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

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



Case Details

This is page 18 out of 43

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VAERS ID: 1236407 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-16
Onset:2021-03-23
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cerebrovascular accident, Computerised tomogram head abnormal, Condition aggravated, Death, General physical health deterioration, Intensive care, Mental status changes, Status epilepticus
SMQs:, Systemic lupus erythematosus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 81 and presented to the ED w/ altered mental status on 2/18/21 after receiving COVID vaccine on 2/16/21. Patient was also previously admitted earlier that month for a retroperitoneal hemorrhage that had similar presentation of altered mental status. CT this admission showed a new CVA. He was eventually transferred to the ICU for nonconvulsive status epilepticus and eventually transitioned to hospice care after further decline in status. Wife elected to stop dialysis and he passed away on 3/23/21. Comorbidities include ESRD on dialysis, CVA, DM, prostate cancer.


VAERS ID: 1236408 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-22
Onset:2021-03-14
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cholelithiasis, Colonoscopy abnormal, Computerised tomogram abdomen abnormal, Death, Diverticulum, Intensive care, Pleural effusion, Ulcer haemorrhage, Umbilical hernia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal ulceration (narrow), Gastrointestinal haemorrhage (narrow), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Gastrointestinal nonspecific inflammation (broad), Ischaemic colitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

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

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was hospitalized in early 02/2021 at Medical Center in the ICU for a bleeding ulcer. Was inpatient for over a month, but do not have records due to it being outside facility. Received a colonoscopy report which showed. diverticulosis and CT of abdomen showing pleural effusion, umbilical hernia and gallstones. Notable comorbidities include emphysema, CKD, CAD, ICM, and T2DM.


VAERS ID: 1236409 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-23
Onset:2021-03-05
   Days after vaccination:41
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / UN

Administered by: Other       Purchased by: ?
Symptoms: Death, Fall
SMQs:, Accidents and injuries (narrow)

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

Write-up: Death Narrative: Patient was not previously COVID positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 97 and admitted to Hospital on around 2/20/2021 due to a fall at home. He later passed away on 3/5/21.


VAERS ID: 1236410 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-03-03
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

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

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

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient found decreased at home on 3/3/21. No apparent cause of death. Telephone appt on 2/10/21 was unremarkable other than patient having mild shortness of breath and chest discomfort. Comorbidities include COPD, HTN, HLD, and age of 74.


VAERS ID: 1236413 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-03-07
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was hospitalized in 02/2021 at facility for unknown reason until his passing on 3/7/2021. He had dx of HCV in 01/2021 that was cured but left him with cirrhosis s/p TIPS procedure. Was not liver transplant candidate due to home O2 needs. Other major comorbidities include COPD and diabetes.


VAERS ID: 1241401 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-04-13
   Days after vaccination:89
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Respiratory disorder
SMQs:, Acute central respiratory depression (broad), Respiratory failure (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: N/A
CDC Split Type:

Write-up: DEATH Narrative: Patient died after COVID vaccine dose #1. 01/14 COVID vaccine dose #1 04/13 pt died Patient with advanced ALS, progressive respiratory difficulty and passed away while on hospice. Vaccine did not likely contribute to the patient''s death, but was due to advanced ALS. Patient was not hospitalized prior to vaccine or immediately after vaccine. No adverse event following vaccine. No previous COVID diagnosis known.


VAERS ID: 1241403 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-03-24
   Days after vaccination:75
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cardiac failure, Death, Multiple organ dysfunction syndrome, Pneumonitis, Renal failure, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Interstitial lung disease (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

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 tested positive for COVID-19 on 1/25/21 after receiving her first vaccine on 1/8/21. He was discharged from hospital on 1/26/21 with admitting diagnosis of COVID pneumonia. He did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient had made it through the COVID infection period but suffered complications including pneumonitis, lung, heart, and kidney failure requiring high flow oxygen. He required readmission to hospital for the complications in 3/2021 but ultimately passed away on 3/24/21 likely due to the multi organ failure complication of COVID


VAERS ID: 1241405 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-10
Onset:2021-03-23
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Circumstances surrounding his death are not documented in chart. Comorbidities include Hepatitis C, HTN, T2DM.


VAERS ID: 1236785 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-04-16
Onset:2021-04-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Resuscitation, Unresponsive to stimuli, Vital functions abnormal
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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASA, Tramadol, Eliquis, Proscar, Carvedilol, Atorvastatin,Tamsulosin, Colchicine, Fenofibrate, Thiamine, Lisinopril, Folic Acid, Glimepiride
Current Illness: cellulitis and abcesses of Lower extremeties. pressure ulcers
Preexisting Conditions: Type 2 DM, Essential HTN, BPH, CKD Stage 3, Hyperlipidemia Anemia, ASHD, Gout, Peripheral artery disease,Arterial stenosis, pacemaker ( inserted 1/27/2021), Atrial fibrillation recent with TEE cardioversion 3/31/2021, cellulitis and abcesses of the lower extremeties, pressure injuries-unstageable to bilateral heels and side of the foot., S/P PTA of the right peroneal artery (1/2021) , fall March 2021
Allergies: Oxycodone
Diagnostic Lab Data: N/A -
CDC Split Type:

Write-up: Resident found unresponsive and without vital signs the morning on April 17, 2021 at 6:35am. The nurse started CPR, called a code, 911 called, AED applied. Local EMS responded, took over the code. EMS had contact with the local hospital ER, code called at the facility. Resident expired.


VAERS ID: 1237069 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-18
Onset:2021-04-02
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown, but did report use of blood thinner during vaccination visit.
Current Illness: None - per telephone interview with spouse
Preexisting Conditions: Unknown - none reported at vaccination visit
Allergies: NKA
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Spouse reported that patient was taken to The Hospital after unresponsive in the home on 4/2/2021. States was told that cause of death was heart failure.


VAERS ID: 1237427 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Influenza like illness, Laboratory test abnormal, Pain in extremity
SMQs:, Retroperitoneal fibrosis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Humera, multi-vitamin, prednisone, iron
Current Illness:
Preexisting Conditions: COPD, Rheumatoid arthritis
Allergies: Adavan
Diagnostic Lab Data: Patient had just received positive lab results back from primary care physician visit prior to vaccine.
CDC Split Type:

Write-up: Arm soreness 1-3 days post vaccine flu like symptoms 4-7 days post vaccine Severe back pain 4-10 days post vaccine Death 11 days post vaccine


VAERS ID: 1237511 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-18
Onset:2021-04-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Anticoagulant therapy, Asthenia, Breath sounds abnormal, Cardiac arrest, Chest X-ray abnormal, Computerised tomogram head normal, Endotracheal intubation, Lung opacity, Pneumonia aspiration, Therapeutic hypothermia, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), 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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg tablet, amiodarone 200mg tablet, aspirin 81mg tablet, atorvastatin 40mg tablet, carvedilol 12.5mg tablet, clopidogrel 75mg tablet, folic acid 1mg, Levemir, Humalog, losartan-HCTZ 100/25mg tablet, omeprazole 40mg capsule, p
Current Illness:
Preexisting Conditions: Diabetes Mellitus Type 2, ICD Pacemaker, Renal disorder, gout
Allergies: Unable to assess at the time of hospitalization
Diagnostic Lab Data: CT Head done - no acute findings suggestive of stroke, hemorrhage Chest XRay showed Bilateral R$gL opacities and lung sounds coarse
CDC Split Type:

Write-up: Patient brought in by ambulance after cardiac arrest witnessed by patient''s wife at 4/19/21 1:37AM. Per ED, the wife reports he had complained of feeling weak over the last few days without clear reason, then this morning patient had episode of emesis after which he told wife to call 911 and then suddenly became unresponsive. In ED was intubated, started on hypothermia protocol, Patient sedated on Propofol and started on a heparin drip, clopidogrel, aspirin and empiric antibiotics for aspiration Pneumonia


VAERS ID: 1237530 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: BLOOD THINNING, THYROID, HYPERTENSION
Current Illness: NONE
Preexisting Conditions:
Allergies: PENICILLIN AND GARLIC
Diagnostic Lab Data: At age 91 we did not do an autopsy
CDC Split Type:

Write-up: Mom was feeling fine the day of the vaccine. Last spoke with her at 6:30 PM and she said she wasn''t feeling anything but would go to bed early. I said OK I will check on you in the morning. She never woke up!


VAERS ID: 1238170 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-04-10
Onset:2021-04-20
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: COPD Flair
Preexisting Conditions: COPD, Smoker, Depression
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Found dead at home 10 days post vaccine administration. Unclear correlation.


VAERS ID: 1238188 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-15
Onset:2021-04-16
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The decedent suffered fever and malaise after the second dose on 04/13/2021.


VAERS ID: 1238235 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-04-10
Onset:2021-04-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Death, Fatigue, Nausea, Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   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: None.
Preexisting Conditions: PTSD and chronic pain (patient was a veteran)
Allergies: Patient''s wife stated that patient did not eat pork. She is unsure if that is due to allergy.
Diagnostic Lab Data: Wife stated that an autopsy was conducted and that she should be getting the results this week.
CDC Split Type:

Write-up: Information received by wife. Patient was fatigued 4/10/21 after vaccination. His wife stated that she talked with him and he seemed fine. When his wife went to bed early that evening, the patient was sitting in the recliner in the living room. On the morning of 4/11/21, patient''s wife found him unresponsive in the recliner. She called an ambulance but patient was deceased. Patient''s wife stated that she noted a trashcan next to the chair the patient was sitting in. The trashcan did not have emesis in it but patient''s wife assumes he had been nauseated that evening before he passed away.


VAERS ID: 1238254 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-04-15
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

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

Write-up: This 85 year old male received the Covid shot on 2/23/21 and subsequently died on 4/15/21. Please refer to the other details submitted within this report and contact the person who submitted this report via email for additional follow up details and investigation.


VAERS ID: 1238280 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-10
Onset:2021-04-05
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M2OA / 1 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: No adverse event
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: The decedent was visiting family. There are no reported adverse effects known.


VAERS ID: 1238316 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-12
Onset:2021-02-28
   Days after vaccination:47
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037KZOA / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Decreased appetite, Fall, SARS-CoV-2 test negative
SMQs:, Accidents and injuries (narrow), COVID-19 (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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide, Dipyramid, Losartan, Simvastatin.
Current Illness: Unknown.
Preexisting Conditions: Dementia, Cholesterol, Depression, Osteoarthritis.
Allergies: Unknown.
Diagnostic Lab Data: COVID-19 PCR test result negative.
CDC Split Type:

Write-up: Suffered a fall, stopped eating, on February 28, 2021 was found without vital signs.


VAERS ID: 1238566 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-09
Onset:2021-04-18
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Completed suicide
SMQs:, Suicide/self-injury (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On April 18, 2021, nine days after the person got his second dose of Moderna vaccine, he committed suicide using a gun in the presence of his family.


VAERS ID: 1238733 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-04-20
Onset:2021-04-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident was found kneeling over walker with face down in the bathtub right before 1700. Code called and initiated. Resident pronounced dead at 1721 by EMS.


VAERS ID: 1238843 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-23
Onset:2021-02-18
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: levothyroxine, metformin, simvastatin, baby aspirin, gabapentin, Alendronate, multiple vitamins , calcium/vitamin D, oxycodone.
Current Illness: no acute illness
Preexisting Conditions: HTN, type II diabetes, hyperlipidemia, CKD stage III, hypothyroid, overweight
Allergies: IV contrast
Diagnostic Lab Data:
CDC Split Type:

Write-up: per patient''s family report: patient complained severe leg pain a few days before she was found dead in her apartment on 2/18./2021. It was likely she had sudden death as she did not activate her neck alert or call button in her apartment. Family request we report the incident, she was last seen on 12/15/2020 for pacemaker check, she also had medical message communication with me on 2/8 to request refill on her Percocet that she takes occ for her joint pain only at bed time. family suspect possible DVT with PE after getting more informed about vaccine side effects. however no autopsy was done.


VAERS ID: 1240254 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-05
Onset:2021-04-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebral haemorrhage, Chills, Computerised tomogram head abnormal, Death, Disorientation, Electroencephalogram, Fall, Gait disturbance, Gait inability, Illness, Initial insomnia, Laboratory test, Magnetic resonance imaging, Mobility decreased, Pyrexia, Sleep disorder, Snoring, Vomiting, Weight bearing difficulty, Withdrawal of life support
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Depression (excl suicide and self injury) (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   Days after onset: 14
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: Eliquis (5mg 2x day); Levothyroxine (88mcg 1 x day), metoprolol tartrate (25 mg 2x day), multivitamin, vitamin c, probiotic, just started diclofenac as a topical creme for arthritis in his feet.
Current Illness: None
Preexisting Conditions: Afib,, hypo active thyroid, arthritis in his feet acting up.
Allergies: None
Diagnostic Lab Data: CT Scans daily April 7 - 18 MRI (about April 13) EEG (abt April 13) Labs and other test in hospital records, I don''t know them.
CDC Split Type:

Write-up: Monday night pt. became ill, threw up and had a fever. He went to bed, but around 11 pm he woke up disoriented, unable to walk. Was helped to the bathroom, but was unable to get back to bed on his own. Fell on his bottom. I had to call our son to come pick him up and help him back to bed, unable to hold his own weight.. Had trouble sleeping. Abt 1 pm needed help getting up again, same disorientation, also fell off the toilet and needed help getting back to the bed, unable to hold his own weight. Finally fell asleep. Next day seemed fine enough. Tuesday night, became ill again, went to bed. Got up to go to the bathroom, was wobbly, but able to make it. Was helped back, wobbly but able to walk. Trouble falling asleep, fever, chills. Finally fell asleep at 3 am Wed morning. I had to go to the doctor early, so left him sleeping in bed. When I came back around 11 am, he was still sleeping, snoring loudly. Became concerned. Wouldn''t wake up. Called Paramedics. CT scan at the hospital revealed a brain bleed. Transported to hospital. Put on support for almost 2 weeks. No progress, no response. Finally support was discontinued and he died April 19th at 7:52 pm.


VAERS ID: 1241383 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-25
Onset:2021-03-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Food refusal
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: 80 yr old metastatic lung cancer, had stopped eating, still wanted vaccine, Died on hospice service. no vaccine complications reported.


VAERS ID: 1241384 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-03-27
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   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 was 96 yr old, prostate cancer, peg tube placed, Died on Hospice service, No vaccine complication reported.


VAERS ID: 1241385 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-04-15
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Condition aggravated, Death, Dyspnoea, Fatigue, Oedema peripheral
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: 4/12 patient had fatigue/dyspnea -Per NP visit/note: -" reviewed with office/clinic team MD on phone, clinically does not appear to have fluid overload, has chronic LE edema which is no worse than usual, could be pneumonia possible aspiration related to dyaphagia. patient does not want to go to hospital for evaluation and treatment. Spoke with patient''s daughter, confirms DNR and LST wishes, no hospitalization, no cpr/ventilation/feeding tubes. She is agreeable to treating with low dose diuretic and antibiotic in effort to help symptoms. She is agreeable to hospice consult. -cipro 250 mg po bid x 7 days, furosemide 10 mg qday and kcl 10 meq x7 days called into pharmacy. caregiver to pick up today. reviewed s/e and precautions with meds in addition to indications - caregiver encouraged to keep patient upright in chair or bed for easier breathing. "


VAERS ID: 1241386 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-22
Onset:2021-03-18
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: EXPIRED Narrative: 86 y/o male who received first dose of COVID-19 vaccine (Moderna) 1/22/21 and never returned for second dose. COVID-19 clinic alerted the pharmacist that patient expired prior to receiving second dose. Unknown reason.


VAERS ID: 1241389 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-03-24
   Days after vaccination:41
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Diarrhoea, Encephalopathy, Fall, Haematochezia, Hypotension, Melaena, Pneumonia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (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 was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient presented to the ER on 3/8/21 after being sick the prior 2 weeks with loose, bloody/tarry stools, frequent falls, and hypotension. Hospital course progressed to worsening encephalopathy secondary to decompensated alcoholic cirrhosis. Developed pneumonia that did not improve with antibiotics and progressed to palliative care with him passing away on 3/24/21. Comorbidities include COPD, alcoholism, Takotsubo cardiomyopathy, HTN, cirrhosis, HLD, former smoker.


VAERS ID: 1241390 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-22
Onset:2021-03-09
   Days after vaccination:46
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   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 was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 94 and receiving hospice care for end life care in the months leading up to his passing on 3/9/21. In addition to his advanced age, the patient had chronic afib on anticoagulation, hypothyroidism, HTN, HLD, COPD, depression, and increasing cognitive and memory issues towards the end of his life.


VAERS ID: 1241391 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-10
Onset:2021-03-07
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 86 but did not have a lot of history of receiving medical care in the system. There is note mentioned his death in the chart. His possible contributing comorbidities are advanced age, HTN, HLD, DM, mitral valve insufficiency.


VAERS ID: 1241393 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-14
Onset:2021-02-05
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, COVID-19 pneumonia, Death, Hyperhidrosis, Hypotension, Presyncope, Respiratory failure
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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

Write-up: Death Narrative: The patient did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. Patient transported to ER on 1/14/21 after receiving first COVID-19 vaccine earlier that day. He was reported to have a reaction to the vaccine including diaphoresis, new onset afib, and hypotension(vasovagal reaction). He was discharged the next day with no signs of afib. Patient was later hospitalized around 1/28/21 for COVID pneumonia. He later passed away on 2/5/21 due to hypoxic respiratory failure secondary to COVID-19. Comorbidities include advanced age, obesity, HLD, atherosclerosis, DM2, HTN.


VAERS ID: 1241394 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-02-24
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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 was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 90 but not receiving frequent care from facility and circumstances regarding his cause of death not certain. His comorbidities include advanced age, afib, cardiac pacemaker, HTN, Barrett''s esophagus, HTN, and hypothyroidism.


VAERS ID: 1241396 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-10
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 81 and brought to the Hospital ER on 3/4/21 w/ a STEMI. He did not recover and later passed away there on 3/10/21. Comorbidities include diabetes, HLD, HTN, cardiac murmur.


VAERS ID: 1241397 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-04-03
   Days after vaccination:65
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Ischaemic skin ulcer
SMQs:, Drug reaction with eosinophilia and systemic symptoms syndrome (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? 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: 91 yr old Arterial ulcer on toe, not surgical candidate, patient opted palliative care, hospice enrolled, Died on hospice service. No vaccine complications reported.


VAERS ID: 1241399 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-03-09
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-09
   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: 95 yr old Renal failure, renal anemia, Died on Hospice service. No vaccine complications reported.


VAERS ID: 1241587 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-14
Onset:2021-01-21
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

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

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

Write-up: She was a healthcare worker. It was reported to me by her immediate supervisor that she tested positive for COVID-19 the day after her first vaccination. She became symptomatic around January 21, 2021. She was scheduled to return to work on January 29, 2021 but did not come in. She died on February 2, 2021.


VAERS ID: 1241639 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-24
Onset:2021-02-27
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose normal, Hypertension, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopryl 10 MG, Procardia 30 MG, Ativan 2 MG, Klonopin 2 MG.
Current Illness: Unknown.
Preexisting Conditions: Cardiomegalia, COPD, CHR.
Allergies: Unknown.
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Two days after the 2nd dose, the patient presents the following symptoms: 75% oxigenation, 35% Puls, 153 sugar, HBP 64/44 and vomiting.


VAERS ID: 1241676 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-26
Onset:2021-04-12
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Heart rate decreased, Hypotension, Respiratory disorder
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   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: Omeprazol 20 mg, Isosorbide mononitrate, vitamina D3, Melatonina, Lasiz, Lurasidone -HCL, Eliquis, Atorvastatin, itamina B12, Divalpropex- NA, Metoprolol, eye drops.
Current Illness: Unknown.
Preexisting Conditions: Dementia, atrial fibrillation, arterial coronary disease, Alzheimer, mayor neurocognitive disorder, dysphagia, hyperlipidemia, hypertension, moderate depression.
Allergies: Unknown.
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: The patient was with respiratory difficulties, low pressure and low pulse.


VAERS ID: 1242022 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-04-13
Onset:2021-04-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Cough, Death, Dyspnoea, Headache, Oropharyngeal pain
SMQs:, Anaphylactic reaction (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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: 2021-04-18
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: baclofen carbidopa/levodopa furosemide gabapentin lactulose rifaximin spironolactone tamsulosin vit B12 acetaminophen
Current Illness: alcoholic cirrhosis with ascites type 2 diabetes hyponatremia spinal stenosis vitamin B12 deficiency
Preexisting Conditions: see item 11
Allergies: no known allergies
Diagnostic Lab Data: None - my understanding is that autopsy will be done, medical examiner to determine cause of death.
CDC Split Type:

Write-up: Patient care coordinator on PCP team learned of patient death, as documented: TC to pt family for a welfare ck d/t co-worker mentioned saw in social media pt had passed? PCC-spoke with pt daughter states father passed on 4/18/2021 in the PM unknown exact time of death at home. PCC gave family condolences for their loss. Patient reports father got covid-19 vaccine on 4/13/2021 and he started having severe HA''s on this day. Sx increased for the next few days, he had dry cough,sore throat,chest pain,SOB. States father declined for family to called an ambulance while sx were increasing. States ambulance was called on Sunday 4/18/2021 to take body to the morgue. States they are awaiting for autopsy results,and death certificate. States father''s body will be taken to his family. On what date did they pass away? 418/2021 unknown time, at home Do you know what the cause was? Family is not sure of cause of death


VAERS ID: 1242079 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-15
Onset:2021-03-22
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cough, Death, Diarrhoea
SMQs:, Anaphylactic reaction (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: diarrhea. No fevers. Occasional cough. No loss of taste or smell.


VAERS ID: 1242118 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-13
Onset:2021-03-26
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Bacteraemia, COVID-19 pneumonia, Death, Endotracheal intubation, Gastrointestinal haemorrhage, Hyperkalaemia, Hypoxia, Oliguria, Renal replacement therapy, Sepsis, Shock, Therapeutic embolisation
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Ischaemic colitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   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: aspirin EC 81 mg daily, metformin ER 500 mg BID, atorvastatin 40 mg daily
Current Illness: fall/trauma with rib fractures
Preexisting Conditions: CAD s/p CABG, dementia, diabetes, aortic valve replacement
Allergies: Iodine, penicillin (no reactions listed for either)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented after being found down next to toilet found to have COVID-pneumonia and sepsis needing intubation for ARDS and CRRT for hyperkalemia and oliguria. Hospitalization complicated by GIB s/p rectal artery embolization by IR and GNR bacteremia requiring cefepime. Due to worsening hypoxia and shock, patient was made comfort care/hospice by family and passed away on 4/9.


VAERS ID: 1242160 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-01
Onset:2021-04-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Resuscitation, 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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: AICD ,FAILURE TO THRIVE ,AFIB ,SEVERE CARDIOMYOPATHY DEMENTIA
Preexisting Conditions: AICD ,FAILURE TO THRIVE ,AFIB ,SEVERE CARDIOMYOPATHY DEMENTIA
Allergies:
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: CALLED TO TRANSFER PATIENT FROM 2C ADMITTING AREA TO ENDOSCOPY UNIT AROUND 1410. UPON ARRIVAL IN 2C TO TRANSFER PATIENT, PATIENT WAS ALERT AND RESPONSIVE TO NAME. WHEN WHEELED TO BEDSIDE IN ENDOSCOPY UNIT PATIENTS RIGHT ARM SLUMPED AND HE BECAME UNRESPONSIVE. RAPID RESPONSE CALLED. PATIENT TRANSFERRED TO STRETCHER, CODE BLUE CALLED, AND CPR STARTED. DR. ANESTHESIA AT BEDSIDE MANAGING AIRWAY. CODE TEAM RESPONDED. REFER TO ARREST RECORD.


VAERS ID: 1242376 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-04-10
Onset:2021-04-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death, Dizziness, Dyspnoea, Nausea, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril, Atorvastatin, Amlodipine, Metoprolol, Hydrochlorothiazide, Hydralazine, and Spironolactone
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine on 04/10/21.Shortness of breath, dizziness, nausea 04/13/2021. Death on at hospital on 04/14/2021 Autopsy found Bilateral pulmonary thromboemnbolus


VAERS ID: 1242520 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-03-10
Onset:2021-04-17
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 2 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Apnoea, Arthralgia, Blood glucose normal, C-reactive protein normal, Cardio-respiratory arrest, Chest pain, Dizziness, Electrocardiogram normal, Head injury, Labile blood pressure, Loss of consciousness, Pulse absent, Pulseless electrical activity
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), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Arthritis (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   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: Acetaminophen 650 mg up to 2x daily Alvesco 80mcg/actuation - 1 puff 2 times every day Claritin 10mg daily Ferrous Sulfate 325mg two times daily Folic Acid 1mg two times every day Levothyroxine 100mcg tablet daily Methotrexate Sodium 2.5mg
Current Illness: 35 y/o with asthma (on alvesco and singulair), GERD, morbid obesity (BMI 45) and RA (on prednisone and MTX, SZA.) Vaccinated for COVID 2.12. and 3.10 Recent lab 3/17- normal, including negative CRP. Code continued for 50 minutes, no shock advised. PEA, gave Epi X 4. Normal BS. Considered narcan. Over the weekend- 4/17/21 Chest pain that started with eating. Labile blood pressure. EKG showed NSR rate 64. Treated with ASA 325, clear liquid diet and rest. Treated with toradol and Zofran. Improved. At f/u on Monday, discussed chronic knee pain was overall better. Normal for her exam. BP 136/79. Felt dizzy and then passed out, hitting her head, became pulseless an apneic and was coded for over an hour.
Preexisting Conditions: Asthma, RA, constipation, Hypothyroidism, Anemia
Allergies: Morphine Sulfate
Diagnostic Lab Data:
CDC Split Type:

Write-up: 35 y/o with asthma (on alvesco and singulair), GERD, morbid obesity (BMI 45) and RA (on prednisone and MTX, SZA.) Vaccinated for COVID 2.12. and 3.10 Recent lab 3/17- normal, including negative CRP. Code continued for 50 minutes, no shock advised. PEA, gave Epi X 4. Normal BS. Considered narcan. Over the weekend- 4/17 Chest pain that started with eating. Labile blood pressure. EKG showed NSR rate 64. Treated with ASA 325, clear liquid diet and rest. Treated with toradol and Zofran. Improved. At f/u on Monday, discussed chronic knee pain was overall better. Normal for her exam. BP 136/79. Felt dizzy and then passed out, hitting her head, became pulseless an apneic and was coded for over an hour.


VAERS ID: 1242607 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-04-20
Onset:2021-04-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046B21A / 2 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Joint swelling, Malaise, Nervousness, Neuropathy peripheral, Pain in extremity, Tremor
SMQs:, Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   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: Atorvastatin, Enalapril, Furosemide, Gabapentin, Humalog, Lantus, Metoprolol and Plavix.
Current Illness: none reported
Preexisting Conditions: CHF, IDDM, HTN and CABG
Allergies: Codeine only/no food allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Ankle swelling with extreme foot pain(has neuropathy) No symptoms in 15 minutes after injection on both injections After the second injection had complaints of being shaky, not feeling well with generalized weakness


VAERS ID: 1242654 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-09
Onset:2021-03-18
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Acute respiratory distress syndrome, Acute respiratory failure, Lung infiltration, Pneumonia
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), 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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA Comfort Cares-acute hypoxic respiratory failure in the setting of bilateral pulmonary extensive infiltrates due to ARDS, pneumonia and possible component of CHF exacerbation. Non-ST elevation myocardial infarction.


VAERS ID: 1242660 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-14
Onset:2021-04-21
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   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: Combigan Opthalmic solution, Bumex 2mg 2x a day, Tamsulosin 0.4mg daily, Travoprost opthalmic solution, Aspirin EC 81 mg daily, Entresto 49mg/51mg daily, Artificial tears, Ferrous Sulfate 325mg daily, Pantoprazole 20mg 2x daily, Multivitami
Current Illness: 3/11/21: Bumex increased to 2mg twice a day for 7 days for CHF 3/25/21: Increased weight due to edema/CHF
Preexisting Conditions: Chronic Diastolic Congestive Heart Failure, Chronic Kidney Disease (stage 3), Anemia, Sick Sinus Syndrome, Presence of Cardiac Pacemaker, Basal Cell Carcinoma of Skin, Glaucoma, Essential (primary) Hypertension, Atrial Fibrillation, other Ill-Defined Heart Diseases, Polyp of Colon, Osteoarthritis, Benign Prostatic Hyperplasia, Difficulty walking, History of Gastrointestinal Hemorrhage
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient has a long standing chronic history of CHF which he was recently hospitalized for, returning from an overnight stay at the hospital as a DNR/DNH/DNI.


VAERS ID: 1242850 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Malaise, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 11
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: HIV medications, Hyterpertensive medications, cardiac meds
Current Illness: None
Preexisting Conditions: HIV+ since 1980''s. Chronic Hypertension ( well controlled), Cardiac bypass surgery two years ago
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Received #2 Moderna on 3/5/2021. Started to not feel well the next day. By 3/9/2021, he was too sick to get out of bed. Friends stayed with him the previous night and opted to call 911 for hospital transport on 3/9. He was admitted to a Medical Center and diagnosed with pneumonia. He died on 3/18/2021 in patient.


VAERS ID: 1242858 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-07
Onset:2021-04-19
   Days after vaccination:102
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   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: unnknown
Current Illness: unknown
Preexisting Conditions: chronic kidney disease, history of CVA
Allergies: penicillins, albuterol
Diagnostic Lab Data: COVID + 4/8/21
CDC Split Type:

Write-up: Patient contracted COVID 19 and subsequently expired from respiratory distress, following completion of the serious of two vaccination shots. She received her Moderna vaccinations on 1/7/21 and 2/4/21. I do not have access to the lot # info- would have to contact vaccination site to obtain


VAERS ID: 1242950 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-22
Onset:2021-04-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / UNK UN / UN

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   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: Atorvastatin, Pantoprazole, Metoprolol, Lisinopril
Current Illness: unk
Preexisting Conditions: A-fib, HTN
Allergies: Penicillian
Diagnostic Lab Data: Blood draw done on decedent 04-22-2021
CDC Split Type:

Write-up: Receiver of vaccine was reported dead on 04-22-2021 TOD 0809 to Medical Examiner''s Office Report # 052-EMF-79-21


VAERS ID: 1243053 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-16
Onset:2021-04-19
   Days after vaccination:62
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-19
   Days after onset: 0
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized x 2 and died within 60 days of receiving a COVID vaccine


VAERS ID: 1243206 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-07
Onset:2021-04-07
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   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:
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: 1243301 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-18
Onset:2021-03-02
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-22
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: 2021-04-18
   Days after onset: 46
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:
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: 1243358 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-09
Onset:2021-04-07
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
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


VAERS ID: 1243360 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

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

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received first Moderna Vaccine on 02/26/2021 and second Moderna Vaccine on 03/26/2021. Health Department was notified of patients death on 03/27/2021, today 04/22/2021. Any further information is unknown by the health department for patients cause of death that occurred on 03/27/2021.


VAERS ID: 1243461 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-20
Onset:2021-03-25
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

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

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

Write-up: My father passed away on the 5th day and was in pretty good health.


VAERS ID: 1243596 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-24
Onset:2021-04-07
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / UNK - / IM

Administered by: Pharmacy       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: Called to verify coming in for second dose on 4/21/21, family member confirmed death a few weeks ago (a few weeks after first covid dose). Cause of death unknown


VAERS ID: 1243650 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-04-19
Onset:2021-04-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine Naproxen
Current Illness:
Preexisting Conditions: Hypertension Osteoarthritis of knee
Allergies: NKA
Diagnostic Lab Data: County Medical Examiner Case
CDC Split Type:

Write-up: Unexpected death; found unresponsive 04/20/21 morning and pronounced dead after unsuccessful resuscitative efforts


VAERS ID: 1243791 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-04-10
Onset:2021-04-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: 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: Per family, Xarelto
Current Illness: None communicated at this time to this office
Preexisting Conditions: History of clotting disorder at age 16 with Xarelto treatment and hospitalization
Allergies: None communicated to this office
Diagnostic Lab Data: None known at this time.
CDC Split Type:

Write-up: Per the father, the deceased received his first shot of Moderna vaccine on Saturday, 4/10/2021 at a local church. He did not work on 4/11/2021. Worked on 4/12/2021. The deceased was found dead at 6:43 p.m. at his home.


VAERS ID: 1243832 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-08
Onset:2021-03-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Atrioventricular block, Body temperature increased, Cardiac arrest, Chills, Condition aggravated, Death, Electrolyte imbalance, Fall, Fatigue, Feeling abnormal, Loss of consciousness, Pain in extremity, Pyrexia, Respiratory arrest, Rhinorrhoea
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), 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: 2021-03-23
   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: Unknown
Current Illness: None reported
Preexisting Conditions: Anorexia, 2nd Degree Type II heart block, pacemaker
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 4.21.2021- I spoke with (patient''s husband) related to spouse. Husband stated the patient has a history of 2nd Degree Type 2 heart block, pacemaker placed at the age of 14, and she currently has issues with an eating disorder dx with anorexia. Patient is reported to be approximately 68-70 pounds at the time of vaccination. March 8.2021- Husband states he and his wife came to receive the vaccine around 1630. After, receiving the vaccine the patient stated to her Husband "my arm really hurts." She begin experiencing s/s at approximately 1900 including: fever, chills, runny nose, fatigued and tired - reportedly temperature was 100.0 and the patient began to drink Gatorade and take Tylenol. Monday, 3.15.2021 patient continued to have symptoms therefore, (husband) contacted Moderna Representatives from the safety team, to determine if it would be safe for the patient to get the 2nd vaccine dose - advised everyone that does not have contraindications should be vaccinated-advised to reach out to PCP. Husband stated that the patient did not want to go to her PCP because of her eating disorder. The patient worked from bed during the week per the husband and spent 90-95% of her time in the bed after receiving the vaccine. Husband states on Saturday 3.20.2021 the patients fever had subsided however, she continued to feel poorly and remained bedbound most of the time. Husband is an Pilot 3.23.2021 stated once, he had landed he began trying to contact wife but she was not answering the phone, after several attempts to contact wife - Husband called a neighbor to check on wife. Upon, entering the residence the neighbor found wife lying on the floor unconscious and not breathing. The neighbor notified Husband and called 911. EMS arrived at the scene and pronounced the patient as a DOA. Husband states that the death certification list cardiac arrest, electrolyte imbalance, and heart block, as causes for death. Husband is concerned that the vaccine may have contributed in some way demise of his wife as he stated "she was never the same after the vaccination."


VAERS ID: 1244814 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-03-19
Onset:2021-04-14
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03ZM20A / 2 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Cough, Death, Dizziness, Laboratory test, Magnetic resonance imaging normal, Muscular weakness, X-ray
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Vestibular disorders (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Ventolin Inhaler, Statin and Breo Inhaler
Current Illness:
Preexisting Conditions: COPD
Allergies: Unsure
Diagnostic Lab Data: MRI showed normal age related changes. She had blood work drawn, I do not know the results of it. She was at the Hospital and had an xray and lab work about 2 to 3 weeks before she passed. I do not know the results of the tests at this time.
CDC Split Type:

Write-up: Dizziness off and on for 2 weeks along with muscle weakness and developed a cough about a week after this injection. My mother passed away.


VAERS ID: 1244990 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-03-19
Onset:2021-03-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Catheterisation cardiac abnormal, Chest pain, Death, Echocardiogram abnormal, Injection site pain, Laboratory test, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: He had lab work, cardiac cath and an echo
CDC Split Type:

Write-up: After receiving the second dose of the vaccine, my husband experienced left arm pain which he thought was from the injection. About a week later, the pain got worse and moved toward his chest. It got so bad, he had to be taken by ambulance to the hospital to find out he had been having a heart attack. He spent nearly three weeks in the hospital before he died on 4/15/21


VAERS ID: 1245299 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-04-09
Onset:2021-04-11
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute myocardial infarction, Blood creatinine increased, Blood lactic acid normal, Blood urea increased, Cardiac failure congestive, Chest X-ray abnormal, Death, Haematocrit decreased, Lip swelling, Lipase, Liver function test, N-terminal prohormone brain natriuretic peptide normal, Platelet count normal, Pulmonary oedema, SARS-CoV-2 test negative, Troponin, Urine analysis, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (narrow), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   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: acetaminophen allopurinol atorvastatin atropine cal-mag-zinc vitamin D3 clopidogrel hydrocodone-acetaminophen lorazepam memantine morphine multivitamin-minerals olanzapine oxybutynin quetiapine sennosides-docusate sodium trazodone
Current Illness: No recent acute illnesses
Preexisting Conditions: On hospice for dementia with decline History of stroke hyperlipidemia prediabetes osteoarthritis gout CKD 3b history of recurrent UTIs
Allergies: none
Diagnostic Lab Data: All tests on 4/11 CXR confirmed pulmonary edema N-terminal pro-BNP 29,100 Troponin 0.29 SARS-CoV-2 negative hct/hct 28.8/9.0 (slightly lower than his baseline), wbc 10, plat 253 BUN/cr 74/2.2 (baseline cr 1.6) Lytes, LFT''s, lipase, lactic acid normal Blood cx negative Urine cx negative
CDC Split Type:

Write-up: Patient developed swelling of his upper and lower lip on 4/11 and was given 25 mg benadryl at the care home. Swelling subsequently worsened and 911 was called, with EMS noting SpO2 at 88%. He was transported to the ER and found to have CHF/pulmonary edema and NSTEMI. Comfort care measures were implemented and he died 4/15.


VAERS ID: 1245370 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-30
Onset:2021-03-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Fatigue, Influenza like illness, Vaccination site pain
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: OXYCODONE; AMBIEN CR; BAYER ASPIRIN; CARDIZEM CD; COMPAZINE [PROCHLORPERAZINE EDISYLATE]; IRBESARTAN; IMITREX [SUMATRIPTAN]; LEFLUNOMIDE; NEURONTIN; PILOCARPINE; PREVACID; RINVOQ; SINGULAIR; TIZANIDINE; VALIUM; ZOFRAN [ONDANSETRON]; CBD OIL
Current Illness: Degenerative bone disease; Dermatomyositis; Immune disorder (NOS); Muscular dystrophy; Osteoarthritis; Osteoporosis; Polymyositis; Raynaud''s phenomenon; Rheumatoid arthritis
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: very tired and sleep 18 hours; passed away; severe flu-like symptoms; chest pain; Soreness at injection site; This spontaneous case was reported by a patient family member or friend and describes the occurrence of DEATH (passed away) in a 54-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 020B21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Dermatomyositis, Polymyositis, Osteoarthritis, Degenerative bone disease, Osteoporosis, Muscular dystrophy, Rheumatoid arthritis, Immune disorder (NOS) and Raynaud''s phenomenon. Concomitant products included MONTELUKAST SODIUM (SINGULAIR) for Asthma, PILOCARPINE for Dry mouth, IRBESARTAN for Hypertension, DILTIAZEM HYDROCHLORIDE (CARDIZEM CD) for Hypertension and Chest pain, SUMATRIPTAN (IMITREX [SUMATRIPTAN]) for Migraine, TIZANIDINE for Muscle spasms, PROCHLORPERAZINE EDISYLATE (COMPAZINE [PROCHLORPERAZINE EDISYLATE]) and ONDANSETRON (ZOFRAN [ONDANSETRON]) for Nausea, GABAPENTIN (NEURONTIN) for Nerve pain, OXYCODONE for Pain, LEFLUNOMIDE and UPADACITINIB (RINVOQ) for Rheumatoid arthritis, ZOLPIDEM TARTRATE (AMBIEN CR), ACETYLSALICYLIC ACID (BAYER ASPIRIN), LANSOPRAZOLE (PREVACID), DIAZEPAM (VALIUM), CANNABIDIOL (CBD OIL) and IRON (IRON COMPLEX [IRON]) for an unknown indication. On 30-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 30-Mar-2021, the patient experienced VACCINATION SITE PAIN (Soreness at injection site). On 31-Mar-2021, the patient experienced INFLUENZA LIKE ILLNESS (severe flu-like symptoms) and CHEST PAIN (chest pain). On an unknown date, the patient experienced FATIGUE (very tired and sleep 18 hours). On 02-Apr-2021, INFLUENZA LIKE ILLNESS (severe flu-like symptoms), CHEST PAIN (chest pain), FATIGUE (very tired and sleep 18 hours) and VACCINATION SITE PAIN (Soreness at injection site) outcome was unknown. The patient died on 02-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. On 02-APR-2021 at 1: 30 AM mother found her daughter lying on the floor unresponsive. Paramedics and police came to the house. Paramedics tried to revive her and she was pronounced dead at the scene. This is a 54 year-old, female patient who received mRNA-1273 Vaccine) (batch no. 020B21A) and died 3 days after receiving first dose of vaccine and experiencing Influenza like symptoms. Medical hx of several auto immune disorders were provided. Conmeds include Hypertensive and Chest pain meds. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. No further information is expected.; Sender''s Comments: This is a 54 year-old, female patient who received mRNA-1273 Vaccine) (batch no. 020B21A) and died 3 days after receiving first dose of vaccine and experiencing Influenza like symptoms. Medical hx of several auto immune disorders were provided. Conmeds include Hypertensive and Chest pain meds. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. No further information is expected.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1245371 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-03-10
Onset:2021-03-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac disorder, Cerebrovascular accident, Coma, Dyspnoea, Fatigue, Headache, Heart rate increased, Muscular weakness, Thrombosis
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (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), Thrombophlebitis (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), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-17
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? Yes
Previous Vaccinations:
Other Medications: ELIQUIS; ENTRESTO; METOPROLOL
Current Illness: AFib; Heart disease, unspecified; Hypertension
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: irritated her heart condition; Clot blood; weakness in legs, couldnt walk with legs; Coma; couldn''t breathe; stroke/massive stroke in left side of her brain; Irritated her heart condition, rapid heart beat; Headache; Tiredness; This spontaneous case was reported by a consumer and describes the occurrence of CEREBROVASCULAR ACCIDENT (stroke/massive stroke in left side of her brain), CARDIAC DISORDER (irritated her heart condition), DYSPNOEA (couldn''t breathe), THROMBOSIS (Clot blood), COMA (Coma) and MUSCULAR WEAKNESS (weakness in legs, couldnt walk with legs) in a 95-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for Covid-19 Vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Heart disease, unspecified, Hypertension and AFib. Concomitant products included APIXABAN (ELIQUIS) for Anticoagulant therapy, SACUBITRIL VALSARTAN SODIUM HYDRATE (ENTRESTO) for Hypertension, METOPROLOL for an unknown indication. On 10-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 11-Mar-2021, the patient experienced HEADACHE (Headache) and FATIGUE (Tiredness). On 12-Mar-2021, the patient experienced MUSCULAR WEAKNESS (weakness in legs, couldnt walk with legs) (seriousness criterion hospitalization). On 13-Mar-2021, the patient experienced CARDIAC DISORDER (irritated her heart condition) (seriousness criterion hospitalization), THROMBOSIS (Clot blood) (seriousness criterion hospitalization) and HEART RATE INCREASED (Irritated her heart condition, rapid heart beat). On 15-Mar-2021, the patient experienced CEREBROVASCULAR ACCIDENT (stroke/massive stroke in left side of her brain) (seriousness criteria death and medically significant). On 16-Mar-2021, the patient experienced DYSPNOEA (couldn''t breathe) (seriousness criterion hospitalization prolonged) and COMA (Coma) (seriousness criterion hospitalization prolonged). The patient was hospitalized on 13-Mar-2021 due to CARDIAC DISORDER, COMA, DYSPNOEA, MUSCULAR WEAKNESS and THROMBOSIS. The patient died on 17-Mar-2021. The reported cause of death was massive stroke in left side of her brain. It is unknown if an autopsy was performed. At the time of death, CARDIAC DISORDER (irritated her heart condition), DYSPNOEA (couldn''t breathe), THROMBOSIS (Clot blood), COMA (Coma), MUSCULAR WEAKNESS (weakness in legs, couldnt walk with legs), HEART RATE INCREASED (Irritated her heart condition, rapid heart beat), HEADACHE (Headache) and FATIGUE (Tiredness) outcome was unknown. Action taken with mRNA-1273 in response to the events was not Applicable. This case concerns an 95 year old female patient, with medical history of A Fib, Heart disease, Hypertension who experienced a serious unexpected event of Death 8 days after receiving 1st dose of mRNA- 1273 . Very limited information regarding these events has been provided at this time. However, the patient''s advance age, multiple co-morbidities, may remain as risk factors. Further information is requested. This case was linked to MOD-2021-074814 (Patient Link).; Sender''s Comments: This case concerns an 95 year old female patient, with medical history of A Fib, Heart disease, Hypertension who experienced a serious unexpected event of Death 8 days after receiving 1st dose of mRNA- 1273 . Very limited information regarding these events has been provided at this time. However, the patient''s advance age, multiple co-morbidities, may remain as risk factors. Further information is requested.; Reported Cause(s) of Death: massive stroke in left side of her brain


VAERS ID: 1245392 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Texas  
Vaccinated:0000-00-00
Onset:2021-04-13
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Fatigue, Vaccination site pain
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: arm was really sore; felt tired; passed away / she was dead; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (passed away / she was dead) in a 71-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included No adverse event (No reported medical history). On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired). The patient died on 13-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, VACCINATION SITE PAIN (arm was really sore) and FATIGUE (felt tired) outcome was unknown. No treatment information was provided. No concomitant medications was provided. Reporter did not allow further contact; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1245400 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Texas  
Vaccinated:0000-00-00
Onset:2021-04-14
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (Medical history was not reported)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death) in a 57-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event (Medical history was not reported). On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 14-Apr-2021 The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided Concomitant product use was not provided by the reporter. No treatment information was provided. Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed. Action taken with mRNA-1273 in response to the event was not applicable.; Sender''s Comments: Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested. The cause of death was not reported. It is unknown if an autopsy was performed.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1245485 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

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

Write-up: death after 1 dose of vaccine; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (death after 1 dose of vaccine) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (death after 1 dose of vaccine) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided The reporter stated that she was not sure of the vaccine name that the patient used.; Sender''s Comments: This is a male patient of unknown age, who received mRNA-1273 Vaccine and died on an unknown date after receiving first dose of vaccine. No medical hx or conmeds were provided. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. Further information is expected.; Reported Cause(s) of Death: death after 1 dose of vaccine


VAERS ID: 1246110 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-04-02
Onset:2021-04-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, Headache, Influenza virus test positive, Lethargy, SARS-CoV-2 test positive, Tryptase
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   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: Xanax
Current Illness: Postmortem COVID-19 test positive
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Postmortem CDC Influenza SARS-CoV-2 Multiplex Positive for COVID-19; Postmortem tryptase 8.3 mcg/L; Postmortem lung cultures Few WBCs seen, no organisms seen, no aerobes or anaerobes isolated day 4
CDC Split Type:

Write-up: Lethargy, weakness, headache; ultimately pronounced on 4/3/2021 at 1310 hours


VAERS ID: 1246484 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-04-16
Onset:2021-04-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide 20mg , Losartan Potassium 100mg, Bayer COntour Test in Vitro Strip, Vit, D3, Atorvastatin Calcium 10mg, Glipizide ER 2.5mg, B complex, one touch delica lancets 33g, multivitamin, amlodipine besylate 10mg, mtroprolol tartrate 25mg
Current Illness:
Preexisting Conditions: urge incontinence, stress, ,menopausal and postmenopausal disorder, postmenopausal vag. bleeding, fall risk, cirrhosis, mobitz type 2 second degree av block, adenocarcinoma of endometrium, right bundle branch block, preop cardiovascular eval, thrombocytopenia, pacemaker, acute kidney failure,, atrioventricular block , 2nd degree, anemia, chronic deep venous thrombosis, venous stasis, hx of DVT, pulmonary embolism, CKD stage 3, wrist tenderness, cataract, vit. D deficiency, morbid obesity, hypertension, type 2 diabetes,
Allergies: PCN, Etodolac, Codeine, ASA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient received her first Moderna dose on 03/12/21 at 1:24pm in the Right Deltoid, Lot# 036A21A, no reaction after 15 min. No reaction was reported 15 min. after her second dose which was in the opposite arm. See was being watched by her family members that evening, family members did not report anything at that time. Her temperature on 4/16/21 was 97.1


VAERS ID: 1246486 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-04-22
Onset:2021-04-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048B21A / 2 - / IM

Administered by: Work       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac assistance device user, Death, Dyspnoea, Endotracheal intubation, Malaise, Resuscitation, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   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:
Preexisting Conditions: Hypertension
Allergies:
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient reported to onsite health clinic to see nurse at 1930. Complaints of not feeling well. Vomited then dyspnea. Went into cardiac arrest, AED used x1. EMS called at 1945. CPR, intubation until 2055. Time of death 2055.


VAERS ID: 1246534 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Female  
Location: New York  
Vaccinated:2021-04-09
Onset:2021-04-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032B21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Cardiomegaly, Death, Nausea, Pain in extremity, Renal disorder, Vomiting
SMQs:, Cardiac failure (broad), Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   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: Acetaminophen at approximately 5:00pm.
Current Illness: No.
Preexisting Conditions: Asthma, stomach ulcers.
Allergies: No.
Diagnostic Lab Data: Dr. from the Office of Chief Medical Examiners is currently conducting an autopsy report but shared some initial findings such as: an enlarged heart and patches on her kidney (4/10/21)
CDC Split Type:

Write-up: Patient felt initially well, but later in that afternoon her arm started hurting and she felt increasingly nauseous and started vomiting at 10:49pm, two hours later she was pronounced dead at approximately 12:30am.


VAERS ID: 1247180 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-03-17
Onset:2021-04-04
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 UN / SYR

Administered by: Public       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: 2021-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Opiramate 50 mg/day, Escitalopram oxolate 30 mg/day, Bupropion HCL ER 300 mg/day, Alprazolam 0.25 mg as needed (2x/day)
Current Illness: none (had foot surgery -- bunionectomy -- 2 days prior to vaccine administration)
Preexisting Conditions: none (though overweight)
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away suddenly and unexpectedly at home the morning of April 4, 2021. The ER doctor was unable to ascertain a cause. The preliminary autopsy conducted by the medical examiner within 24 hours of death was inconclusive, but I''m told tests of samples are ongoing.


VAERS ID: 1247315 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-04-15
Onset:2021-04-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 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: Metoprolol, Trazodone, Rosuvastatin, Norco, Gabapentin, Lexapro, Wellbutrin, Lisinopril, Allopurinol
Current Illness: none
Preexisting Conditions: hypertension, hyperlipidemia, arthritis, depression, gout, chronic pain
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death less than 24 hours after vaccine administration


VAERS ID: 1247318 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-04-22
Onset:2021-04-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006C21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   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: Abilify; Acidophilus; Albuterol sulfate; Amantadine; Anoro Elipta; Betamethasone; Cyanocobalamin (monthly) Diclofenac; Lomotil (prn); Fluticasone propionate; Furosemide; Ipratropium-Albuterol; losartan Potassium; Mucinex (prn); Namenda; Nor
Current Illness:
Preexisting Conditions: CHF, COPD, Fibromyalgia, Major depressive d/o, anemia, edema, cellulitis,
Allergies: PCN, Morphine; Sulfa Atb, Tetracycline, Keflex, Mandol
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


VAERS ID: 1247401 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-04-16
Onset:2021-04-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046B21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Abdominal Ascites, recent shock liver peri-arrest, recent subdural hematoma, recent cardiac arrest
Preexisting Conditions: ESRD, AFib, HTN, Anemia, Migraine headaches, Bipolar disorder, Hx of polysubstance use on methadone, Gout, COVID-19 infection 3/27/2020
Allergies: Morphine, Phenergan, Unasyn
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received Moderna Vaccine on Friday 4/16/2021 12:00pm in dialysis clinic. Over the weekend family called and left a message stating that patient CTB on Friday 4/16/2021 around 8pm.


VAERS ID: 1247465 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-04-15
Onset:2021-04-22
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap normal, Aspartate aminotransferase normal, Basophil count normal, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood calcium normal, Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood osmolarity normal, Blood potassium normal, Blood sodium normal, Blood urea normal, Carbon dioxide normal, Chest X-ray abnormal, Chills, Death, Eosinophil count decreased, General physical health deterioration, Haematocrit decreased, Haemoglobin decreased, Influenza A virus test negative, Influenza B virus test, Laboratory test, Lymphocyte count increased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Monocyte count normal, N-terminal prohormone brain natriuretic peptide increased, Neutrophil percentage increased, Platelet count normal, Pneumonia, Productive cough, Protein total normal, Pyrexia, Red blood cell count normal, Red cell distribution width normal, Tremor, Urine analysis normal, Vomiting, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (narrow), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Parkinson-like events (broad), Biliary system related investigations, signs and symptoms (narrow), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   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: TYLENOL(ACETAMINOPHEN [325 MG] TABLET) 325 MG Tablet 325 mg Oral as needed every 6 hours 03/08/2021 07:00 VITAMIN C(ASCORBIC ACID [500 MG] TABLET) 500 MG Tablet 500 mg Oral EVERY MORNING 03/08/2021 07:00 03/04/2021 08:00 ECOTRI
Current Illness: Foot/heel ulcer
Preexisting Conditions: Type ll Diabetes mellitus with diabetic polyneuropathy Hypertension Hyperlipidemia COPD Benign prostatic hypertrophy GERD History of TIA Weakness secondary to previous COVID Coronary artery disease with cardiac ischemic myopathy CHF Myocardial Infarction
Allergies: Biguanides Sulfa Metformin and related
Diagnostic Lab Data: Chest xray IMPRESSION: Pneumonia, also possible mild congestive heart failure. WBC 13.2 H 10^3/uL 4.0 - 11.0 (10^3/uL) 04/22/2021 07:23 Final RBC 4.57 N 10^6/uL 3.80 - 6.50 (10^6/uL) 04/22/2021 07:23 Final Hgb 12.9 L g/dL 14.0 - 18.0 (g/dL) 04/22/2021 07:23 Final Hct 39 L % 42 - 54 (%) 04/22/2021 07:23 Final MCV 86.0 N fL 79.0 - 99.0 (fL) 04/22/2021 07:23 Final MCH 28.2 N pg 28.0 - 34.0 (pg) 04/22/2021 07:23 Final MCHC 32.8 N g/dL 32.0 - 36.0 (g/dL) 04/22/2021 07:23 Final RDW 16.1 N % 11.0 - 16.5 (%) 04/22/2021 07:23 Final Platelet Count 246 N 10^3/uL 150 - 450 (10^3/uL) 04/22/2021 07:23 Final NE% 89.4 H % 45.0 - 76.0 (%) 04/22/2021 07:23 Final LYMPH% 4.5 LL % 20.0 - 40.0 (%) 04/22/2021 07:23 Final MONO% 5.4 N % 0.1 - 10.0 (%) 04/22/2021 07:23 Final EO% 0.5 L % 1.0 - 6.0 (%) 04/22/2021 07:23 Final BASO% 0.2 N % 0.0 - 2.0 (%) 04/22/2021 07:23 Final NE# 11.83 H 10^3/uL 2.00 - 8.00 (10^3/uL) 04/22/2021 07:23 Final LYMPH# 0.60 LL 10^3/uL 1.50 - 4.00 (10^3/uL) 04/22/2021 07:23 Final MONO# 0.71 N 10^3/uL 0.20 - 0.80 (10^3/uL) 04/22/2021 07:23 Final EO# 0.07 N 10^3/uL 0.04 - 0.40 (10^3/uL) 04/22/2021 07:23 Final BASO# 0.02 N 10^3/uL 0.02 - 0.10 (10^3/uL) 04/22/2021 07:23 Final Sodium Serum (Na) 138 N mmol/L 136 - 145 (mmol/L) 04/22/2021 07:23 Final Potassium Serum (K) 4.2 N mmol/L 3.5 - 5.1 (mmol/L) 04/22/2021 07:23 Final Chloride Serum 103 N mmol/L 98 - 107 (mmol/L) 04/22/2021 07:23 Final Carbon Dioxide (ECO2) 24 N mmol/L 21 - 32 (mmol/L) 04/22/2021 07:23 Final BUN (Blood Urea Nitrogen) 20 N mg/dL 10 - 25 (mg/dL) 04/22/2021 07:23 Final Creatinine 1.40 H mg/dL 0.55 - 1.30 (mg/dL) 04/22/2021 07:23 Final Glucose Serum 159 H mg/dL 74 - 99 (mg/dL) 04/22/2021 07:23 Final Calcium Serum 8.9 N mg/dL 8.5 - 10.1 (mg/dL) 04/22/2021 07:23 Final ALP - Alkaline Phosphatase 101 N U/L 46 - 116 (U/L) 04/22/2021 07:23 Final ALT (SGPT) 22 N U/L 14 - 63 (U/L) 04/22/2021 07:23 Final AST (SGOT) 19 N U/L 15 - 37 (U/L) 04/22/2021 07:23 Final Protein Total - TP 6.8 N g/dL 6.4 - 8.2 (g/dL) 04/22/2021 07:23 Final Albumin Serum 3.0 L g/dL 3.4 - 5.0 (g/dL) 04/22/2021 07:23 Final Globulin Calculated 3.8 N g/dL 1.3 - 5.0 (g/dL) 04/22/2021 07:23 Final Bilirubin Total (TBI) 1.4 H mg/dL 0.2 - 1.0 (mg/dL) 04/22/2021 07:23 Final Osmolality Calculated 282 N mOsm/L 275 - 295 (mOsm/L) 04/22/2021 07:23 Final Anion gap 15 N mmol/L 5 - 19 (mmol/L) 04/22/2021 07:23 Final Albumin/Globulin Ratio Cal''n 0.80 L calculated 1.10 - 1.80 (calculated) 04/22/2021 07:23 Final BUN/Creatinine Ratio 14.10 N calculated 6.00 - 20.00 (calculated) 04/22/2021 07:23 Final eGFR/1.73 sq M, Male 51 calculated 04/22/2021 07:23 Final C-Reactive Protein 3.80 H mg/dL 0.00 - 0.90 (mg/dL) 04/22/2021 07:23 Final Urine Color Yellow N 04/22/2021 08:01 Final Urine Clarity Clear N 04/22/2021 08:01 Final Dipstick Glucose Negative N 04/22/2021 08:01 Final Dipstick Bilirubin Negative N 04/22/2021 08:01 Final Dipstick Ketones 1+ AB 04/22/2021 08:01 Final Dipstick Specific Gravity 1.020 04/22/2021 08:01 Final Dipstick Blood Negative N 04/22/2021 08:01 Final Dipstick pH 5.0 04/22/2021 08:01 Final Dipstick Protein Negative N 04/22/2021 08:01 Final Dipstick Urobilinogen 0.2 E.U./dL N 04/22/2021 08:01 Final Dipstick Nitrite Negative N 04/22/2021 08:01 Final Dipstick Leukocyte Esterase Negative N 04/22/2021 08:01 Final Influenza A Ag Negative A N 04/22/2021 08:09 Final Influenza B Ag Negative B N 04/22/2021 08:09 Final BNP (Pro-BNP) 725 H pg/mL 0 - 125 (pg/mL) 04/22/2021 07:00 Fina
CDC Split Type:

Write-up: Patient received vaccine on 4/15/21 2nd dose of 2 dose series. He woke up the morning of 4/22/21 at 6:15am with vomiting. His temperature spiked to 104.2 and his O2 sat dropped to 98%. He developed shaking chills, and a loose wet sounding cough. He had chest xray and labs. Started on treatment for pneumonia with rocephin, zithromax and solumedrol. Declined throughout the day and had increasing requirements for O2 and patient passed away at 1355 on 4/22/21.


VAERS ID: 1247865 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-04-04
Onset:2021-04-17
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / UN

Administered by: Pharmacy       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: 2021-04-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: One week and 6 days after second vaccine fatal heart attack


VAERS ID: 1247898 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-02
Onset:2021-04-08
   Days after vaccination:65
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death, Dyspnoea, SARS-CoV-2 test positive, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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: Unknown
Current Illness: Unknown
Preexisting Conditions: Dementia, Cardiovascular Disease, Coronary Artery Disease, Peripheral Vascular Disease
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had second covid 19 vaccine on 2/2/21 at pharmacy. Was admitted on 4/6/21 to hospital with Shortness and Breath, Vomiting, and COVID-19 (tested positive on 4/6/21). Patient expired on 4/8/21 @ 1954.


VAERS ID: 1248086 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-02-05
Onset:2021-04-06
   Days after vaccination:60
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anticoagulant therapy, Blood immunoglobulin G, Cardiac arrest, Death, Deep vein thrombosis, Haematocrit decreased, Haemoglobin decreased, Platelet count decreased, Pulmonary embolism, Resuscitation, Thrombocytopenia, Transfusion
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-20
   Days after onset: 14
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: amoxicillin, apple cider vinegar, Excedrin migraine, atorvastatin, chlorthalidone, vitamin D3, cyclobenzaprine, doxycycline, escitalopram, ferrous sulfate, gabapentin, ginseng, ibuprofen, lisinopril, loratadine, potassium, teriparatide, Tob
Current Illness: progressive lower extremity paresthesias/myelopathies and gait/balance abnormalities, severe T11-12 stenosis (thoracic decompression 3/30/21)
Preexisting Conditions: anemia, osteoporosis, hyperlipidemia, hypertesnion, low testosterone, sleep apnea, spondylosis of lumbar region, hepatitis, obesity, history of spinal osteomyelitis, deep vein thrombosis
Allergies: lamotrigine, rifampin, tramadol
Diagnostic Lab Data: Heparin-induced thrombocytopenia antibody: negative (three days after surgery) Heparin induced IGG antibody, IA: positive (thirteen days after surgery) Prior to surgery: platelets 307 10*9/L, hemoglobin 13.3 g/dL, hematocrit 41.7% Intraoperative: Platelet: 89 10*9/L Fibribnogen: 223 mg/dL INR: 1.2 Immediately after surgery: Platelets: 5 10*9/L, hemoglobin: 3.2 g/dL, hematocrit: 10.1%
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: patient underwent L1-2 corpectomy, pedicle subtraction osteotomy, and extension of fusion from T4 to the pelvis two months after vaccination. During surgery patient became thrombocytopenic and required massive transfusion. Thirteen days after surgery found to have bilateral pulmonary embolisms and deep vein thromboses and placed on anticoagulation. Patient subsequently suffered cardiac arrest and was unable to be resuscitated.


VAERS ID: 1248554 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-15
Onset:2021-03-29
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiovascular disorder, Death, Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: AUTOPSY REPORT SHOWS HYPERTENSION AND CARDIOVASCULAR DISEASE
CDC Split Type:

Write-up: PATIENT RECEIVED THE VACCINE ON 3/15, HE PASSED AWAY ON 3/29


VAERS ID: 1248842 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-16
Onset:2021-04-22
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031821A / 2 OT / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Blood gases abnormal, Chest X-ray abnormal, Death, Electrocardiogram normal, Full blood count normal, Hypercapnia, Pulmonary congestion, Respiratory acidosis, Troponin normal
SMQs:, Cardiac failure (broad), Lactic acidosis (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   Days after onset: 1
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: coreg, bumex, gabapentin, glimeperide, hctz, protoni, citalopram, eliquiss, lamictal
Current Illness: none
Preexisting Conditions: dm-2, atrial fib, chf, gerd, dementia, pacemaker
Allergies: pcn
Diagnostic Lab Data: high sensitivity troponin was 10/10 with delta of 0 cxr mild pulmonary vascular congestion abg ph 7.29 pco2 89- improved to 7.34 and pco2 of 80 on repeat with improved mentation. o2 sats were 98% on abg initially on 2L oxygen(wears 2 L chronically) sats on bipap were 95% cmp was normal cbc normal except for stable baseline anemia
CDC Split Type:

Write-up: Pt received his 2nd moderna covid vaccine on 4/16/2021. admitted on 4/22/2021 from his long term care facility due to concerns for a chf exacerbation and acute on chronic respiratory failure. Pt was given IV Lasix. chest x ray showed mild pulm vascular congestion. there was no hypoxia, tachycardia and pt was on eliquis so pe was felt to not be a possibility. abg showed acute respiratory acidosis with hypercapnia which improved with bipap administration. His troponins and ekg were negative. vitals on arrival were stable. He was admitted. Labs were otherwise unremarkable. Pt began to have pauses on telemetry and was last seen awake and alert but when nursing staff went back to check on him minutes later he was found deceased


VAERS ID: 1249559 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: New Jersey  
Vaccinated:0000-00-00
Onset:2021-04-08
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Pulmonary embolism, Respiratory distress
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Lipid metabolism disorder NOS
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: respiratory distress; cardiac arrest; pulmonary emboliasm; This spontaneous case was reported by a consumer and describes the occurrence of RESPIRATORY DISTRESS (respiratory distress), CARDIAC ARREST (cardiac arrest) and PULMONARY EMBOLISM (pulmonary emboliasm) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Lipid metabolism disorder NOS. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 08-Apr-2021, the patient experienced RESPIRATORY DISTRESS (respiratory distress) (seriousness criterion death), CARDIAC ARREST (cardiac arrest) (seriousness criterion death) and PULMONARY EMBOLISM (pulmonary emboliasm) (seriousness criterion death). The patient died on 11-Apr-2021. It is unknown if an autopsy was performed. Not Provided For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. NO treatment or Concomitant medication were provided. Company Comment This is a case of sudden death in a 76-year-old female patient with a history of Lipid metabolism disorder, who died (date unknown) of respiratory distress, cardiac arrest and PULMONARY EMBOLISM after receiving first dose of vaccine. Very limited information has been provided at this time.


VAERS ID: 1249616 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Aorta problem
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: MY HUSBAND DIED WITHIN 24 HOURS OF RECEIVING THE VACCINE. I WANT TO CONFIRM THAT YOU KNOW ABOUT THIS. PLEASE CALL ME ON MY CELL PHONE , THANK YOU,


VAERS ID: 1249652 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Patient died in his sleep 2 days after receiving 1st dose; This spontaneous case was reported by a patient family member or friend and describes the occurrence of DEATH (Patient died in his sleep 2 days after receiving 1st dose) in an 84-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 011M20A) for COVID-19 vaccination. No Medical History information was reported. On 10-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) .5 milliliter. Death occurred on 12-Feb-2021 The patient died on 12-Feb-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Concomitant product use was not provided by the reporter. The patient''s wife went to wake him up but he was found dead in his sleep. She was hearing impaired and was not able to give any other information. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not applicable. This is a case of sudden death in a 84-year-old male, who died 2 days after receiving ffirst dose of vaccine. Very limited information has been provided at this time.; Sender''s Comments: This is a case of sudden death in a 84-year-old male, who died 2 days after receiving ffirst dose of vaccine. Very limited information has been provided at this time; Reported Cause(s) of Death: Patient died in his sleep 2 days after receiving 1st dose


VAERS ID: 1249681 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-09
Onset:2021-04-17
   Days after vaccination:39
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Feeling abnormal, Malaise
SMQs:, Dementia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
   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: Anticoagulant therapy ("Patient started on a blood thinner in January 2021"); Blood pressure abnormal ("Patient was on blood pressure medications for the last 20 years")
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Found dead; Felt crappy; Wasn''t feeling well; This spontaneous case was reported by a health care professional (subsequently medically confirmed) and describes the occurrence of DEATH (Found dead) in a 75-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 047B21A and 040A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Blood pressure abnormal ("Patient was on blood pressure medications for the last 20 years") and Anticoagulant therapy ("Patient started on a blood thinner in January 2021"). On 09-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 15-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 17-Apr-2021, the patient experienced FEELING ABNORMAL (Felt crappy) and MALAISE (Wasn''t feeling well). On 18-Apr-2021, FEELING ABNORMAL (Felt crappy) and MALAISE (Wasn''t feeling well) outcome was unknown. The patient died on 18-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Concomitant product use was not provided by the reporter. The patient was on blood pressure medications (unspecified) for the last 20 years. She was started on blood thinner (unspecified) in January 2021. Treatment information leading up to the patient''s death was not reported. Action taken with mRNA-1273 in response to the events was not applicable. A case of death of a 75-year-old, female patient 3 days after the second dose of mRNA-1273 (Lot # 040A21A). Patient had developed abnormal feeling and malaise 2 days after vaccine use and based on temporal association cannot be excluded. However, causality cannot be established for the death as cause of death is unknown. Further information is being requested.; Sender''s Comments: A case of death of a 75-year-old, female patient 3 days after the second dose of mRNA-1273 (Lot # 040A21A). Patient had developed abnormal feeling and malaise 2 days after vaccine use and based on temporal association cannot be excluded. However, causality cannot be established for the death as cause of death is unknown. Further information is being requested.; Reported Cause(s) of Death: Found dead


VAERS ID: 1249697 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Virginia  
Vaccinated:2021-04-09
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Intentional self-injury
SMQs:, Suicide/self-injury (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: passed away from self inflicted injury; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by an other health care professional (subsequently medically confirmed) and describes the occurrence of INTENTIONAL SELF-INJURY (passed away from self inflicted injury) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event. On 09-Apr-2021, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced INTENTIONAL SELF-INJURY (passed away from self inflicted injury) (seriousness criterion death). The patient died on 18-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Concomitant product use was not provided by the reporter. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. Reporter did not allow further contact; Sender''s Comments: Patient died of an unknown cause from a self-inflicted injury nine days after receiving second dose of Moderna Vaccine. Very limited information regarding this event has been provided at this time. Further information can not be requested.; Reported Cause(s) of Death: cause of death unknown


VAERS ID: 1249748 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-01-23
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Death, Dyspnoea, Headache, Hypertension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 38
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: High blood pressure
Allergies:
Diagnostic Lab Data: Unknown. Please contact her doctor
CDC Split Type:

Write-up: At first my mother had a headache. Then My mother was feeling weak and could not breathe. She continued to suffer so went to the doctor to get a check up but continued to suffer and finally died on 2/8/21 due to a couple of reasons which include hypertension


VAERS ID: 1254024 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Michigan  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Completed suicide, Tinnitus
SMQs:, Suicide/self-injury (narrow), Hearing impairment (narrow)

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

Write-up: committed suicide; ringing in his ears; This spontaneous case was reported by a consumer and describes the occurrence of COMPLETED SUICIDE (committed suicide) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced COMPLETED SUICIDE (committed suicide) (seriousness criterion death) and TINNITUS (ringing in his ears). The patient died on an unknown date. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, TINNITUS (ringing in his ears) outcome was unknown. Concomitant medications were not reported; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1254028 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Pennsylvania  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Hypotension, Thrombosis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATXINC.MOD2021083

Write-up: Patient passed away; patient had blood clots in his brain/ Legs/ Lungs/ Arms; Severe hypotension; This spontaneous case was reported by a physician (subsequently medically confirmed) and describes the occurrence of DEATH (Patient passed away), THROMBOSIS (patient had blood clots in his brain/ Legs/ Lungs/ Arms) and HYPOTENSION (Severe hypotension) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included No adverse event. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced DEATH (Patient passed away) (seriousness criterion death), THROMBOSIS (patient had blood clots in his brain/ Legs/ Lungs/ Arms) (seriousness criterion death) and HYPOTENSION (Severe hypotension) (seriousness criterion death). The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Treatment information was not provided. Company comment: This case concerns the death of a patient of unknown age and gender after administration of mrna-1273 ()LOT UNKNOWN). Very limited information regarding this event/s has been provided at this time. Further information has been requested. Critical details such as the mRNA-1273 date of administration, onset of any signs an d symptoms, and date of death is lacking.; Sender''s Comments: This case concerns the death of a patient of unknown age and gender after administration of mrna-1273 ()LOT UNKNOWN) . Very limited information regarding this event/s has been provided at this time. Further information has been requested. Critical details such as the mRNA-1273 date of administration, onset of any signs an d symptoms, and date of death is lacking.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1256000 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-12
Onset:2021-03-20
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA G38A21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Death, Diarrhoea, Fatigue, Haemoptysis, Pallor, Rectal haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cardedilol, Enestro, Cartia, Elquis, Asprin, Flower, Ameprazole, Latanopost, Calcuim, Vitamin D, Furosomide
Current Illness:
Preexisting Conditions: Asthma, A-Fib
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pallor, Fatigue, loss of vitality, diarrhea, profuse rectal bleeding, coughing up blood, death 25 days after vaccine


VAERS ID: 1256666 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-31
Onset:2021-04-01
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 1 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Dizziness, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: several, would need to get more info
Current Illness:
Preexisting Conditions: diabetes, asthma
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient started complaining of being short of breath, weak and dizzy a day or two after receiving the shot. He started taking the asthma inhaler constantly rather than just once in months. He lay down for a nap and never woke up exactly 3 weeks after getting the shot. (more exact details will need to come from his wife).


VAERS ID: 1256806 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-25
Onset:2021-04-10
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bystolic Quinapril Chlortalidone Atorvastatin Fenofibrate
Current Illness:
Preexisting Conditions: HTN, DM
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: My Sister was found dead on 4/27/2021. She had been dead aprx. 0ne week. She received her 1st Moderna shot on March 25th.


VAERS ID: 1257062 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-04-16
Onset:2021-04-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Aspartate aminotransferase increased, Blood triglycerides increased, CD25 antigen positive, Computerised tomogram abdomen abnormal, Computerised tomogram pelvis abnormal, Death, Diarrhoea, Hepatosplenomegaly, Pyrexia, Serum ferritin increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Tumour markers (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Lipodystrophy (broad), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone 10 mg, mycophenolate 360 mg BID, betalacept, sodium bicarbonate 1300 mg BID, magnesium oxide 400 mg daily, carvedilol 25 mg BID, atorvastatin, clindamycin 150 mg daily
Current Illness: ESRD s/p renal transplant, hypertension, relapsing cellulitis
Preexisting Conditions: ESRD s/p renal transplant, hypertension, relapsing cellulitis
Allergies:
Diagnostic Lab Data: Ferritin: $g15000 CD25: 9908 CT Abdomen/Pelvis with hepatosplenomegaly Triglycerides 326 AST 54
CDC Split Type:

Write-up: The patient developed high fevers, profound watery diarrhea up to 13L/day, requiring IV administration of replacement fluids. He ultimately developed ARDS and succumbed to this illness.


VAERS ID: 1257197 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-03-27
Onset:2021-04-04
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 310M20A / UNK UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / UNK UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: insulin, lithium and maybe blood pressure medicine
Current Illness: upper respiratory infection
Preexisting Conditions: diabetes, bipolar disorder, frequent upper respiratory infections, possibly high blood pressure
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient died sometime between Sunday evening, April 4 and Monday morning, April 5. I looked at the browser history in her cellphone and on the night of April 4, she googled "Heart attack symptoms in women" and "Moderna vaccination side effects." I think she didn''t go to the doctor because she figured her symptoms were related to her vaccine -- even though it had been a week. I wanted to report her death because I don''t trust her doctor to do it. It took him two weeks and a call from me to complain before he signed her death certificate. He listed April 9, 2021 as the official date of death because that''s when she was found, even though the deputy coroner told me she died on either the 4th or the 5th.


VAERS ID: 1257204 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-03-03
Onset:2021-03-23
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Gait disturbance, Internal haemorrhage, Multiple organ dysfunction syndrome, Pain, Peripheral embolism, Pulmonary embolism, Resuscitation, Transfusion
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (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), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Birth Control pills
Current Illness:
Preexisting Conditions: obesity
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient began experiencing pain and difficulty walking on Tuesday, March 23. Later that afternoon she was taken to an Urgent care, who sent her to the ER for evaluation. She was diagnosed with a very large blood clot in her leg, spanning from just above the knee to her groin area. They admitted her and began treating her with blood thinners. While undergoing that treatment, her heart stopped 3 times and she had to be resuscitated. They discovered a pulmonary embolism. While removing a large clot from her lungs, the doctor found that her lungs were riddled with hundreds of tiny blood clots. They also said that she was bleeding internally, very heavily, from an unknown location. In all, they gave her 20 units of blood, and none of it stayed in her veins. The doctor said it seemed to just disintegrate. At that point, her brain and organs had begun shutting down and family made the decision to remove her from life support. She passed away Thursday evening, March 25, 2021.


VAERS ID: 1257832 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-25
Onset:2021-04-14
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Mental status changes, SARS-CoV-2 test positive
SMQs:, Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: epilepsy, history of traumatic brain injury status post craniotomy, nonverbal at baseline, persistent atrial fibrillation, hypertension, hyperlipidemia, asthma,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalized +Covid post vaccination with decreased mental status


VAERS ID: 1258054 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-19
Onset:2021-03-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 11
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stroke, hospitalized 5 days, sent to skilled care (nursing home), death 2 weeks after stroke


VAERS ID: 1258236 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-04-20
Onset:2021-04-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood glucose, Chest X-ray abnormal, Death, Depressed level of consciousness, Dysphagia, Full blood count, Hemiparesis, Metabolic function test, Pneumonia, Unresponsive to stimuli, Urine analysis, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), 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 (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (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: 2021-04-22
   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: pro stat awc, med pass supplement, Synthroid, neurotin, Metoprolol, Digoxin, Plavix, Cozaar, Mobic, Preservision AREDS, Biotene, Dilantin, Systane balance eye drops, sodium chloride tabs, vitamin D3, lactulose, Tylenol, Norco prn, morphine
Current Illness: Resident had diagonisis of DM type 2, diabetic neropathy, HTN, Hypothyroidism, vit d deficiency, chronic a fib, seizure disorder, metabolic encephalopathy, hyponatremia, macular degeneration, dry mouth, sepsis, hx of PNA, and hx of UTI. The day after vaccine she was diagnosed with PNA.
Preexisting Conditions: Resident was on Hospice. See diagnosis above. The day before she expired she was diagnosed with PNA.
Allergies: Keflex and Penicillin
Diagnostic Lab Data: Resident had a cbc, bmp, chest xray, u/a, and CBG on 4/21/21
CDC Split Type:

Write-up: resident was hospice she was afebrile day of vaccine on 4/20. on am of 4/21/21 0600 nurse stated no c/o of pain or discomfort. Resp were even and unlabored. That morning at 1145 charge nurse stated she was extremely hard to rouse. Vs were ok. SHe had some weakness in right side. they notified hospice. She had labs done. She was diagnosed with PNA and started on Abt. That night she was unresponsive to verbal commands and couldn''t get po med. she received gentamicin im. on 4/22/21 charted she was vommiting small amount. She expired late that night. MD doesn''t believe the vaccine caused the death, but thinks it has the potential.


VAERS ID: 1258269 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-04-01
Onset:2021-04-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, Diarrhoea, Dyspnoea, Hypoxia, Nausea, Respiratory failure, SARS-CoV-2 test positive, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   Days after onset: 22
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: trulicity, pravastatin, multivitamin, vitamin D, vitamin B complex, cymbalta, losartan, famotidine, admelog, proair
Current Illness: none
Preexisting Conditions: Insulin-dependent diabetes, morbidly obese, knee OA, cervical dysplasia, asthma, HTN, CKD stage 4, glaucoma, daibetic retinopathy
Allergies: lyrica (hives), lisinopril (cough)
Diagnostic Lab Data: Initially evaluated and admitted, then transferred to hospital
CDC Split Type:

Write-up: This pt came in to see me in her normal state of health and then received moderna #1 here on 4/1. Developed SOB 2 hrs after vaccination. Presented to ER on 4/2 with hypoxia (80%) and was + for covid. The ER triage notes states ?C/O SOB, Nausea, vomiting, diarrhea that started yesterday 2 hours after he first COVID Vaccine?. Notes quote her saying ?I got my vaccine yesterday and I started to feel short of breath.? She died from covid respiratory failure on 4/23.


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