/4/21-2/10/21.
CDC Split Type:

Write-up: Developed blood clot in heart -- $g went into Atrial Fibrilation with no prior history of A FIb -- $g Large clot was thrown from the heart into the brain splitting into two clots, one blocking brain stem and one blocking right hemisphere -- $g Death on 2/10/21


VAERS ID: 1208628 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-04-09
Onset:2021-04-13
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   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: Coreg, Furosemide, Aspirin, Fish Oil, Nitroglycerin, Nystatin topical, Lasix, Lactulose, Potassium Chloride, Omeprazole, Loratadine, Flomax, Gabapentin, Narcan, Tramadol, Zolpidem, Combivent, Imdur
Current Illness: Essential hypertension, Cardiomyopathy, Chronic viral Hepatitis C, Cirrhosis of the liver, Hypokalemia, Anxiety disorder, CHF, Gout, Ischemic heart disease, COPD, Smoker, Diabetic neuropathy, Lipid disorder, Diabetes Mellitus, Cataracts, Chronic insomnia, Radiculopathy lumbar region, GERD, Benign prostatic hyperplasia with lower urinary tract symptoms, Chronic kidney disease stage 3, Seasonal allergies, BMI 39.0-39.9
Preexisting Conditions: Essential hypertension, Cardiomyopathy, Chronic viral Hepatitis C, Cirrhosis of the liver, Hypokalemia, Anxiety disorder, CHF, Gout, Ischemic heart disease, COPD, Smoker, Diabetic neuropathy, Lipid disorder, Diabetes Mellitus, Cataracts, Chronic insomnia, Radiculopathy lumbar region, GERD, Benign prostatic hyperplasia with lower urinary tract symptoms, Chronic kidney disease stage 3, Seasonal allergies, BMI 39.0-39.9
Allergies: Codeine, Lipitor
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: It was reported by the Sheriff''s Dept. that patient was found expired on 4/13/21 - sitter reported that patient went to take a nap and the sitter went to check on him and found him unresponsive and called 911; patient was DOA on arrival


VAERS ID: 1208670 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-05
Onset:2021-04-11
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1208718 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-09
Onset:2021-04-05
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized and died within 60 days of receiving a COVID vaccine series


VAERS ID: 1208762 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-13
Onset:2021-04-08
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   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: 1208807 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-08
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Anaemia, Death, Generalised oedema, Hyperammonaemia, Hypermagnesaemia, Mental status changes, Pulmonary oedema
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Angioedema (broad), Haematopoietic erythropenia (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Anasarca Hyperammonemia Altered mental status Pulmonary edema Hypermagnesemia ARF (acute renal failure) Anemia


VAERS ID: 1208905 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-26
Onset:2021-03-01
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Fatigue, Malaise
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 35
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient felt fatigue, malaise, SOB and chest pain 2-4 days after vaccine


VAERS ID: 1209096 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-19
Onset:2021-04-05
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1209139 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-17
Onset:2021-03-19
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Sepsis
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Shortness of breath Sepsis


VAERS ID: 1209252 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-11
Onset:2021-03-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Reported being immunocompromised or on a medication that affect your immune system and note of pituitary gland.
Preexisting Conditions: Reported being immunocompromised or on a medication that affect your immune system and note of pituitary gland.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 4/13 patient''s daughter in law called public health department to report that patient was found by EMS on 3/12/21. They believe patient had passed away over night. No autopsy was done. Family member reported that EMS believed the cause to be heart attack or pulmonary embolism.


VAERS ID: 1209422 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Diabetes mellitus, Diabetic complication, Dyspnoea, Electrolyte imbalance, Impaired driving ability, Myocardial infarction, Nausea, Unresponsive to stimuli, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Insulin, albuterol, metoprolol, trazodone, duloxetine, cephdinir
Current Illness: Unknown
Preexisting Conditions: Asthma, obesity, insulin-dependent DM
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Per the patient''s husband, on 03/26/2021, the day after vaccination, the decedent complained of nausea with vomiting, and had difficulty driving. On 03/27/2021, her nausea continued and she complained of shortness of breath while walking. On 03/28/2021, she was short of breath before vomiting a small amount. She then became unresponsive. Death was pronounced a short time later. Per her treating physician who signed the death certificate, the cause of death is felt to be probable myocardial infarction due to electrolyte abnormalities due to complications of her diabetes mellitus.


VAERS ID: 1209441 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-20
Onset:2021-01-31
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Brain injury, Death, Deep vein thrombosis, Peripheral swelling, Pulmonary embolism, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Generic lipitor medication for polymyalgia rheumatica
Current Illness: None
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: My mother and I received the Moderna vaccine on January 20th. About two weeks later on January 31st, she complained about her leg. It was swollen. Later on that day, she collapsed, was rushed to the hospital. Died on February 4th due to anoxic brain injury due to DVT that caused a massive pulmonary embolism.


VAERS ID: 1209447 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-15
Onset:2021-02-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: famotidine, gabapentin, metoclopramide, pantoprazole, raloxifene, and a low dose antibiotic for a low grade conjunctival infection
Current Illness: low grade conjunctival infection
Preexisting Conditions: Hypertension GERD Mild neurocognitive impairment
Allergies: No known allergies
Diagnostic Lab Data: Autopsy 02/19/2021
CDC Split Type:

Write-up: Sudden death No reported symptoms 24 hours after vaccine


VAERS ID: 1209462 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin, atorvastatin calcium, carboxy methylcellulose, cetirizine, citalopram, docusate, fish oil, guaifenesin, ketotifen, lisinopril, metformin, Tamsulosin,
Current Illness: Hypertension, Diabetes Mellitus
Preexisting Conditions: Chronic Heart Failure
Allergies:
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: NA


VAERS ID: 1209647 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-08
Onset:2021-02-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Blood test, Cerebral haemorrhage, Computerised tomogram
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CT scan, blood tests
CDC Split Type:

Write-up: Acute brain hemmorhage


VAERS ID: 1209906 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-02-16
Onset:2021-03-04
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Arthralgia, Arthritis, Asthenia, Cardiac arrest, Death, Disorientation, Endotracheal intubation, Fall, Joint effusion, Joint injury, Mechanical ventilation, Nausea, Pain, Pneumonia, Resuscitation, Sepsis, Vomiting, Walking aid user, X-ray abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (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), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Arthritis (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fosamex and viagra
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: March 8 - Severe arthritis March 16 - Sepsis and Pneumonia
CDC Split Type:

Write-up: On March 4 patient experienced vomiting. Early morning March 5 he fell and landed on his hip after being disoriented and experienced aches, weakness, and nausea without vomiting throughout the day. On March 6 he experienced excruciating pain in his left hip and went to the local emergency room following guidance from his primary care physician. He was diagnosed with fluid near his hip joint at the hospital and was discharged the same day. The next day, March 7 he was still in pain but able to walk with assistance. On March 8 he got an x-ray from an orthopedic physician and severe arthritis was found. March 10 the severe pain persisted, but he was able to walk with a walker. On March 12 he received a cortisone shot and required emergency medical assistance to get into a personal vehicle with a family member who drove to the appointment. The next few days, the pain persisted, became worse, and spread throughout his body. On March 16 he was transported by emergency medical services to the local emergency room for treatment and was diagnosed with sepsis and pneumonia. On March 18 he was still being treated when he experienced cardiac arrest while being intubated. He was resuscitated and was on a ventilator being treated for a few more days but ultimately succumbed to sepsis on March 30.


VAERS ID: 1210267 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: SCA 6
Preexisting Conditions: SCA 6
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dad became very sleepy the day after. He quickly declined and died on Feb. 7 th. I feel the vaccine may have had something to do with his death.


VAERS ID: 1210317 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-17
Onset:2021-03-22
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046A21A / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, Brain hypoxia, Brain injury, Cardiac arrest, Death, Loss of consciousness, Resuscitation, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Convulsions (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Warfarin Metoprolol Keppra Rosuvastatin Hydralazine Lantus insulin
Current Illness: none
Preexisting Conditions: Stage 4 CKD High blood pressure Syncope Congestive heart Chronic systolic heart Stroke Heart thrombus Reduced heart EF of 28%~
Allergies: Sulpha Diabetic meds i.e . Metformin , Januvia, etc,
Diagnostic Lab Data: Contact Hospital
CDC Split Type:

Write-up: We both got our shot at the same time on March 17, 2021. Then on March 22, 2021 at 9:20 PM my husband suffered cardiac arrest and a seizure. His heart was revived however, due to lack of oxygen to his brain he suffered brain damage and never regained consciousness and passed on 4/3/21 with acute respiratory failure.


VAERS ID: 1211110 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-03-13
Onset:2021-03-27
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Thyroxine, estradiol, hctz, Klor-con er wax tabs, celecoxib, Flonase, omeprazole
Current Illness:
Preexisting Conditions: 1 kidney
Allergies: None
Diagnostic Lab Data: Cardiac Arrest
CDC Split Type:

Write-up: Death


VAERS ID: 1211145 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-18
Onset:2021-04-14
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Fatigue, Mouth haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (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: Levothyroxine, Losartan/Hydrochlorothiazide
Current Illness: Hypothyroidism, Hypertension
Preexisting Conditions: Hypothyroidism, Hypertension, history of Asthma
Allergies: Penicillin
Diagnostic Lab Data: none performed
CDC Split Type:

Write-up: Deceased unexpectedly. From day of second dose 3/18/21, patient reported feeling tired ( no fever, no shortness of breath) but was able to walk 3 flights of stairs on 4/11/21 and felt slightly better. Went to church that Sunday 4/11. Was not seen after that, then found deceased at home 4/14/21 with blood in mouth, no other signs such as lacerations or incontinence or other vomitus.


VAERS ID: 1212227 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-02-11
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Death, Dementia, Fall, Urinary tract infection, Urine analysis
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (narrow), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

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

Write-up: death Narrative: Patient received COVID vaccine #1 on 1/13/2021. On 1/19/2021, notes from primary care indicate advancing dementia and a urinalysis suggestive of a UTI, he was ordered a course of cefdinir and PCP at that time suggested long term care. On 2/1/2021, he was admitted to a facility for acute kidney failure and was also noted to have frequent falls at home, no scanned records from that hospitalization are available. On 2/7/2021, he discharged from that facility with home hospice. On 2/11/2021 at 0140, Patient passed away at home. No autopsy results available.


VAERS ID: 1212418 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-04
Onset:2021-02-04
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Incomplete course of vaccination, Syncope, Urinary tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Medication errors (narrow), Hypoglycaemia (broad)

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

Write-up: death Narrative: Patient received his COVID #1 vaccine on 1/4/2021. He is noted to be a dialysis patient and on 1/21/2021 was given a RX for treatment of a UTI. On 1/24/2021, he was admitted to a facility with a syncopal episode. He remained there until 2/2/2021 when he discharged to home. On 2/4/2021, notes indicate that he passed away in his sleep that night. No autopsy reports available. 31 days from time of vaccine #1 and date of death, does not appear that he received vaccine #2.


VAERS ID: 1212251 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-06
Onset:2021-04-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Angiogram, Blood culture, Cerebrovascular accident, Computerised tomogram, Condition aggravated, Culture urine, Electrocardiogram, Fall, Full blood count, Metabolic function test
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin Cardizem CD Trelegy Ellipta Glimepiride Levemir Xalatan Synthroid Metformin Actos Zoloft Timolol
Current Illness: STROKE/FALL
Preexisting Conditions: #Acute CVA with left upper extremity hemiplegia #Acute hypercapnic/hypoxic respiratory failure #Underlying COPD #Peripheral vascular disease status post right femoropopliteal bypass 2/16/2021 #CT of the chest with 50-60% stenosis right and 50% stenosis left and plaque on the aorta that was concerning for ulceration #Diabetes mellitus type 2 with nephropathy and neuropathy #Paroxysmal atrial fibrillation #Anxiety/depressio
Allergies: NKDA
Diagnostic Lab Data: CT/CTA CMP/CBC Urine Blood cultures EKG
CDC Split Type:

Write-up: Fall and stroke


VAERS ID: 1213081 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Blood test, Condition aggravated, Death, Decreased appetite, Fatigue, Gastric disorder, Malaise, Pain, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-13
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix, Lisinoprol, Avorstatin, Cardivirol
Current Illness: heart failure, kidney disease
Preexisting Conditions: heart failure, kidney disease
Allergies: strawberries
Diagnostic Lab Data: Blood test
CDC Split Type:

Write-up: Fever, Sick on stomach, aches, fatigue, extreme weakness. Symptoms were extreme. Generally felt terrible after being very stable and active. No improvement and condition worsened daily with loss of appetite. Death occurred on March 13, 2021.


VAERS ID: 1213115 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-10
Onset:2021-04-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036B21A / 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: 2021-04-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ferrous Sulfate 325 (65 Fe) MG Tablet 1 tablet Orally BID-TID Vitamin C 500 mg Tablet 1 tablet Orally Once a day Ozempic 0.5mg , Notes: rx''d by endo Metformin HCl 500 mg Tablet 2 TABS Orally twice a day Metoprolol Succinate ER
Current Illness: None
Preexisting Conditions: E78.5 Other and unspecified hyperlipidemia R31.0 Gross hematuria K21.9 Esophageal reflux N40.0 Enlarged prostate without lower urinary tract symptoms I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris K62.5 Hemorrhage of anus and rectum N40.0 Benign prostatic hyperplasia without lower urinary tract symptoms D64.9 Anemia I10 HTN (hypertension) R41.82 Altered mental status, unspecified altered mental status type I25.10 CAD (coronary artery disease) F03.90 Dementia C18.9 Colon adenocarcinoma K21.9 Gastroesophageal reflux disease, esophagitis presence not specified E11.59 Type 2 diabetes mellitus with cardiac complication E11.69 Hyperlipidemia associated with type 2 diabetes mellitus E55.9 Vitamin D deficiency Stg III Colon cancer s/p sigmoidectomy, chemo CAD s/p PCI 2016. Diabetes. Benign Hypertension. Hypokalemia. BPH/kidney stones 10/2016 (SB Uro) s/p ?TURP.
Allergies: Bactrim: itching
Diagnostic Lab Data: None
CDC Split Type:

Write-up: cardiac arrest at approximately 4:35pm, patient expired.


VAERS ID: 1213217 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-05
Onset:2021-03-23
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac failure, Death, Stress cardiomyopathy, Vaccination complication
SMQs:, Cardiac failure (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: SQUAMOUS CELL LUNG CANCER, CIGARETTE SMOKER, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, PERIPHERAL NEUROPATHY, HISTORY OF MALIGNANT NEOPLASM OF THE BREAST
Allergies:
Diagnostic Lab Data: Cause of Death A: TAKOTSUBO BIVENTRICULAR HEART FAILURE Cause of Death B: ADVERSE EFFECT OF VACCINATION FOR COVID 19 Cause of Death C: Null Cause of Death D: Null Cause of Death Other: SQUAMOUS CELL LUNG CANCER, CIGARETTE SMOKER, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, PERIPHERAL NEUROPATHY, HISTORY OF MALIGNANT NEOPLASM OF THE BREAST
CDC Split Type:

Write-up: Death - no symptoms, signs or treatment provided


VAERS ID: 1213285 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-27
Onset:2021-04-08
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient received his first COVID-19 vaccination 2/27/2021 and received his second COVID-19 vaccination 03/27/2021. Patient had not been tested for COVID per chart review and had no contraindications to receiving the vaccine. Patient did not experience any adverse events to the COVID-19 vaccine between time of vaccination and the time of death 12 days later. Of note, patient was receiving home hospice at the time of his death (04/08/2021) for his advanced acute myeloid leukemia.


VAERS ID: 1213286 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-07
Onset:2021-03-09
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 LA / IM

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

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

Write-up: death Narrative: Patient received Moderna COVID vaccine #1 on 1/10/21, he was seen by his PCP for a routine 6 month check up on 1/14/21. Notes at that time indicate he had a left great toe, he wound and was receiving home health and IV daptomycin through a PICC line. On 2/7/21, he received vaccine #2. Notes then indicate that on 3/9/21, he was found passed away in his home by family. No autopsy results available. 30 days form date of vaccine #2 to date of death.


VAERS ID: 1213287 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-27
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Dyspnoea, Endotracheal intubation, Fluid overload, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   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. Narrative: Patient received Moderna COVID vaccine #1 on 3/3/21. He is noted to be a dialysis patient. On 3/24/21, his wife took him to a facility ER due to intermittent shortness of breath over the previous week. He was admitted for fluid overload. On 3/27/21, he was found unresponsive and CPR was initiated and a code blue was called. He received defibrillation, epinephrine, IV calcium, sodium bicarb and amiodarone and was intubated; however he did not survive and time of death is recorded as 3/27/21 at 0138. No autopsy results available. 24 days from time of vaccine to date of death.


VAERS ID: 1213288 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-09
Onset:2021-04-11
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Pt received second Moderna COVID vaccine dose on 2/9/21. Pt enrolled in hospice house for end-of-life care 4/8, however, diagnosis was not available in database for enrollment in hospice. Pt''s son emailed affairs to report the passing of the patient 4/11/21 with no additional details or reasoning; death has not been verified. Was pt previously covid positive? no Are there any predisposing factors (i.e. PMH, HPI, allergy history etc) for patient experiencing adverse drug event? Yes, CHF potentially a contributing factor to hospice status and death Any occurrence of an ADR at time of administration or during time of observation? No Was there an ADR between observation period and date of death? No Was patient hospitalized prior to vaccination? No Was patient hospitalized prior to death No What are the possible cause of death? unknown, pt enrolled in hospice services outside of the facility.


VAERS ID: 1213289 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-03-12
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received Moderna COVID #1 on 2/4/21 and #2 on 3/4/21. He was seen by his PCP via telephone visit on 3/2/21 for a routine follow up, no acute issues noted and follow up was planned for 6 months. On 3/12/21, he passed away, no notes in medical records or scanned records to indicate what happened. No autopsy results available. 8 days from date of last vaccine and date of death.


VAERS ID: 1213290 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-03
Onset:2021-03-25
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

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

Write-up: Was informed at the time the client was to be seen for booster dose of COVID vaccine that he had recently passed away. Unable to contact family for more information.


VAERS ID: 1213291 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-03
Onset:2021-03-28
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

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:

Write-up: Was informed at the time the client was to be seen for booster dose of COVID vaccine that he had recently passed away. Unable to contact family for more Information.


VAERS ID: 1213304 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-11
Onset:2021-03-24
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

Administered by: Other       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: 2021-03-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received Moderna Covid #1 on 3/11/21 in his home by nurse. On 3/25/21, a note was entered to indicate that is wife had called EMS the day before as "his heart stopped" and he passed en route to the hospital. No further details available. No autopsy results available. 13 days between date of vaccination and date of death.


VAERS ID: 1213364 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-02-19
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Atrial fibrillation, Bacteraemia, Chills, Death, Deep vein thrombosis, Hypertension, Neutropenia, Platelet count decreased, Productive cough, Pyrexia, Sputum discoloured, Thrombocytopenia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Guillain-Barre syndrome (broad), Hypertension (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad), Dehydration (broad), Sepsis (broad), Opportunistic infections (broad)

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

Write-up: death Narrative: Patient received Moderna COVID #1 vaccine on 1/28/21. On 2/3/21, he was admitted to a facility for fever, weakness, chills and rigor. Noted history of B cell lymphoma not on chemotherapy at the time. He also had reports of productive cough with thick brown/green sputum. He was admitted to the hospital and given 1 round of methotrexate and Rituxan. Hospital course was complicated with bacteremia (given vancomycin and cefepime), A fib, AKI, HTN, neutropenia (received Neupogen), acute popliteal VT (unable to anticoagulated due to thrombocytopenia - platelets as low as 20). No bleeding issues noted. On 2/18/21, family opted to change his status to DNR with hospice/comfort care and he passed on 2/19/21. No autopsy results available. 22 days from date of vaccine to date of death.


VAERS ID: 1213566 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-03
Onset:2021-03-09
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Back pain, Cough, Death, Fall, Thoracic vertebral fracture
SMQs:, Anaphylactic reaction (broad), Retroperitoneal fibrosis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad)

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

Write-up: death Narrative: Patient received his COVID #1 Moderna vaccine on 2/3/2021. On 2/9/21, he reported to our ER with severe upper back pain x 2 weeks, notes indicate that he fell 12/2020 and sustained a fracture to T5, he denied shortness of breath but did report a cough. He was given morphine 10mg IM x 1 dose, ondansetron 4mg SL x 1 dose and an outpatient RX for Norco and discharged. On 2/11/21, his wife reported that he fell out of bed and he was taken to a facility via EMS. No records from that visit are available. On 3/9/2021. it was reported that he passed away. No autopsy reports available. 34 days from time of vaccine to date of death.


VAERS ID: 1213567 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-08
Onset:2021-03-01
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: Narrative: On 1/11/21, patient received Moderna COVID vaccine #1 and on 2/8/21, she received dose #2. No notes record any adverse events to vaccine. There is a scanned document from 2/24/21 where patient agreed to home hospice care. Date of death is recorded as 3/1/21. No documentation of any events from time of vaccines to date of death. No autopsy results reported. 21 days from date of vaccine #2 and date of death.


VAERS ID: 1213568 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-20
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Cardiac failure congestive, Cardio-respiratory arrest, Catheter placement, Confusional state, Death, Dyspnoea, Endotracheal intubation, Intensive care, Respiratory distress, Resuscitation, Sepsis
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)

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

Write-up: death Narrative: Patient received Moderna covid vaccine # 1 on 2/26/21. Per scanned records on 3/18/21, he presented to the ER with reports of shortness of breath and was subsequently admitted and treated for acute CHF, NSTEMI and sepsis (ceftriaxone and azithromycin). He later developed AKI and surgery was consulted for placement of a Trialysis catheter. After placement of this catheter, he developed increasing respiratory distress and confusion and was transferred to the ICU where he received vasopressors, intubation and unsuccessful resuscitation after a code blue. Autopsy reports not available. 22 days from date of vaccine to date of death.


VAERS ID: 1213569 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-04
Onset:2021-02-24
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

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

Write-up: death Narrative: Patient received COVID vaccine #1 on 2/4/21. On 3/1/21, it was reported to the facility that patient had passed away on 2/24/21. No notes on file with respect to what happened around the time of his passing. No autopsy results available. 20 days from time of vaccine to date of death.


VAERS ID: 1213570 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-03-21
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Dysarthria, Gait inability
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient received Moderna Covid vaccine #1 on 2/12/21. On 2/17/21, his son contacted the clinic social worker to inquire about home health services as he thought Patient had had a stroke (no longer able to walk and slurred speech). Patient refused to go to the hospital and son agreed to not have him admitted for fear that he would die alone in a hospital. Patient receives primary care from a provider and social worker suggested that he contact his PCP regarding home hospice services. No further notes of what occurred after that conversation and his date of death is reported as 3/21/21. No autopsy results available. 37 days from date vaccine to date of death.


VAERS ID: 1213571 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-01
Onset:2021-03-25
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Cardio-respiratory arrest, Coronary artery bypass, Death, Dialysis, Oliguria, Pneumonia pseudomonal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Other ischaemic heart disease (narrow), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death. Narrative: Patient received Moderna COVID vaccine #1 on 3/1/21. On 3/17/21, he was admitted to a facility for a CABG. Per notes, after his CABG, he developed Pseudomonas pneumonia, AKI requiring dialysis and ultimately became oliguric. He required epinephrine, dobutamine, dopamine, amiodarone and went through two code blues prior to pronouncement of death on 3/25/21 at 2305. No autopsy reports available. 24 days from time of vaccine to date of death.


VAERS ID: 1213572 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-01
Onset:2021-02-28
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Hypopnoea, Respiratory rate increased, Terminal state, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

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

Write-up: death Narrative: Patient received COVID vaccine #1 on 12/30/20 and #2 on 2/1/21. He was an inpatient in the facility and had been under hospice care since 12/9/20. No adverse events to vaccine found per notes. On 2/27/21, he began to have short and rapid respirations and was unresponsive. He was given morphine, atropine sublingual, lorazepam and nebulizers per hospice care orders and was determined to be imminent. On 2/28/21 at 2230, he passed. No autopsy results available. 27 days from date of vaccination to date of death.


VAERS ID: 1214135 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-04-07
Onset:2021-04-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   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: N/A
Current Illness: Chronic Kidney disease, coranary disease, mulitple medical , full list can be gotten from primary
Preexisting Conditions: stage 4 renal failure,
Allergies: none listed
Diagnostic Lab Data: none
CDC Split Type:

Write-up: unknown, death at home, with no one in attendance. Pt with mulitple medical conditions, when RN adminstered 2nd dose on 4/07/2021. They dicussed how the first one went. Pt states, besides sore arm nothing. She did have acid reflux, (common for her) which she took regular medication which took care of it. But denied any other problems with first dose. Seccond dose given with no reaction during 15 min observation time. EMS was called to scene on 4/08/2021 at approx 1630 hrs, to find pt deceased, spine in bed. approx down time 2-3 hrs. Pt''s primary Dr. contact as well as corner. With pt''s medical history no further investigation was done.


VAERS ID: 1214139 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-04-15
Onset:2021-04-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046B21A / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute cardiac event, Blood glucose normal
SMQs:, Myocardial infarction (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   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: Unknown
Preexisting Conditions: Unknown
Allergies: Unknow
Diagnostic Lab Data: Glucose 143
CDC Split Type:

Write-up: Cardiac Event


VAERS ID: 1214277 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-10
Onset:2021-02-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Antacid, Cephalexin, Daily Vitamin, Levothyroxine, Magnesium-OX, Metoprolol, Omeprazole, Vitamin D, Acetaminophen, Bisacodyl, Docustate Sodium, Haloperidol, Loratadine, Morphine, Ondansetron, Pepto Bismol, Balmex, Polyeth Glycol Powder
Current Illness: Resident had a steady decline over several months. She was under comfort care and it was the resident and families request to not be transferred to hospital and not to perform any medicals tests for diagnosis and treatment.
Preexisting Conditions: HTN, Hyperlipidemia, Hypothyroidism, Diverticulosis, Osteoporosis, Hypomagnesemia, Cognitive Impairment, Hearing Loss, HS Hiatal Hernia, Colon Polyps, S/P Compression FX,
Allergies: Sulfa, Antibiotics, Bactrim, Actonel
Diagnostic Lab Data:
CDC Split Type:

Write-up: After resident received vaccine there continued to be a decline in her overall health. Resident died on 2/26/21 at the age 102. The County Health Department requested that her information be forwarded to VAERS. There is no evidence that resident had a adverse reaction to the vaccination.


VAERS ID: 1214516 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-17
Onset:2021-03-22
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 RA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: No
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Client was monitored after being Vaccinated for 15 minutes and staff observed no symptoms. DHS CRT was made aware of the death two days prior to 2nd dose Vaccine Clinic.


VAERS ID: 1214783 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-03-03
Onset:2021-03-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: wool
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown details of event as pt was in LTC facility where medical records would be located. Pt is reported to have expired at the facility.


VAERS ID: 1214800 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-04-06
Onset:2021-04-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Public       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: 2021-04-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: family states oral medication for diabetes and 2 medications for hypertension but unknown names
Current Illness: unknown
Preexisting Conditions: DM, HTN
Allergies: NKA
Diagnostic Lab Data: death
CDC Split Type:

Write-up: Patient per tracking received 2nd COVID vaccine on 4/5/2021 from Health Department. Patient to Hospital Emergency department via EMS 4/6/2021 with cardiac arrest and death


VAERS ID: 1214882 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-05
Onset:2021-04-03
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: nkma
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown


VAERS ID: 1215095 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-18
Onset:2021-03-23
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Anaemia, Antibody test positive, Asthenia, Autoimmune haemolytic anaemia, Back pain, Bilevel positive airway pressure, Blood bilirubin increased, Blood creatine abnormal, Blood lactate dehydrogenase increased, Cardio-respiratory arrest, Chest X-ray abnormal, Chest pain, Chromaturia, Cold agglutinins negative, Computerised tomogram head normal, Condition aggravated, Confusional state, Death, Decreased appetite, Disorientation, Dizziness, Dyspnoea, Endotracheal intubation, Erythroid series abnormal, Fatigue, Feeling abnormal, Haematochezia, Haemoglobin decreased, Haemolysis, Haptoglobin increased, Hypersensitivity, Hypertension, Impaired work ability, Leukoerythroblastic anaemia, Mobility decreased, Muscular weakness, Myalgia, Normochromic anaemia, Pain in extremity, Plasmapheresis, Platelet count decreased, Rash, Red blood cell count increased, Red blood cell spherocytes present, Sinus tachycardia
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Liver related investigations, signs and symptoms (narrow), Haemolytic disorders (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Parkinson-like events (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Biliary system related investigations, signs and symptoms (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Ischaemic colitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Vasculitis (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Myelodysplastic syndrome (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol 108 MCG/ACT inhaler - Inhale 1-2 puffs into the lungs every 4 hours as needed Ascorbic Acid (VITAMIN C GUMMIE PO) 100 mg daily atorvastatin (LIPITOR) 40 MG tablet dao;y beclomethasone HFA (QVAR REDIHALER) 80 MCG/ACT inhaler - two
Current Illness: Thyroid Nodule Invasive Lobular Carcinoma of the Breast
Preexisting Conditions: Obstructive sleep apnea Hyperlipidemia Essential Hypertension Allergic rhinitis Moderate persistent asthma GERD Restless leg syndrome Major depressive disorder Chronic Kidney Disease Type 2 Diabetes Mellitus Morbid Obesity
Allergies: Gemfibrozil - itchiness Lisinopril - rash Received her first COVID vaccine on Thursday, March 18. On 3/23/21 she started to have new onset of generalized muscles aches and weakness. She started feeling some pain in her back, which then spread to arms and legs. She is now beginning to feel weakness in her core and extremities. Having difficulty lifting arms above head. She is still able to walk without difficulty but legs do feel weak. Increase in SOB as well. Myalgias and chest pain resolved within a week, however she continued to feel weak, tired, and had DOE. She developed "brain fog" and talked to her boss about taking short-term disability as it had been hard to work. No appetite
Diagnostic Lab Data: See above
CDC Split Type:

Write-up: Received her first COVID vaccine on Thursday, March 18. On 3/23/21 she started to have new onset of generalized muscles aches and weakness. She started feeling some pain in her back, which then spread to arms and legs. She is now beginning to feel weakness in her core and extremities. Having difficulty lifting arms above head. She is still able to walk without difficulty but legs do feel weak. Increase in SOB as well. Myalgias and chest pain resolved within a week, however she continued to feel weak, tired, and had DOE. She developed "brain fog" and talked to her boss about taking short-term disability as it had been hard to work. No appetite. On 4/1/21, she presented to the ED with 2 weeks of worsening generalized weakness, SOB, lightheadedness, dizziness and found to have acute anemia. Was admitted for further workup. Hgb at admission was 5.4. This admission diagnosed her with a new warm autoantibody hemolytic anemia. This is new since the COVID vaccine was administered. Upon admission there was no thrombocytopenia, so there was low suspicion for microangiopathic hemolytic anemia, TTP/HUS, or DIC. Peripheral blood smear at that time suggested a leukoerythroblastic blood picture (could be Bone Marrow recovery post chemo) but with marked normocytic, normochromic anemia, and with increased circulating erythroid precursors and increased red blood cell regeneration; spherocytes and fragments are present supporting hemolysis. DAT positive (both IgG and C3) along with other hemolysis lab including elevated LDH, Bilirubin, haptoglobin 3, and PBS c/w hemolysis; no evidence of MAHA. So warm autoantibody hemolytic anemia is the most likely explanation. She had negative cold agglutinin antibodies <1:32 on 4/9. Started on methylprednisolone on 4/2/21, but Hgb continued to steadily decline despite treatment. Continued on methylprednisolone 87.5mg daily. Rituxan 375mg/m2 was started on 4/6/21 with plans for weekly infusions for a total of 4 weeks. there was concern for a GI bleed on 4/10-4/11 due to bright red fluid appearing like blood in the toilet after a stool. This led to her receiving roughly 5 units of pRBCs. After these 5 units she started urinating red urine and we became highly concerned for hyperhemolysis. She did not have any further stools so we did not think a GI bleed was likely. She was given 1 dose of Eculizumab (Soliris) (4/12). This treatment is for complement mediated intravascular hyperhemolysis. Unfortunately it did not appear to help her. On 4/14, we were thinking TTP could be contributory with numerous schistocytes on peripheral smear. Her T bili was up to 7.8, and her hemoglobin plasma was trending up, in the 380 -- $g 610 and in the 800s today. Cr was worsening. Platelet count was dropping. With her worsening condition and concern for both hyperhemolysis and possible TTP, we decided to start her plasma exchange followed by her second dose of Rituximab. Unfortunately she became disoriented/confused following line placement and while receiving plasmaphoresis. CT head returned without acute findings. She then had an allergic reaction with a rash during PLEX which was stopped (4L completed with a goal of 5L). Improved with benadryl. She was then administered rituximab. Then she developed worsening sinus tachycardia and HTN. Her respiratory status deteriorated and she eventually required high-flow oxygen to maintain saturations $g 90%. CXR showed bilateral opacities, not drastically changed from previous films. Rituximab was stopped halfway through its infusion in case this was an adverse effect to the drug. She was given 20 mg IV Lasix per the nighttime sign-out. She was initially given ceftriaxone and azithromycin IV to cover CAP but later ABx were broadened to vanc and Zosyn with rising lactate of unknown source. Ultimately she had acute respiratory failure with hypoxia and need BiPAP. She was eventually intubated and a code blue was called. She unfortunately died shortly after intubation.


VAERS ID: 1215373 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-09
Onset:2021-04-06
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   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: Proair, EQ Allergy Relief, Albuterol, HCTZ, Prednisone, Singulair, Symbicort, Bumetanide, Carvedilol, Azithromycin
Current Illness:
Preexisting Conditions: Chronic systolic congestive heart failure, Pulmonary fibrosis
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: The pt missed her scheduled appointment for COVID vaccine #2, so I called her to reschedule. Today I reached her mother, who informed me that pt passed away last Tuesday. I did not ask for any details of her death at this time.


VAERS ID: 1215882 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-04-01
Onset:2021-04-14
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Deep vein thrombosis, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hyperactive airway disease
Allergies:
Diagnostic Lab Data: autopsy
CDC Split Type:

Write-up: fatal pulmonary embolism from RLE DVT


VAERS ID: 1216264 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-01-26
Onset:2021-03-28
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Acute respiratory failure, COVID-19 pneumonia, Death, Endotracheal intubation
SMQs:, Anaphylactic reaction (broad), Angioedema (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), Haematological malignant tumours (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 10
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:
Other Medications:
Current Illness: depression, hyperlipidemia
Preexisting Conditions:
Allergies: penicillin, shellfish,
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted 3/28/2021 with severe COVID 19 pneumonia. She progressed to acute respiratory failure and was intubated. During her hospitalization she was diagnosed with acute myeloblastic leukemia. Her family withdrew care and she died on 4/7/2021


VAERS ID: 1216355 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-12
Onset:2021-03-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / UNK - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Breath sounds abnormal, Cerebrovascular accident, Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Irbesartan 75mg 1pill a day omeprazole 40 mg 1 daily Lovastatin 40 mg 1 daily Amloodipine 5 mg 1 day Plavix 1 daily vitamin D 1 daily Metoprolol 25 mg
Current Illness: none
Preexisting Conditions: High Blood Pressure
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: At 5 AM on 3/21/2021 my father was in bed sleeping and started to gurgle, he was unresponsive, 911 was called he was unresponsive and taken to the Hospital and died at 3:22 PM on 3/21/2021. from a C V A.


VAERS ID: 1217813 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-13
Onset:2021-04-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown; not currently ill per screening form
Preexisting Conditions: unknown
Allergies: none reported per screening form
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: deceased on 4/13/21


VAERS ID: 1218422 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-04-05
Onset:2021-04-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 2 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death, Diarrhoea, Loss of consciousness, Myocardial infarction, Vomiting projectile
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

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

Write-up: DEATH! About 24 hours after getting his 2nd Moderna Covid-19 shot, patient got deathly ill with explosive vomiting and diarrhea. Not long later he was passing out. Paramedics were called, and he was taken to the hospital where he passed away from a massive heart attack. The doctors gave him clot-busting drugs in an attempt to save him. He has never had problems with blood clots in his life. He was the healthiest one of us all, and was almost never sick. The doctor said that it was probably no coincidence that he died so soon after receiving his Covid shot. I am convinced that they are connected. A healthy man suddenly gets blood clots in his heart 24 hours after getting his shot? Not a coincidence!!!!!!!!!!!!!!1


VAERS ID: 1218454 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-12
Onset:2021-04-03
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Sudden 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: 2021-04-03
   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: Patient''s sister, spoke to Public Health staff to say that he passed away suddenly on 4/3/21 from a cardiac arrest, he had no underlying health conditions she states but did take some medications, she believes for blood pressure.


VAERS ID: 1218464 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-03-13
Onset:2021-03-19
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Peripheral coldness, Pulse absent, Respiratory arrest, Trismus
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dystonia (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: folic acid, gabapentin, hydrochlorothiazide, continued page 2
Current Illness: back pain, neuropathy, tremor, gallstone, anemia
Preexisting Conditions: hypertension, seronegative rheumatoid arthritis, lumbar disc disease, GERD, gastric ulcer, depression, continued pg 2
Allergies: sulfa
Diagnostic Lab Data: none
CDC Split Type:

Write-up: EMS was dispatched to patient''s home for "non breathing." EMS found patient on the floor in the kitchen with sheet already over her. No pulse, patient cold to the touch, jaw was locked shut. Patient''s family members stated the last time they saw the patient alive was around 2:30 am on the same day. Patient pronounced dead on arrival at 6:20 am. No evidence of foul play noted.


VAERS ID: 1218467 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-14
Onset:2021-03-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute left ventricular failure, Acute pulmonary oedema, Acute respiratory failure, Catheter placement, Catheterisation cardiac, Endotracheal intubation, Sepsis, Troponin increased, Vitamin B12 deficiency
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient hospitalized Hospital Admission Diagnoses: Severe sepsis (CMS/HCC) [A41.9, R65.20] Discharge Diagnosis: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 Discharge Diagnoses: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 *Acute respiratory failure with hypoxia (CMS/HCC) 03/24/2021 *Acute pulmonary edema (CMS/HCC) 03/24/2021 *IVH (Intraventricular hemorrhage) (CMS/HCC) 06/06/2018 *Brain edema (CMS/HCC) 06/06/2018 *Brain compression (CMS/HCC) 06/06/2018 *Benign essential HTN *Coronary artery disease * Type 2 diabetes mellitus with hemoglobin A1c goal of less than 7.0% (CMS/HCC) *Nontraumatic right thalamic hemorrhage (HCC) 06/05/2018 Consults: IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOLOGY INPATIENT CONSULT TO PHARMACY INPATIENT CONSULT TO PHARMACY IP CONSULT TO NUTRITION SERVICES IP CONSULT TO NUTRITION SERVICES Procedures: Intubation Catheterization Significant Diagnostic Studies: Cardiac Catheterization


VAERS ID: 1218468 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-18
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
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: Patient''s daughter called and reported he was hospitalized for a heart attack and passed away on 4/5/2021.


VAERS ID: 1218469 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-12
Onset:2021-04-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032B21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal discomfort, Death, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   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: Patient passed away on April 13, 2021 at home at 1810 He was 72 years old had severe aortic stenosis and hypertension and had an aortic valve replacement (TAVR) at hospital on Jan 20, 2021. He was readmitted to hospital for shortness of breath which was evaluated from Feb 19 - Feb 21, 2021 I spoke with his daughter today. She was with him at home when he went to the bathroom and since he had not come out for some time, she knocked on the door and found him collapsed in the bathroom. She called 911, who did CPR, however he had passed away. He was referred to the coroner. He had his first Moderna vaccine on March 15, 2021 after which he had not had any side effects. He received his second dose on April 12, 2021 and had not mentioned any side effects other than mild abdominal discomfort. Daughter said his shortness of breath had been improving after his discharge from the hospital. He had not complained of chest pain, cough, fever, diarrhea, in the last few days. I paid condolences to daughter and told here we would be reviewing the case to see if there was any relationship to him receiving the Covid19 vaccine and that the case had already been referred to the coroners office.


VAERS ID: 1218714 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-15
Onset:2021-04-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043B21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac assistance device user, Death, Resuscitation, 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: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was returning to unit. When patient reached unit doors, patient collapsed. Health Care called, 3 nurses and Mini Ambulance deployed. Upon the Staff''s arrival CPR was in progress, AED in place, Narcan administered. Ambulance call, transported to Facility. Patient pronounced 0724 hours


VAERS ID: 1218779 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-04-14
Onset:2021-04-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O31B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   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: Basaglar, Trulicity, Metformin, Plavix, Crestor, Lasix, Enalapril, Synthroid, Arimidex, Xanax
Current Illness: No acute illness at the time of the vaccine. Was having problems with uncontrolled DM2.
Preexisting Conditions: DM2, HPL, HTN, Breast CA in remission, Lung CA in remission, CVA, hypothyroidism, asthma
Allergies: Codeine, Invokana, Glyburide, Aleve, Aromacin
Diagnostic Lab Data: None. Found dead outside of home by EMS.
CDC Split Type:

Write-up: Death


VAERS ID: 1219000 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-02-06
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, ferrous sulfate, folic acid
Current Illness:
Preexisting Conditions: HTN, DM, right BKA, CVA, CAD
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was alert and verbally responsive in usual state of health on 1/11/2021 received Moderna vaccination dose 1. Patient seemed stable until 2/6/21. Then on 2/6/21, patient was noted with slight elevated temp of 99.2, pulse 100, spo2 94%RA at 2:15am. By 5:20am, patient was pronounced dead.


VAERS ID: 1219100 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-17
Onset:2021-03-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, 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: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: None Listed on Consent to Treat
Diagnostic Lab Data: There should be a full report coming to the Coroner''s office soon. They expect that report any day now.
CDC Split Type:

Write-up: This patient was at work two days after her vaccine and went to the bathroom. When she did not come back to work after around 20 minutes, she was found unresponsive and an ambulance was called. The patient was declared deceased at the ER with the cause of death initially as cardiac arrest however a full autopsy was performed and Coroner''s office is awaiting that report at this time. We did not know of the death until we went back this week to complete the second round of vaccinations. Since the death happened in such close proximity to the vaccination date we felt it prudent to report.


VAERS ID: 1219229 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-02-10
Onset:2021-03-02
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20-A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Cardiac pacemaker insertion, Cardiomegaly, Chest X-ray abnormal, Death, Dizziness, Fall, Fatigue, Hypotension, Hypoxia, Laboratory test, Lactic acidosis, Sinus node dysfunction, Syncope, Troponin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Disorders of sinus node function (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   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: Garlic, Preservision AREDs Softgel, Multivitamins with minerals. Aspirin, Levothyroxine, Amlodipine, Losartan
Current Illness: Denied any illness at time of receiving vaccine, uncertain as to how pt. felt one month prior to vaccine.
Preexisting Conditions: Current everyday smoker, Hypothyroidism, HTN, Hyperlipidemia, Osteoarthritis, Osteoporosis
Allergies: NKA
Diagnostic Lab Data: Lab and CXR done in ER. Troponin level was 117; HR 40''s, BP 93/44. CXR indicated mild cardiomegaly and no acute infiltrates.
CDC Split Type:

Write-up: Pt. c/o symptoms of fatigue and dizziness on 3/2. On 3/3 pt. presents to ER, afebrile, c/o fatigue, feeling of being lightheaded, reports syncope and falling x''s 2. Pt. according to MD documentation was in good health. Denies any recent illness. Pt. was found to be bradycardic, sick sinus syndrome, r/o MI. Pt. was transferred to higher level of care hospital on 3/3. Pt. had emergency pacemaker insertion. She became hypotensive and hypoxic post-op and was found to in lactic acidosis. Pt. expired on 3/3/21.


VAERS ID: 1219402 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Alaska  
Vaccinated:2021-04-14
Onset:2021-04-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   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: Acetaminophen 500mg q 4hr prn, alendronate 70mg q 7 days, aspirin 81mg daily, atrovastin 40mg daily, baclofen 20mg 4 x day, buspirone 30mg bid, calcium carbonate 1000mg bid, carvedilol 6.25 bid, vitamin D3 1000 units daily, diclofenac sodiu
Current Illness: Decubitus sacral ulcer, stage 3, iron deficiency anemia, urinary tract infection associated with cystostomy catheter, class 1 obesity, wound infection, dysautonomia orthostatic hypotension syndrome, hypersomnia with sleep apnea, obstructive sleep apnea, autonomic dysreflexia, t4 spinal cord injury (chronic), major depressive disorder, pain medication agreement, chronic suprapubic catheter, hypothyroidism, hyperlipidemia, generalized anxiety disorder, neurogenic bladder, chronic pain, osteoarthrosis involving lower legs, DM type 2.
Preexisting Conditions: See item 11
Allergies: metoprolol, mirtazapine, olanzapine, sulfamethoxazole, cephalexin, erythromycin base, pioglitazone
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Homebound visit complete 4/14/21 around 1230-1300, monitored for 15 minutes, left attended with home health nurse. Patient was found dead per EMS and had passed sometime during the night.


VAERS ID: 1219404 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-02-19
Onset:2021-04-14
   Days after vaccination:54
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory distress syndrome, COVID-19 pneumonia, Chronic kidney disease, Diabetic ketoacidosis, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 3
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, Lipitor, Insulin, Nifedipine, Gabapentin, Hydroxyurea
Current Illness:
Preexisting Conditions: HTN, CAD status bypass graft x4, T2DM, peripheral and retinal neuropathy, CKD 3b, thrombocytosis, diabetic foot ulcer, remote ovarian cancer
Allergies: Sulfa
Diagnostic Lab Data: COVID-19 PCR positive 4/15
CDC Split Type:

Write-up: Pt was admitted with COVID-19 pneumonia on 4/15 that has progressed to COVID ARDS, DKA, AKI on CKD, NSTEMI


VAERS ID: 1219667 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-06
Onset:2021-04-09
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol, Hydralazine, Furosemide, Warfarin, Potassium, Glipizide
Current Illness: none
Preexisting Conditions: Diabetic, Stage 4 Kidney Failure, Heart Disease, High Blood Pressure, Sleep Apnea.
Allergies: None
Diagnostic Lab Data: CT Scans
CDC Split Type:

Write-up: Patient had a Hemorrhagic stoke and passed away.


VAERS ID: 1219828 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-19
Onset:2021-03-01
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / 1 LA / IM

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 44
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: levothyroxine, furosemide
Current Illness:
Preexisting Conditions:
Allergies: no known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received his first Moderna vaccine 3-19-21. He was due for his 2nd dose 4-16-21. We followed up with his sister due to missed appointment and was informed that he passed away 4-15-21 due to a blood clot.


VAERS ID: 1220264 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-03-17
Onset:2021-04-06
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Dementia
Allergies: Unkown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient was scheduled for second dose on 4/14/21. Wife called that morning to say that patient passed away on 4/6/21. Wife Callie stated he saw the neurologist on 4/1/21. On 4/6 he was doing very well in the am and pm. She put him to bed, he woke up and called to her, gasped and passed away. She reports he tolerated the 3/17 vaccination well. I called the doctor on 4/16/21 for more information but he has not returned my call as of yet.


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