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

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

Government Disclaimer on use of this data



Case Details

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VAERS ID: 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.


VAERS ID: 1258483 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-23
Onset:2021-04-04
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Subdural haematoma
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Accidents and injuries (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, Omeprazole, Testosterone
Current Illness: AHSD
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 4/4/2021 from subdural hematoma


VAERS ID: 1258524 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-01
Onset:2021-03-19
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away in between dose 1 and 2. Cause unknown.


VAERS ID: 1258858 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-31
Onset:2021-04-22
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 RA / IM
VARZOS: ZOSTER (SHINGRIX) / GLAXOSMITHKLINE BIOLOGICALS 94B7F / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died on 4/22/21. Vaccinated with 2nd dose of Moderna on 3/31/21. Vaccinated with Shingrix on 4/15/21.


VAERS ID: 1259240 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-28
Onset:2021-04-13
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   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: TRULICITY,DOXAZOSIN,ESCITALOPRAM,LEVOTHYROXINE,CARVEDILOL,TRAMADOL, VITAMIN D3, MULTIVITAMIN, HUMULIN, FENOFIBRATE, FLUTICASONE PROPIONATE, LOW DOSE ASA, ZYRTEC, ONDANSETRON, OMEGA 3-6-9, ALDACTONE, OMEPRAZOLE, IRBESARTAN, FUROSEMID
Current Illness:
Preexisting Conditions: TYPE 2 DM, CHRONIC KIDNEY DISEASE, SLEEP APNEA, HYPOTHRYOIDISM, HYPERLIPIDEMIA, VITAMIN D DEFICIENCY,
Allergies: NORVASC - EDEMA, LIPITOR
Diagnostic Lab Data: UNKNOWN ONLY REPORTED BY FAMILY
CDC Split Type:

Write-up: PATIENT DID NOT SHOW FOR SECOND DOSE OF VACCINE WHEN CALLED WE WERE TOLD BY HIS WIFE THAT HE HAD A HEARTATTACK AND PASSED AWAY ON 04/13/2021


VAERS ID: 1259351 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-24
Onset:2021-04-01
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 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: 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 84 year old male was a hospice patient and received the Covid shot on 2/24/21 . The patient died on 4/1/21. 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: 1259763 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-29
Onset:2021-04-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Death, Dyspepsia, Fatigue, Headache, Myocardial infarction, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: High cholesterol
Allergies: none
Diagnostic Lab Data: I don''t have anything
CDC Split Type:

Write-up: Fever, chills, headache, and tiredness (2nd day of receiving the 2nd dose) Feeling good on the 3rd day Headache, stomach burn, throwing up, and heart attack (4th day of receiving the 2nd dose) Passed away on April 2, 2021


VAERS ID: 1260018 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-04-23
Onset:2021-04-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Was sweaty, unresponsive, and breathing shallow a few mins after administration. BP 97/68. Within a few mins, patient became responsive and BP 146/81. Patient chose not to go with EMS and walked out of store after they were feeling better. Today (3 days later) received report from medical examiner that patient passed away.


VAERS ID: 1260747 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 AR / SYR

Administered by: Other       Purchased by: ?
Symptoms: Angioplasty, Death, Dialysis, Fatigue, Fistulogram, Injection site pain, Peripheral swelling, SARS-CoV-2 test
SMQs:, Acute renal failure (narrow), Cardiac failure (broad), Angioedema (broad), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 5
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: Dialysis patient receiving treatment 3 times per week and took various medications due to her illness. She was also a diabetic and had high blood pressure and took medication for it.
Current Illness: She had kidney disease and received dialysis treatment 3 times per week. She also had muscle weakness, pain in her leg and back, and often need pain management services.
Preexisting Conditions: She had kidney disease and received dialysis treatment 3 times per week. She also had muscle weakness, pain in her leg and back, and often need pain management services. She was a diabetic and had high blood pressure and took medication for it.
Allergies: Penicillin
Diagnostic Lab Data: None that we know off
CDC Split Type:

Write-up: Patient received notice of her vaccination appoint shortly before her AV Fistulogram, with angioplasty surgery on Tues, 2/2/21. She was nervous about getting the vaccine just days prior to her scheduled surgery. We called her primary doctor and was told to contact the surgeon. After multiple attempts to reach the surgeon and speaking with hospital staff, assuring us it was fine to get the vaccine prior to surgery. I still wanted to confirm with the surgeon and was finally able to speak to him. He assured me and to inform patient that it was fine to get the vaccine prior to surgery. On Sat, 1/30/21, patient received her Covid-19 Moderna vaccine. On Sun, 1/31/21, she got a covid-19 test to prepare for her surgery on Tues, 2/2/21. Her vaccine injection site was sore and she was tired, so she rested and took naps. On Mon, 2/1/21, she went to dialysis as usual. On Tues, 2/2/21, she had her surgery in morning. On Wed, 2/3/21, her dialysis facility could not perform treatment due to swelling of her arm. On 2/4/21 she rested, her arm still bothering her but had been assured to rest. On Fri 2/5/21, she went for her usual dialysis treatment but the facility was not able to perform dialysis and shortly after starting treatment, the facility called 911 to take patient to the hospital. Patient died with the next few hours without her family at her side.


VAERS ID: 1261483 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-28
Onset:2021-01-02
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Herpes zoster
SMQs:, Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 42
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: VALTREX
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: Diagnosed with shingles; passed away suddenly; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (passed away suddenly) and HERPES ZOSTER (Diagnosed with shingles) in a 75-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 (No reported medical history). Concomitant products included VALACICLOVIR HYDROCHLORIDE (VALTREX) for an unknown indication. On 28-Dec-2020 at 3:30 PM, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 02-Jan-2021, the patient experienced HERPES ZOSTER (Diagnosed with shingles) (seriousness criterion hospitalization). The patient died on 13-Feb-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, HERPES ZOSTER (Diagnosed with shingles) outcome was unknown. Treatment included antiviral medication valtrex 1 mg. The action taken with mRNA-1273 with events was not applicable. Cause of death was unknown. Plans for an autopsy were not provided. This case concerns a 75-year-old, male patient, who experienced herpes zoster 5 days after and died 1 month 15 days after receiving the first dose of mRNA-1273. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. The cause of death was not reported. It is unknown if an autopsy was performed. Most recent FOLLOW-UP information incorporated above includes: On 11-Apr-2021: Follow-up included fatal event.; Sender''s Comments: This case concerns a 75-year-old, male patient, who experienced herpes zoster 5 days after and died 1 month 15 days after receiving the first dose of mRNA-1273. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. 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: 1261526 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-03-24
Onset:2021-03-29
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Blood creatine, Cardiac failure, Glomerular filtration rate, Haemoglobin, Hypotension, Liver function test, Renal failure, SARS-CoV-2 test, Troponin, Troponin increased, Type 2 diabetes mellitus, White blood cell count
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (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), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Multi organ failure (Kidneys and liver are VERY messed up showing multi-organ failure.); Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: creatine; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: GFR; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: GFR; Test Result: Inconclusive ; Result Unstructured Data: 5.0; Test Name: hemoglobin; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: Liver lft; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: covid test; Test Result: Negative ; Result Unstructured Data: Negative; Test Name: Covid test; Test Result: Negative ; Result Unstructured Data: Negative; Test Name: TROPONIN; Test Result: Inconclusive ; Result Unstructured Data: 14.0; Test Name: triponin; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: wbc; Result Unstructured Data: normal (in range)
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Type 2 Diabetes; Hypotension; heart started to drop; Renal failure; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 20-Apr-2021 and was forwarded to Moderna on 20-Apr-2021. This spontaneous case was reported by a patient family member or friend (subsequently medically confirmed) and describes the occurrence of CARDIAC FAILURE (heart started to drop), RENAL FAILURE (Renal failure), TYPE 2 DIABETES MELLITUS (Type 2 Diabetes) and HYPOTENSION (Hypotension) in a 69-year-old patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Multi organ failure (Kidneys and liver are VERY messed up showing multi-organ failure.) and Type 2 diabetes mellitus. On 24-Mar-2021, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 29-Mar-2021, the patient experienced CARDIAC FAILURE (heart started to drop) (seriousness criteria death and medically significant) and RENAL FAILURE (Renal failure) (seriousness criteria death and medically significant). On an unknown date, the patient experienced TYPE 2 DIABETES MELLITUS (Type 2 Diabetes) (seriousness criterion death) and HYPOTENSION (Hypotension) (seriousness criterion death). The patient died on 29-Mar-2021. The reported cause of death was Renal failure, type 2 diabetes, Hypotension and heart started to drop. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Blood creatine: 9.93 (Inconclusive) Inconclusive. On an unknown date, Glomerular filtration rate: 5 (Inconclusive) Inconclusive and 5.0 (Inconclusive) 5.0. On an unknown date, Haemoglobin: 7 (Inconclusive) Inconclusive. On an unknown date, Liver function test: 500 (Inconclusive) Inconclusive. On an unknown date, SARS-CoV-2 test: negative (Negative) Negative and negative (Negative) Negative. On an unknown date, Troponin: 14 (Inconclusive) 14.0. On an unknown date, Troponin increased: 500 (Inconclusive) Inconclusive. On an unknown date, White blood cell count: normal (normal) normal (in range). The action taken with mRNA-1273 in response to the event was not applicable. He was feeling unwell. He had vomited prior and felt sick. His blood sugar was 136 or 139, nothing bad. Treatment details included antibiotics going into him, sleeping meds, meds to rise his blood pressure,Dextrose, Propofol, Dexmedtominine. Company comment: This is a 69-year-old, patient of unknown gender who received mRNA-1273 Vaccine who experienced cardiac failure and died, 6 days after receiving second dose of vaccine. Medical history includes Type 2 diabetes mellitus and Multi organ failure. No conmeds were provided. Very limited information has been reported at this time. No further information is expected.; Sender''s Comments: This is a 69-year-old, patient of unknown gender who received mRNA-1273 Vaccine who experienced cardiac failure and died, 6 days after receiving second dose of vaccine. Medical history includes Type 2 diabetes mellitus and Multi organ failure. No conmeds were provided. Very limited information has been reported at this time. No further information is expected.; Reported Cause(s) of Death: renal failure; type 2 diabetes; hypotension; heart started to drop


VAERS ID: 1261766 (history)  
Form: Version 2.0  
Age: 1.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-04-08
Onset:2021-04-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature increased, Death, Seizure
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: increased body temperature, seizure, death


VAERS ID: 1262218 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-20
Onset:2021-01-24
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute hepatic failure, Alanine aminotransferase increased, Aspartate aminotransferase increased, Biopsy bone marrow normal, Blood alkaline phosphatase increased, Blood bilirubin increased, Death, Fatigue, Fibrin D dimer increased, Haemoglobin decreased, Haemophagocytic lymphohistiocytosis, Hyperferritinaemia, Platelet count decreased, Pneumonia legionella, Pruritus, Serum ferritin increased, Sleep disorder, T-lymphocyte count increased, Transaminases increased
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Biliary system related investigations, signs and symptoms (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 50
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol Flecainide Vitamin D3 Folic acid Magnesium oxide Omeprazole Pentamidine IV monthly Valacyclovir Diltiazem Melatonin Decitabine
Current Illness:
Preexisting Conditions: AML, post matched-unrelated donor HCT on 2/10/2020 Atrial fibrillation Aortic stenosis Hypertension GERD Prior embolic CVA
Allergies: Iodinated contrast
Diagnostic Lab Data: Ferritin (2/26): 30,450 IL2ra (2/26): 3,003.1 ALT (2/25): 2,168 AST (2/25): 1,114 TBili (2/25): 2.4 Hgb (2/25): 9.6 Platelet (2/25): 21 D-dimer (2/26): 0.63
CDC Split Type:

Write-up: Pt received dose #1 of Moderna on 1/20/2021 at clinic. On 1/24/2021, developed self reported fatigue and sleep disturbances with pruritis. Sought no medical care. Routine labs were obtained on 2/23 which demonstrated new-onset transaminitis and hyperferritinemia (ALT 2366, AST 1260, alk phos 362, ferritin 32,000) and was admitted to hospital for evaluation. No etiology for acute liver failure identified, including comprehensive evaluation for viral hepatitis and other common causes of hepatitis common after transplant. Concern raised for hemophagocytic lymphohistiocytosis (HLH) due to extreme hyperferritinemia, although bone marrow biopsy negative. Ultimately transferred to another hospital for further care at patient''s request. No specific treatment was given and transaminitis ultimately resolved. Soluble IL-2 receptor (CD25) level checked on 3/2, at time of admission, markedly elevated at 2338.6, consistent with diagnosis of HLH. Pt discharged on 3/5. Ultimately readmitted on 3/9 and found to have rapidly progressive Legionella pneumonia and died on 3/16. Two events felt to be unrelated and pneumonia not felt to be cause of HLH due to patient''s status at time of initial admission.


VAERS ID: 1262319 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-04-23
Onset:2021-04-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: hydralazine Hall Tablet 50 MG, Vitamin C-Rose Hips Tablet 500 MG, Aspirin Tablet Chewable 81 MG, Acetaminophen Tablet 500 MG, Ipratropium-Albuterol Solution 0.5-2.5, Pantoprazole Sodium Tablet Delayed Release 40 MG, Isosorbide Dinitrate Tab
Current Illness: pneumonia, acute pulmonary edema, acute respiratory failure with hypoxia,
Preexisting Conditions: congestive heart failure, chronic respiratory failure with hypoxia, COPD, Cerebral Infarction, sleep apnea, GERD,
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per Review of Charge Nurses Notes. Please see Below Called in to residents room by CNA, resident without respirations or pulse, resident placed on floor and CPR initiated at 0725, EMSA notified and called time of death at 0751. Specialists on call for Dr. notified. daughter notified. cremation services notified.


VAERS ID: 1262349 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-04-05
Onset:2021-04-27
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Fibrin D dimer increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt came in with positive D-dimer, coded and passed


VAERS ID: 1262410 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: New York  
Vaccinated:2021-04-01
Onset:2021-04-08
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Death, Myocardial infarction, Stent placement
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 2
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: Gout
Allergies: None
Diagnostic Lab Data: Blood work, stents, pump device, meds
CDC Split Type:

Write-up: Heart Attack 2 days after 2nd dose of moderna vaccine - followed by death


VAERS ID: 1262415 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Chest X-ray, Chills, Death, Dysstasia, Electrocardiogram, Muscular weakness, SARS-CoV-2 test, Skull X-ray, Syncope, Urine analysis
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol PRN; cholesterol medication, Blood pressure medication
Current Illness: denied
Preexisting Conditions: MDS, high cholesterol, high blood pressure.
Allergies: no known allergies
Diagnostic Lab Data: 3/31/2021: CXR; head x-ray, bloodwork, urine test, COVID-19 test, EKG
CDC Split Type:

Write-up: Information obtained from clients wife. patient received his first dose of Moderna 2/24/21 lot 024M20A with no reported issues except for a sore arm. patient received his second dose of Moderna on 3/24/21; Lot# 006B21A. No immediate effects from the vaccine. On day 2 post vaccination, patient became to have chills, per wife; did not check temperature and denied any symptoms such as flu-like symptoms. Day 3 post vaccination; patient began to have weakness in the legs. March 31st; patient was unable to stand and the rescue squad was called. patient was taken to the Hospital; where he was evaluated and released home. Pt collapsed at 1am 4/1/2021 and died 4/1/21.


VAERS ID: 1262580 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-26
Onset:2021-04-12
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B218 / 1 LA / SYR

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

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

Write-up: Patient died on April 12th 2021. Not sure exactly what the cause of death but that he was losing blood in in his somewhere. He resided in a nursing home, and was taken to the hospital where he later died


VAERS ID: 1263591 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-09
Onset:2021-04-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   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: Fluoxetine, Gabapentin, Lorazepam, Losartan, Pantoprazole, Crestor
Current Illness: Hypertension, Hyperlipidemia, Chronic back pain
Preexisting Conditions: HTN, CHronic back pain
Allergies: PCN
Diagnostic Lab Data:
CDC Split Type:

Write-up: Within 12 hours of vaccine patient complained of being short of breath and asked his wife to call 911, he then stopped breathing and she did CPR until rescue squad arrived. Pt was unable to be revived and died.


VAERS ID: 1263713 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-03
Onset:2021-03-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Encephalopathy, Feeling cold, Haemorrhage intracranial
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 28
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HTN, ESRD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 3/30/2021 Patient received 1st dose of Moderna vaccine at 11:35AM and subsequently discontinued dialysis treatment 58 minutes early due to being cold. 3/31/2021 Patient went to hospital at 2:28PM with admitting diagnosis of acute encephalopathy due to intra-cranial hemorrhage. 4/1/2021 Patient expired at 3:35AM with cause of death reported as intra-cranial hemorrhage.


VAERS ID: 1263989 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-04-13
Onset:2021-04-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood calcium decreased, Blood creatinine normal, Blood glucose increased, Blood thyroid stimulating hormone decreased, Blood urea normal, Carbon dioxide decreased, Cardiac arrest, Death, Depressed level of consciousness, Diabetic ketoacidosis, Dyspepsia, Full blood count normal, Glycosylated haemoglobin increased, Nausea, Resuscitation, Thyroxine free normal, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypothyroidism (broad), Hyperthyroidism (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Synjardy XR 12.5mg/1000mg bid, Levothyroxine 0.112mg, Trulicity 3mg weekly, Prolia 60mg every 6 mos., Rosuvastatin 10mg, CoQ10, Calcium, MVI, Vitamin D, omeprazole 20mg, Vitamin C, rizatriptan prn, potassium ER 20mEq, probiotic
Current Illness: Diabetes Osteoporosis Hypothyroid Hypokalemia Hyperlipidemia, GERD
Preexisting Conditions: Diabetes Osteoporosis Hypothyroidism
Allergies: none
Diagnostic Lab Data: 3/22/21 A1c 8.8, glucose 127, serum Co2 18, Ca 8.6, Cr 0.58, BUN 17, cbc unremarkable, TSH 0.81, free T4 1.8
CDC Split Type:

Write-up: Nausea, vomiting, burning in stomach, high blood sugars- symptoms started the day after the vaccine. Found obtunded 3 days after vaccine given. 911 called in route to the hospital had a cardiac arrest, resuscitated, arrested again and resuscitated. Upon admission to the hospital diagnosed with diabetic ketoacidosis and died the next day- 4 days after the vaccine was administered


VAERS ID: 1264003 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-04-12
Onset:2021-04-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 1 RA / IM

Administered by: Work       Purchased by: ?
Symptoms: Apnoea, Cardiac arrest, Death, Endotracheal intubation, Pulse absent, Pulseless electrical activity, Resuscitation, Unresponsive to stimuli, Ventricular tachycardia
SMQs:, Torsade de pointes/QT prolongation (narrow), Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Diclofenac gel Gabapentin Glipizide Humalog Hydrochlorothiazide Jardiance Lantus Lasix Lidoderm patch Metformin Novolog Protonix Simvastatin Victoza Vitamin D
Current Illness: Hospitalized, discharge 3/26 DX: Acute kidney injury, chronic respiratory failure, on home oxygen, malignant neoplasm of breast, HTN, Neuropaty, Hyperlipidemia, Diabetes, Anemia, Vitamin D Deficiency
Preexisting Conditions: chronic respiratory failure, on home oxygen, malignant neoplasm of breast, HTN, Neuropaty, Hyperlipidemia, Diabetes, Anemia, Vitamin D Deficiency, Renal Osteodystrophy
Allergies: Peaches
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received 1st COVID vaccine 4/12/2021 at medical center. Per ER report: 4/14/2021 patient was in bed with significant other and was noted to not be responding. EMS was called. Patient was found without a pulse and apneic. CPR began, PEA converted to Vtach, received 8 total epi and 1.5gm lidocaine by EMS. Down 50-55 minutes prior to ER. In ER given 2 additional epi, 2 sodium bicarb, intubated and was PEA then asystole. Pronounced deceased in ER.


VAERS ID: 1264171 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-03-10
Onset:2021-04-07
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

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

Write-up: Pt Deceased prior to dose 2. Reported by home health agency as unrelated to vaccination.


VAERS ID: 1264244 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-25
Onset:2021-03-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chronic obstructive pulmonary disease, Condition aggravated, Death, Hypertension, Type 2 diabetes mellitus
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: COPD, DM Type 2, Hypertension
Preexisting Conditions: See Above
Allergies: none
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Expired in between Dose 1 and 2. Non-vaccine related. Death Certificate indicates, COPD, Type 2 Diabetes & hypertension


VAERS ID: 1264528 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-03-02
Onset:2021-03-19
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041LAUA / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Cough, Death, Dyspnoea, Muscle spasms, Pulmonary embolism
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: OTC allergy medications
Current Illness: None that I''m aware of
Preexisting Conditions: I don''t know her full health history.
Allergies: Some shellfish
Diagnostic Lab Data: Dr. will have her tests and results from her March 19th ER visit. The form is not allowing me to enter her date of death. It was March 19th.
CDC Split Type:

Write-up: My mom was very ill with fever like symptoms following her first vaccination on January 26th. The symptoms were even worse after her second vaccination March 2nd and included muscle cramping in her legs. Once she was recovered she only had a persistent cough which she attributed to allergies as the pollen count had been high. In the early morning hours of March 19th she was having difficulty breathing and chest pains. She was rushed to the emergency room where she subsequently died of cardio pulmonary embolism which the coroner indicated began within three weeks of her death.


VAERS ID: 1264618 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-04-21
Onset:2021-04-26
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B212A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   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: Insulin, Levemir, robinirole seroquel, xanax, gabapentin, oxycodone
Current Illness: Diabetes mellitus, hypertensive and atherosclerotic cardiovascular disease.
Preexisting Conditions: Diabetes mellitus, hypertensive and atherosclerotic cardiovascular disease.
Allergies:
Diagnostic Lab Data: Autopsy results pending
CDC Split Type:

Write-up: 103 fever 2 days after the vaccine. Then became afebrile. Then found deceased on 4-26-2021


VAERS ID: 1264707 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-25
Onset:2021-04-17
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   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:
Current Illness: Cirrhosis of liver
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: death; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of DEATH (death) in a 65-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Cirrhosis of liver. On 25-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 17-Apr-2021 The patient died on 17-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded. It is not clear if the patient was hospitalized at the time of their death, only that they died in hospital; Sender''s Comments: Limited information regarding the patient''s death has been provided at this time and a causal relationship cannot be excluded. It is not clear if the patient was hospitalized at the time of their death, only that they died in hospital; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1294857 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-12
Onset:2021-02-17
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M2CA / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Budesonide,Clopidogrel,Prednisone,Propranolol, Atorvastatin,...
Current Illness: None
Preexisting Conditions: Interstitial Lung Disease Pulmonary Fibrosis
Allergies: Aspirin, Morphine Sulfate, Nsaids, Penicillins, Latex, Lactose
Diagnostic Lab Data: No medical tests, labs, or autopsy was done because we thought patient died of natural causes. After giving it some thought, we wondered if there might be a connection to her death.
CDC Split Type:

Write-up: Five days after receiving the Covid-19 vaccine, patient suddenly began having trouble breathing. We called 911 right away but, by the time EMS arrived, she was unconscious and didn''t appear to be breathing. Patient was not sick at the time this occurred but she was hospitalized in December of 2019 and was diagnosed with pulmonary fibrosis and pulmonary hypertension which required her to go home with and continue on supplemental oxygen. However, she never experienced pulmonary distress after coming home and her SPO2 levels consistently ranged between 96 and 99% with supplemental oxygen. Patient''s death was very sudden and unexpected.


VAERS ID: 1266427 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-19
Onset:2021-02-23
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   Days after onset: 43
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to the ED and was subsequently hospitalized twice within 6 weeks of receiving COVID vaccination. First visit was 2/23/2021 and second visit was 3/14/2021. Patient died on 4/8/2021


VAERS ID: 1266493 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-04-26
Onset:2021-04-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: COPD- wearing oxygen at the time of vaccination
Allergies: NKA
Diagnostic Lab Data: Na
CDC Split Type:

Write-up: Family friend of the wife, called our pharmacy on 04/28/2021 and reported that wife''s appointment would need to be canceled for 04/29/2021 because her spouse passed away the previous night. This prompted our staff to look further and it was noted that her spouse, received his first Moderna vaccine on 4/26/2021 at our pharmacy. Friend was not reporting his death due to the belief that the injection was the cause. Only to report, so upcoming appointment for his wife could be canceled. It was reported to our Medical staff that Patient n has Chronic COPD and had difficulty breathing on the evening of 4/27/2021 and was taken to the hospital where he later passed away. Patient was on portable oxygen and resembled shortness of breath while ambulating at the time of his vaccination appointment on 4/26/2021. Patient immediately recovered from Shortness of Breath once seated in exam room for injection for a few minutes.


VAERS ID: 1266609 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-16
Onset:2021-04-24
   Days after vaccination:67
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MODERNA / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1266821 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-04-23
Onset:2021-04-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Past medical history: Vestibular schwannoma. Cerebellopontine angle tumor. Multiple meningioma. Neurofibromatosis. Cancer of the Breast [Z85.3], left breast-diagnosed 8/2018. Compression of brain stem. Anxiety disorder, generalized [F41.1]. Anemia [D64.9]. Depression. Arthritis [Z87.39],
Allergies: Pollen Extracts- confusion. Sulfamethoxazole- confusion. Cephalexin- hives. Ciprofloxacin- nausea and vomiting. Clindamycin- nausea and vomiting. Grass Pollen. Iron- nausea and vomiting. Latex- rash. Tape Adhesive- rash. Sulfonamide Antibiotics- nausea and vomiting.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was seen in Family Medicine on 4/23/2021. Was given her first Moderna vaccine that day. On-call doctor received phone call on 4/24/2021 that pt had expired. Death certificate states cause of death: seizure due to possible complication of COVID 19 vaccine. Conditions if any, leading to immediate cause: cerebellopontine angle tumor of brain


VAERS ID: 1267074 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-03
Onset:2021-04-26
   Days after vaccination:82
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Angiogram pulmonary normal, Atelectasis, COVID-19, Chest X-ray normal, Chest pain, Computerised tomogram thorax abnormal, Death, Electrocardiogram ST segment elevation, Electrocardiogram T wave inversion, Fibrin D dimer increased, General symptom, Pulmonary mass, Resuscitation, SARS-CoV-2 antibody test negative, SARS-CoV-2 test positive, Troponin normal
SMQs:, Haemorrhage laboratory terms (broad), Myocardial infarction (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Other ischaemic heart disease (broad), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: none
Current Illness: none stated
Preexisting Conditions: no significant past medical history / no home meds
Allergies: intolerance to percocet - nausea / vomiting
Diagnostic Lab Data: 4-26-21 CXR - no acute process 4-26-21 CTAP no contrast: no acute process 4-26-21 CT chest no contrast: bibasilar atelectasis and 8mm upper lobe nodule in R lung ECG 4-26-21 ST elevation in v2, with t wave inversion on v5 and v6 4-26-21 - rapid sarscov2 test - detected 4-26-21 sars covd 2-igg negative 4-26-21 - ddimer 2190
CDC Split Type:

Write-up: #1 = 011J20A on 1-6-21 #2 = 028L20A on 2-3-21 patient presented after sudden onset of chest pain early in morning and found to be covid +. ECG demonstrated diffuse ST elevation, troponins negative. CT without contrast didn''t have much in it. He was found to be COVID rapid test+ and IGG negative. He was admitted into isolation, no oxygen needs. DDIMER was over 2000 and friction rub noted on physical exam. Cardiology ruled out STEMI, thought maybe viral pericarditis - but wanted echo done after out of isolation. CTA was planned for AM on 4-28-21, but patient died 4-27-21 PM after being found down in room. ROSC was not able to be achieved despite aggressive resuscitation efforts


VAERS ID: 1267278 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-10
Onset:2021-04-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Insulin Lispro (HUMALOG KWIKPEN INSULIN) 100 unit/mL SubQ Insulin Pen, INJECT 14 UNITS SUBCUTANEOUSLY TEN MINUTES BEFORE EACH MEAL. USE INSULIN SENSITIVITY RATIO OF 2/50 TO TARGET BLOOD SUGAR OF 150 IF NEEDED. DISCARD USED PENS AFTER 28 DAY
Current Illness:
Preexisting Conditions: LONG TERM INSULIN THERAPY HTN (HYPERTENSION) DM 2 MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE DM 2 W BILAT PROLIFERATIVE RETINOPATHY HX OF VITRECTOMY HX OF PANRETINAL PHOTOCOAGULATION LEGAL BLINDNESS USA DM 2 W MICROALBUMINURIA HX OF MRSA HYPOTHYROIDISM DIASTOLIC HEART FAILURE, CHRONIC HX OF MULTIPLE DRUG RESISTANT ORGANISM HX OF FOURNIER GANGRENE, MALE DM 2 W HYPERGLYCEMIA HX OF PULMONARY EMBOLUS IRON DEFICIENCY ANEMIA ANEMIA OF CHRONIC DISEASE HYPERLIPIDEMIA ANEMIA CHRONIC RESPIRATORY FAILURE HX OF CORONAVIRUS COVID-19 DISEASE DM 2 W ULCER OF LEFT FOOT DM 2 W CKD STAGE 4 (GFR 15-29) MODERATE PROTEIN CALORIE MALNUTRITION DM 2 W CKD STAGE 4 (GFR 15-29) W HTN SECONDARY HYPERPARATHYROIDISM, RENAL ORIGIN SEVERE OBESITY GERD (GASTROESOPHAGEAL REFLUX DISEASE) MOOD DISORDER, UNSPECIFIED TYPE
Allergies: norco
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient passed away 4/12/2021 suddenly, found by family on couch. Was having shortness of breath day before. Per mom, patient had been laughing and talking the morning before patient passed away.


VAERS ID: 1267587 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Vermont  
Vaccinated:2021-04-21
Onset:2021-04-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Atrial fibrillation, Dyspnoea, Electrocardiogram, Electrocardiogram Q wave abnormal, Hypotension, Oedema, Tachycardia
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Dehydration (broad), Hypokalaemia (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? No
Previous Vaccinations:
Other Medications: gabapentin 100 mg once a day
Current Illness: none
Preexisting Conditions: none
Allergies: KNDA
Diagnostic Lab Data: 4/22/2021 EKG: A fib, RVR, 145 bpm, q wave abnormalities showing ischemia inferiorly and anterolaterally.
CDC Split Type:

Write-up: patient woke up on 04/22/2021 with shortness of breath and weakness. On exam, she was hypotensive, tachycardic and edematous


VAERS ID: 1267593 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-30
Onset:2021-02-08
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Fatigue, Headache, Thrombosis
SMQs:, Anaphylactic reaction (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tagamet as needed Advil as needed
Current Illness: None
Preexisting Conditions: None Recurring injury to weak ankle
Allergies: Skin allergy to products with fragrance
Diagnostic Lab Data: Details available upon request.
CDC Split Type:

Write-up: Headache, Increasing fatigue and difficulty breathing over two weeks before 2nd dose -- exacerbated by 2nd dose. Worsening condition led to visit to Primary Care In office tests indicated presence of blood clots and need for emergency hospital treatment. Emergency surgery to remove blood clots throughout her body and attempt to put her on ECMO were unsuccessful and patient succumbed at 12:06 AM 3/3/21.


VAERS ID: 1267641 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-04-15
Onset:2021-04-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   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:
Current Illness:
Preexisting Conditions: Atherosclerotic and hypertensive cardiovascular disease with congestive heart failure, type 2 diabetes mellitus, morbid obesity
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Shortness of breath


VAERS ID: 1267753 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-08
Onset:2021-04-13
   Days after vaccination:95
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Cerebrovascular accident, Mental status changes, Pyrexia, SARS-CoV-2 test positive, Surgery
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: type 2 diabetes, congestive heart failure, anemia in chronic kidney disease on dialysis, and hypertension; COVID-19 reinfection
Preexisting Conditions: type 2 diabetes, congestive heart failure, anemia in chronic kidney disease on dialysis, and hypertension;
Allergies: unknown
Diagnostic Lab Data: Case tested positive for COVID-19 on 12/7/2020; vaccinated on 1/8/2021 and 2/5/2021 with Moderna; re-tested positive for COVID-19 on 4/1/2021.
CDC Split Type:

Write-up: Case tested positive for COVID-19 on 12/7/2020; vaccinated on 1/8/2021 and 2/5/2021 with Moderna; re-tested positive for COVID-19 on 4/1/2021. Case was admitted to hospital on 4/2/2021 for surgery due to a previous fall. Case had altered mental status and fever. Case was found to have an acute CVA.


VAERS ID: 1267794 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-02-05
Onset:2021-02-24
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Brain stem infarction, Cerebellar infarction, Cerebrovascular accident, Death, Dizziness, Ischaemic stroke
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known
Preexisting Conditions: hypertension
Allergies: none known
Diagnostic Lab Data: Extensive over the course of approximately 1 week at Hospital and Medical Center - please contact them for details.
CDC Split Type:

Write-up: Approximately 3 weeks after Moderna Covid-19 vaccine administration, patient began to experience dizziness, transferred to Hospital, diagnosed with ischemic stroke, discharged, returned within days with worsening, diagnosed with new ischemic stroke (contralateral side), transferred to Medical Center, patient''s condition worsened, presumably additional new ischemic stroke, patient ultimately died on 3/5/2021. Diagnosis was acute infarction of the brainstem/pons as well as acute bilateral cerebellar/occipital infarctions.


VAERS ID: 1267803 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-01-07
Onset:2021-02-06
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: C-reactive protein increased, COVID-19, Chest X-ray abnormal, Cough, Death, Full blood count normal, General physical health deterioration, Lung opacity, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 4/14: CRP=4.9, CBC WNL, Chest xray: Bibasilar opacities consistent with known history of Covid pneumonia
CDC Split Type:

Write-up: Patient developed COVID-19 with complaints of increased cough on 4/6. Was found to be COVID positive on 4/12. Recieved combo Bamlanivimab/etesevimab treatment for infusion on 4/14. Patient had initial recovery to baseline period on 4/22. Rapidly declined shortly after and died 4/25.


VAERS ID: 1267822 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-03
Onset:2021-03-14
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: dysarthria, obstructive sleep apnea, coronary artery disease, hyperlipidemia, hypertension
Allergies: Unknown
Diagnostic Lab Data: Tested positive for COVID-19 on 10/21/2020; husband was also positive for COVID-19 around same time. First dose of Moderna vaccine on 3/3/2021.
CDC Split Type:

Write-up: Admitted to hospital on 9/30/2020 and discharged on 10/28/2020.


VAERS ID: 1267948 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-19
Onset:2021-04-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044B21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Fatigue, Pain
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:
Current Illness:
Preexisting Conditions: ESKD, Anemia, Type 2 Diabetes, Hyperparathyroidism, Insulin Dependant WC bound/ required assistance for ADLs, CAD, HTN
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Exact time of symptom onset unknown. Clinic was notified by family at 10am on 4/21 that patient had expired at home. Family member reported that patient was tired and achy and was found deceased on the floor in his room. Patient had a history of Covid-19 in January, 2021.


VAERS ID: 1267987 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-19
Onset:2021-01-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-16
   Days after onset: 55
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: In hospice care
Preexisting Conditions: Acute on chronic congestive heart failure Metabolic encephalopathy
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ? Patient never had a COVID positive test result ? The narrative seemed to shift over time, with the most recent hospital notes stating the headaches started after the vaccination, so I wanted to include a more in depth timeline on this ? General timeline gathered from notes o 01/11/2021: Constant headache ongoing for 3 weeks; discussed scheduling his COVID vaccine, directed to website o 02/02/2021: acknowledges patient has had first dose of COVID vaccine; denies ever being sick or around anyone with COVID o 03/01/2021: patient states he has had a headache since the COVID vaccine 1/19/2021 o 03/03/2021: patient has had both COVID vaccine shots o 03/12/2021: patient has had a headache for a couple months that waxes and wanes, no cause was identified. His headache first began at the end of January after his COVID vaccine


VAERS ID: 1268019 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-04-22
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Anaemia, Clavicle fracture, Death, Fall, Generalised oedema, Hyperkalaemia, Subdural haematoma, Thrombocytopenia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Angioedema (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-27
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 83 year old female received the vaccine on 2/26/21 and went to the ED on 4/22/21 and was admitted with Thrombocytopenia, acute renal failure, fall with subdural hematoma, clavicle fracture, anemia, head injury, anascara, hyperkalemia and died on 4/27/2021. 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: 1268044 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-04-21
Onset:2021-04-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044B21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: ESRD,o Diabeteso Non ST Elevation Myocardial Infarction o Rheumatic Mitral Valve Insufficiency
Allergies: Hydralazine and Betadine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Clinic was informed that patient patient went unresponsive at home at 2pm on 4/21/21 and patient expired.


VAERS ID: 1268049 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-26
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fall Death


VAERS ID: 1268137 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-10
Onset:2021-03-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Encephalopathy, Schizophrenia
SMQs:, Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 35
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: ? RNA+ on 11/21/20 and 1/17/21 ? 1st dose of COVID-19 vaccine (Moderna) on 3/10/21
Preexisting Conditions: chronic schizophrenia
Allergies:
Diagnostic Lab Data: ? RNA+ on 11/21/20 and 1/17/21
CDC Split Type:

Write-up: Cause of Death A: Acute encephalopathy Cause of Death B: COVID 19 IMMUNIZATION FOLLOWING COVID 19 VIRUS INFECTION Cause of Death Other: Chronic Schizophrenia


VAERS ID: 1268212 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-04-16
Onset:2021-04-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / 1 LA / IM

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

Write-up: Patient died on 4/23/21


VAERS ID: 1268373 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New York  
Vaccinated:2021-04-24
Onset:2021-04-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / UNK RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Death, Resuscitation, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (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: 2021-04-25
   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: Carvedilol 25 mg, Ezetimibe 10 mg, Furosemide 20 mg, Lisinopril 40 mg, Omeprazole 40 mg, Rosuvastatin Calcium 10 mg, Loratadine 10 mg, Hydrocortisone cream 2.5%
Current Illness: None
Preexisting Conditions: Type 2 Diabetes, Coronary artery disease, hypertension, hyperlipidemia, obesity, GERD, fatty liver
Allergies: None
Diagnostic Lab Data: Patient was transported via EMS to Emergency Room. He was unable to be resuscitated and pronounced dead. Body was transferred to the Medical Examiner. Autopsy report is pending at this time.
CDC Split Type:

Write-up: Patient collapsed and became unresponsive 24 hours after receiving second dose of vaccine.


VAERS ID: 1268440 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-31
Onset:2021-04-26
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027B21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase increased, Blood glucose normal, Blood pH decreased, Cardiac arrest, Death, Fibrin D dimer increased, International normalised ratio normal, Platelet count normal, SARS-CoV-2 test negative, Troponin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   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: unknown
Current Illness: Diabetic
Preexisting Conditions: Cardiac cath with angioplasty in 2001
Allergies: unknown
Diagnostic Lab Data: ABG-pH 6.97 PTT 13.8 sec INR 1.0 Troponin 26/CK 423/CK-MB 4.4 Platelets 198 D dimer 1.49 COVID negative Glucose 177
CDC Split Type:

Write-up: Death due to cardiac arrest on 4/26/2021


VAERS ID: 1269178 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-03-10
Onset:2021-03-24
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0108218 / 2 UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dyspnoea, Pallor, Peripheral swelling
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: hypertension medications
Current Illness: None as far as we know
Preexisting Conditions: hypertension
Allergies: Penicillin
Diagnostic Lab Data: None as far as was reported
CDC Split Type:

Write-up: Received Moderna Dose #2 on 3/10/2021. About 1-2 weeks after, he started experiencing swollen leg (unsure if left or right), had shortness of breath, and looked pale on 4/22 he was seen by a provider and was prescribed oxygen, later that night he passed.


VAERS ID: 1269219 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-03-08
Onset:2021-04-14
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram, Death, Endotracheal intubation, Fall, Intensive care, Muscular weakness, Unresponsive to stimuli, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Angioedema (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Plavix
Current Illness: None
Preexisting Conditions: Heart ploblems
Allergies: None
Diagnostic Lab Data: 2 CT scans
CDC Split Type:

Write-up: The Patients leg gave out and he fell. Per doctors at hospital, he did not hit his head. He could not get up and he vomited. Ambulance was called and he was taken to the Hospital. The family was told that he had a brain bleed near the thalamus. A few hours later the patient was unresponsive. He was intubated and taken to neuro ICU. Within less then 24 hours from first symptom the patient died.


VAERS ID: 1269282 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-12
Onset:2021-04-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       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: OXYGEN
Current Illness: Immunocompromised
Preexisting Conditions: Medical History/Concurrent Conditions: COPD
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 56-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included COPD. Concurrent medical conditions included Immunocompromised. Concomitant products included OXYGEN for an unknown indication. On 12-Apr-2021 at 12:45 PM, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on 12-Apr-2021 The patient died on 12-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No treatment information were reported.; Sender''s Comments: Limited information regarding the event has been provided at this time and a causal relationship cannot be excluded; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1269854 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-13
Onset:2021-04-10
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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 has a PMH significant for T2DM, CAD, hyperlipidemia, Parkinson''s disease, HTN, Diffuse interstitial Pulmonary fibrosis. No cause of death listed or any notation. Patient deceased on 4/10/202. 2nd dose of Pfizer given 3/13


VAERS ID: 1269855 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-12
Onset:2021-04-05
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac valve vegetation, Cognitive disorder, Culture positive, Death, Device related bacteraemia, Encephalopathy, Mental status changes, Motor dysfunction, Pneumonia
SMQs:, Peripheral neuropathy (broad), Dementia (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   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-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug adverse 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 admitted on 2/27/21 with acute encephalopathy and suffering progressively worsening mental status. He was admitted for over a month through 3/31/21 where he was eventually discharged on hospice before passing on 4/5/21. His hospital course consisted of treating community acquired pneumonia/bacteremia from hemodialysis catheter placement. Patient continued to have positive cultures despite antibiotics due to a found vegetation on the aortic valve. He experienced functional and cognitive decline over his admission. Comorbidities include vascular dementia, h/o stroke, ESRD on HD, HTN, DM2, HLD


VAERS ID: 1269804 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-29
Onset:2021-02-08
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Contusion, Epistaxis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Warfarin, furosemide
Current Illness: n/a
Preexisting Conditions: Congestive heart failure
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: nose bleeds, black and blue marks weeks later,


VAERS ID: 1269849 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-16
Onset:2021-04-12
   Days after vaccination:86
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Death, Delusion, Hallucination
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad)

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

Write-up: Death Narrative: Patient 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 and ADR that occurred between the observation period and the date of death. Patient was transferred to behavioral health unit at an outside nursing home on 2/15/21 after hospitalization for psychiatric evaluation on 1/29/21 w/subsequent Law for erratic behavior w/ delusions/hallucinations. Patient passed away on 4/12/21 at an outside facility with details surrounding death unknown. PMH significant for CKD, AAA, PVD, anemia, CAD, Dm, HTN, COPD, advanced age.


VAERS ID: 1269850 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-16
Onset:2021-04-02
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chest discomfort, Death, Dyspnoea, Productive cough, Sputum discoloured
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? 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 and ADR that occurred between the observation period and the date of death. Patient has PMH significant for neoplasm of liver, stage 4 esophageal adenocarcinoma congestive cardiomyopathy, AF, htn. Seen 3/22, per not "states that for the past three days he has had constant chest heaviness and shortness of breath along with productive cough with dark sputum." Discharged 3/24. Deceased 4/2/2021 however no notation or death certificate noted.


VAERS ID: 1269852 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-18
Onset:2021-04-16
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthma, Death, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 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 93 and receiving home based palliative care. On 3/30/21 his home nurse reported he was having bilateral lung wheezing. On 4/16/21 patient''s wife stated he passed away at home after suffering an "asthma attack." PMH significant for dementia, malnutrition, reduced mobility, bedbound, Alzheimer''s, DM, afib, CAD, NSTEMI


VAERS ID: 1269853 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-04-16
   Days after vaccination:70
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 RA / IM

Administered by: Other       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? 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. PMH significant for amyotrophic lateral sclerosis, AF, HTN. No notation regarding death, or cause of death. Patient deceased 4.16.21


VAERS ID: 1270366 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-04-19
Onset:2021-04-24
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-28
   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: Wellbutrin
Current Illness:
Preexisting Conditions: Anxiety and depression
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest 5 days post vaccination.


VAERS ID: 1270749 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-04-23
Onset:2021-04-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arteriosclerosis coronary artery, Autopsy, Cold sweat, Coronary artery occlusion, Death, Dyspnoea, Hypotension, Paraesthesia
SMQs:, Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-24
   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: SWEET DREAMS NEUROSLEEP, DREAM WATER, & NATURAL VITALITY CALM
Current Illness: NONE
Preexisting Conditions: ALCOHOLISM (CIRRHOSIS), HTN, TOBACCO ABUSE, ASHD
Allergies: UNKNOWN CATERPILLAR (ANIMAL)
Diagnostic Lab Data: MEDICAL EXAMINER AUTOPSY - MARKED ATHEROSCLEROSIS OF CORONARY ARTERIES WITH ACUTE OCCLUSION OF THE LAD
CDC Split Type:

Write-up: HYPOTENSION (SARASOTA EMS RESPONDED TO PHARMACY); CLAMMY/SOB, EXTREMITY TINGLES; DEATH WITHIN 6-7 HRS


VAERS ID: 1271212 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-04-12
Onset:2021-04-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiogenic shock, Death, Echocardiogram, Laboratory test
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clonazepam, Ambien, Transene
Current Illness: Asma , Anxietyy
Preexisting Conditions: On admission time was found with ejection fraction of 16%
Allergies: NONE
Diagnostic Lab Data: ECHO-CARDIOGRAM BLOOD TEST
CDC Split Type:

Write-up: PATIENT DEVELOP CARDIOGENIC SHOCK AFTER RECEIVED FIRST DOSE OF MODERNA VACCINE ON THURSDAY 29 2021 PATIENT DIED


VAERS ID: 1271305 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-09
Onset:2021-03-29
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 - / -

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

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:
CDC Split Type:

Write-up: Death within 60 days of vaccine


VAERS ID: 1271382 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-01
Onset:2021-02-25
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   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: Unknown
Current Illness:
Preexisting Conditions: Diabetes, heart disease, renal disease, CVA, seizures, dementia, bipolar
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to facility 2/25 and passed away 3/4.


VAERS ID: 1271626 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-04-21
Onset:2021-04-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0071321A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, Chest pain, Fall, Gait inability, Headache, Laboratory test, Malaise, Nausea, Oropharyngeal pain, Rhabdomyolysis, Vomiting
SMQs:, Rhabdomyolysis/myopathy (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dystonia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   Days after onset: 7
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: FLOMAX 0.4MG DAILY IBUPROFEN AS NEEDED
Current Illness: NONE REPORTED
Preexisting Conditions: HYPERLIPIDEMIA
Allergies: NO KNOWN DRUG ALLERGIES REPORTED
Diagnostic Lab Data: LAB TESTING AT MLMC DURING ER AND OBS STAY 04/24-04/26/2021 AND 04/27/2021-04/28/2021
CDC Split Type:

Write-up: SPOUSE REPORTS THE FOLLOWING FOR PATIENT 4/21/2021 @ 9PM GENERAL MALAISE 4/22/2021 APPROX 4AM SEVERE HEADACHE TOOK IBUPROFEN 4/23/2021 AFTER LUNCH, PATIENT WAS UNABLE TO WALK AS PREVIOUS AND HAD 4 FALLS, ALSO COMPLAINED OF A SORE THROAT. 4/24/2021 DID NOT FEEL WELL, TEMP UP TO 100.4, NAUSEA AND VOMITTING X 1 AND CHEST PAIN, CALLED EMS AND WAS TRANSPORTED TO MEDICAL CENTER ER. 4/26/2021 PATIENT WAS DISCHAGED HOME AFTER TREATMENT FOR RHABDOMYOLYSIS AND RETURNED TO THE HOSTPITAL AGAIN ON 04/27/2021 WITH RHABDOMYOLYSIS AS PRIMARY DIAGNSOSIS. RESIDENT DISCHARGED TO SNF ON 04/28/2021.


VAERS ID: 1271674 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-03-20
   Days after vaccination:66
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / UNK - / -

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

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

Write-up: Death within 60 days of vaccination


VAERS ID: 1271737 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-03-02
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Pneumonia, Respiratory failure, Sepsis
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 32
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to the ED and was subsequently hospitalized with sepsis, respiratory failure and pneumonia on 3/2/2021. Patient presented to the ED and was subsequently hospitalized with pneumonia on 3/22/2021. Patient presented to the ED and was subsequently hospitalized with sepsis on 3/31/2021. He died on 4/4/2021.


VAERS ID: 1271786 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-04-21
Onset:2021-04-25
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient came to pharmacy for 1st Moderna Covid-19 vaccination on 4/21/21. Spouse reported she died on 4/25/21. Our pharmacy does not have information about her medications or health conditions as she wasn''t a regular customer of ours.


VAERS ID: 1271827 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-03-05
Onset:2021-03-21
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: lipitor,thyroxine,furosemide,carvedilol,minoxidil
Current Illness: copd
Preexisting Conditions: copd kidney diease
Allergies: none
Diagnostic Lab Data: passed away with in minutes
CDC Split Type:

Write-up: lungs shut down from 95 to 0 in a blink of an eye


VAERS ID: 1271846 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-04-20
Onset:2021-04-25
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009C21A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal distension, Abdominal pain, Acute kidney injury, Acute respiratory failure, Cardiac failure congestive, Chronic kidney disease, Chronic left ventricular failure, Chronic obstructive pulmonary disease, Coronary artery disease, Death, Failure to thrive, Intensive care, Malnutrition, Mental status changes, Metabolic encephalopathy, Renal tubular necrosis, Respiratory failure, Septic shock
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Renovascular disorders (broad), Neonatal disorders (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   Days after onset: 1
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to ED on 04/25/2021 with complaints of abdominal pain, abdominal distension, and AMS. Patient was admitted to ICU with following diagnoses: 1) Septic Shock, 2) A/C hypoxic/hypercapnic respiratory failure, 3) Acute metabolic encephalopathy, 4) Palliative care patient, 5) AE COPD, 6) ARF w/ATN on CKD3, 7) CAD, 8) Chronic sys/dia CHF, 9) Malnutrition/Failure to thrive. Patient died on 04/26/2021 at 1826. Patient was also previously admitted to hospital on 03/23/2021-03/29/2021 for sepsis.


VAERS ID: 1271898 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-04-12
Onset:2021-04-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   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: Prescriptions: oxymorphone 10mg, lyrica 150mg, metoprolol ER 100mg, Novolog 100units/ml, tresiba flextouch 200units/ml, metformin 1000mg, furosemide 40mg, spironolactone 100mg, famotidine 40mg, omeprazole 40mg, lactulose 10gram/15ml, trazod
Current Illness: NA
Preexisting Conditions: diabetes, hypertension, cirrhosis of liver, high cholesterol, sleep apnea
Allergies: No known Drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive on 4/15/2021. Patient seemed to pass in his sleep per family member. The coroner deemed myocardial infarction. No autopsy completed.


VAERS ID: 1272012 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-31
Onset:2021-03-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arthralgia, Chills, Headache, Pain in extremity, Sleep disorder, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   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: Losartan 100mg, Hydrochlorothizide 25 mg, Pioglitazone 30mg, Glipepiride 2mg, Rosuvastatin 10mg, Carvedilol 12.5mg
Current Illness:
Preexisting Conditions: Chronic kidney failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Arm became sore at 5:25 pm (03/31/2021) developed chills, could not sleep for shaking, headache and joint pain (03:08 pm on 04/01/2021) ***this is what she texted to me and my other sister and the 03:08 pm text was the last text she had texted***


VAERS ID: 1272201 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-05
Onset:2021-04-04
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: METFORMIN
Current Illness: Diabetes; Memory loss; Prostate cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Pulmonary embolism; died - autopsy showed multiple blood clots all over his body - pelvic area, hearts,arteries, lungs; This spontaneous case was reported by a consumer and describes the occurrence of THROMBOSIS (died - autopsy showed multiple blood clots all over his body - pelvic area, hearts,arteries, lungs) and PULMONARY EMBOLISM (Pulmonary embolism) in an 83-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 039A21A and 003A21A) for COVID-19 vaccination. Concurrent medical conditions included Diabetes, Prostate cancer and Memory loss. Concomitant products included METFORMIN for Diabetes. On 05-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 02-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 04-Apr-2021, the patient experienced THROMBOSIS (died - autopsy showed multiple blood clots all over his body - pelvic area, hearts,arteries, lungs) (seriousness criterion death). On an unknown date, the patient experienced PULMONARY EMBOLISM (Pulmonary embolism) (seriousness criterion death). The patient died on 04-Apr-2021. The reported cause of death was Pulmonary embolism. An autopsy was performed. The autopsy-determined cause of death was multiple blood clots. Action taken with mRNA-1273 in response to the event was not applicable Other concomitant medications were reported included unspecified medications for memory loss and diabetes. No treatment information was provided.; Sender''s Comments: This is an 83-year-old, male patient who received mRNA-1273 Vaccine who experienced multiple thrombosis and died, 2 days after receiving second dose of vaccine. Medical history includes Diabetes, and Prostate cancer. Conmeds including some unspecified medications for memory loss and diabetes. The autopsy-determined cause of death was multiple blood clots. Very limited information has been reported at this time. Further information is expected,; Reported Cause(s) of Death: Pulmonary embolism; Autopsy-determined Cause(s) of Death: multiple blood clots


VAERS ID: 1272225 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-28
Onset:2021-03-06
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Computerised tomogram head normal, Confusional state, Culture positive, Death, Gait inability, Hypersomnia, Magnetic resonance imaging head abnormal, Neurological symptom, Pneumonia, Respiratory tract congestion, Urinary incontinence, Urinary tract infection, Withdrawal of life support
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Dystonia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Depression (excl suicide and self injury) (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Chemotherapy drugs
Current Illness: Smoldering Myeloma (precursor to blood cancer)
Preexisting Conditions: Diabetes controlled through diet.
Allergies: None
Diagnostic Lab Data: Pnuemonua culture, MRi. Displayed stroke symptoms.but CT scan showed no stroke.
CDC Split Type:

Write-up: Confusion 6 days after shot. Within a week lost ability to walk, became urinary incontinent. Major chest congestion, slept all the time. Rushed by ambulance at day 12.. Diagnosed with pneumonia amd uti. Cardiac arrest at day 14, never woke up. Taken off life support 3/20/21.


VAERS ID: 1272342 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-04-02
Onset:2021-04-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, General physical health deterioration, Nausea, Oxygen saturation decreased, Palpitations, Pneumonia
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   Days after onset: 7
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: Insulin
Current Illness:
Preexisting Conditions: Diabetes, mild hypertension
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed shortness of breath within 12hrs of 2nd Moderna dose along with heart palpitations and nausea. Admitted to hospital 3 days after shot and quickly developed pnemonia and died 4 days later after blood O2 fell below 80%. Had periods of mild improvements followed by more severe declines each time.


VAERS ID: 1272476 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-04-23
Onset:2021-04-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Dizziness, Malaise
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   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: I do not know
Current Illness: Do not know
Preexisting Conditions: Diabetes
Allergies: Do not know
Diagnostic Lab Data:
CDC Split Type:

Write-up: She was quite sick, dizzy, went to ER three times between Saturday and Sunday, they sent her home each time, she died Monday morning.


VAERS ID: 1272739 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-04-28
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001C21A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Symbicort Allopurinol, Pantoprazole, Furosemide,
Current Illness:
Preexisting Conditions: COPD, HTN, DM, A-FIB
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Expired within 72 hours of receiving vaccine.


VAERS ID: 1273174 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-16
Onset:2021-04-05
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   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: laryngectomy (?)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: From one of the nurse vaccinators: the man who had a laryngectomy who gave me a hard time about an id when we first started..I was so happy to see his name on my list this morning. I saw that no one could contact him..I got into the building ..no answer at the door ..phone disconnected ..found the super..he died 3 weeks ago..he didn?t know cause..just emergent situation to hospital and passed.


VAERS ID: 1273324 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-18
Onset:2021-02-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aggression, Agitation, Anger, Cognitive disorder, Computerised tomogram abnormal, Death, Diet refusal, Fall, Fluid intake reduced, Hallucination, Irritability, Neurological symptom, Paranoia, Screaming, Wheelchair user
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hostility/aggression (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-24
   Days after onset: 60
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: See notes under description for 2nd vaccine.
Other Medications: Atorvastatin, Memtone, Lisinopril, fish oil, Vitamin D3, calcium, Antrozole.
Current Illness: None.
Preexisting Conditions: Diagnosed with dementia 9 years ago, high blood pressure, high cholesterol, bilateral mastectomies.
Allergies: None.
Diagnostic Lab Data: As above.
CDC Split Type:

Write-up: The day before the first vaccine she was up and acting normal, laundry, housework and knew what to do. She has severe dementia but was doing OK and knew where she was. She got the first vaccine on 1/29/21, and the 3rd and 4th day they noticed she was having hallucinations and saying things that weren''t there. She could hear baby''s crying but there were no baby''s present. Within 7 days she had what the son described as a stroke. He said that she was watching television and he was on a conference call and he noticed she walked into a wall and he asked if she was okay and starting stumbling across the room and when he touched her she felt very heavy and said that one side of her face was drooping. He got her back into the chair and called 9-1-1. She was so agitated at the hospital that the husband does not know what they gave her and they kept her for a week. They finally got her under control. They discharged her from there and she that was all that they could do with her. They brought her home with nurses assistance and her paranoia was evident, hallucinations were very evident. They said that they tried to do a CAT Scan and an MRI and they said that she did not have a stroke. Restless was very adamant, talking strange things and wanting to go to her son''s house when she was there. Before that vaccination she knew where she was and after that she did not know where she was thinking she was at one location and just confusion. She then got her 2nd vaccine and then her husband went out of town and took her back home on 2/24/21 as he was able to get her in a car and travel and able to eat and knew somewhat what was going on. On 2/25/21 when he brought her home to a long term care facility. She was chanting constantly, had irritability, anger, cognition completely eroded. She was very agitated, very combative. Drugs would not calm her down, and tried to get CAT scans or MRI''s but were unsuccessful due to her combativeness. She was screaming and yelling 24 hours a day to the top of her lungs and gave her Ativan which had the adverse effects of what they were supposed to do. Had biting, hallucinations, paranoia. She had a couple of falls, they had her in a wheelchair and tried to feed her and she would fall down. They took her to the hospital a few times and she progressively got worse. On 4/19/21 she shut down and quit eating, quit drinking, closed her eyes, and lasted a week like that and then she died on 4/24/21 @ 2:30 AM. None of her doctors could figure out what had happened. They were finally able to get a CAT scan and felt that she may have a stroke. Finally they memory care facility told them to come a take her to the hospital and they had moved their hospice patient''s as she was screaming and disruptive and they could not handle her anymore. They thought she was suffering from Lewy body dementia at one point. They were going to have her tested for that and they could not do it on Saturday when she passed for genetics and missed those timelines and could not do it.


VAERS ID: 1273475 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-04-28
Onset:2021-04-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016C21A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Apnoea, Death, Pulse absent, Resuscitation
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   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: Isosource Continuous feeding, Tylenol 650mg PRN; Ibuprofen 400mg PRN; Metoprolol 50mg BID
Current Illness: Anoxic Brain Injury, History of MI, Uterine rupture, dysphagia, PEG TUBE, Tracheostomy
Preexisting Conditions: Anoxic Brain Injury
Allergies: NKA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: on 04/29/2021 Resident was checked at 1830 and found to be at baseline status. At approximately 1855, resident was found pulses and apneic. CPR initiated and resident transferred to medical center. Resident expired 1939.


VAERS ID: 1273511 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-03-25
Onset:2021-04-17
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Atrial fibrillation, Chest X-ray abnormal, Death, Lung consolidation, Nausea, Septic shock, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Toxic-septic shock conditions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (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: Warfarin, Alendronate, Omeprazole, Rosuvastatin, Losartan, Metoprolol, Hydrochlorithiazide
Current Illness: None
Preexisting Conditions: DM II, CKD, Osteoporosis, Hypertensive heart and kidney diease, Hyperlipid, B12 deficiency, History of DVT
Allergies: Side effects to Actonel and Atorvastatin
Diagnostic Lab Data: CXR- mild bilateral bibasilar airspace disease
CDC Split Type:

Write-up: Patient recieved Moderna dose 1 02/23/2021, dose 2 03/25/2021. Nausea and vomitting after 2nd dose, found unresponsive by son on 04/17/2021, taken to ER and diagnosed with new onset Afib with RVR, sepsis with shock. Deceased 04/18/2021


VAERS ID: 1273570 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-01-28
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 48
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reported dyspnea that began about 1 week post 2nd shot in Covid vaccination series. Patient deceased on 3/18/2021


VAERS ID: 1273626 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-22
Onset:2021-03-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Bed rest, COVID-19, COVID-19 pneumonia, Death, Endotracheal intubation, Hypertension, Intensive care, Mechanical ventilation, Multiple organ dysfunction syndrome, SARS-CoV-2 test positive, Type 2 diabetes mellitus
SMQs:, Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Hypertension (narrow), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   Days after onset: 25
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt developed symptoms of COVID-19 and was placed on bedrest on 03/28/2021. The patient was sent to local ED on 04/01/2021 and then tested for COVID-19 with a positive result. Patient was intubated and placed on ventilator. Pt. spent 22 days in ICU. Pt expired on 04/22/2021 with cause of death listed as MODS and COVID-19 related PNA. Related causes of death were listed as HTN, DMII, and ARDS.


VAERS ID: 1273804 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Unknown  
Location: Michigan  
Vaccinated:2021-03-31
Onset:2021-04-10
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Gastrointestinal haemorrhage, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (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), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Ischaemic colitis (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cardizem Norco Neurontin banophen Plavix
Current Illness: None known
Preexisting Conditions: HTN S/P Heart Transplant Hyperparathyroidism Reflux End stage renal disease
Allergies: Aspirin Atrorvastatin Crestor Haldol Haloperidol Lipitor Lisinopril Oxycodone Aldactone Hydralazine
Diagnostic Lab Data:
CDC Split Type:

Write-up: GI Hemorrhage Covid + Respiratory Failure


VAERS ID: 1274247 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-10
Onset:2021-04-22
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

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

Write-up: This 86 year old white male received the Covid shot on 4/10/21 and died on 4/22/21. 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: 1274273 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-06
Onset:2021-04-26
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 86 year old white male received the Covid shot on 03/06/21 and died on 04/26/21 . 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: 1274296 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-22
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 68 year old white female received the Covid shot on 3/3/21 and went to the ED on 3/22/21 and was admitted on 3/22/21 with shortness of breath, pneumonia and died on 4/10/21 . 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: 1274396 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-05
Onset:2021-03-12
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was not vaccinated at our site however was admitted approximately 7-10 days post vaccination and expired.


VAERS ID: 1274456 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-24
Onset:2021-03-31
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

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

Write-up: received vaccine on 3/24/21 at another site. Was admitted to the hospital thru the ED with worsening shortness of breath.


VAERS ID: 1274675 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-04-23
Onset:2021-04-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046A21A / 2 LA / IM

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

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: Humalog Lactulose 20 gram/30 mL solution Lumigan (bimatoprost) 0.01% drops Midodrine 10 mg tablet Rena-Vite Renvela 800 mg Sertraline 50 mg tablet
Current Illness:
Preexisting Conditions: Type 2 Diabetes, Hypertension, Hyperlipidemia, ESRD, Anemia, Hypothyroidism, Coronary Artery Disease, Cardiomyopathy, Liver Cirrhosis, GERD, Anxiety, Depression
Allergies: No know drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine was administered at 1215, patient was monitored for 15minutes per CDC guidelines with not adverse reactions noted. Approximately one hour after administration of vaccine patient noted to be moaning, fingerstick BS at 59mg/dL, Dextrose administered, pt proceeded in to cardiac arrest, CPR was initiated and EMS activated. Pt expired approximately 4 hours after incident at ER.


VAERS ID: 1275915 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-03-10
Onset:2021-03-22
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-05-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Asthenia, COVID-19, COVID-19 pneumonia, Chills, Death, Dyspnoea, Fatigue, Nausea, SARS-CoV-2 test positive, Vomiting, Wheezing
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 22
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: Albuterol, allopurinol, atorvastatin, azithromycin, colchicine, denosumab, ferrous sulfate, isosorbide dinitrate, lactulose, metoprolol, montelukast, omeprazole, sucralfate
Current Illness:
Preexisting Conditions: Asthma, GERD, hypertension
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 3/25/21, patient presented to the ED with several days history of nausea, vomiting, and upper abdominal pain, and 1 day history of shortness of breath and wheeze. Patient recently received her first dose of Moderna COVID vaccination on March 10. Patient''s daughter first developed COVID symptoms approximately 1-2 weeks prior, and was tested positive. Patient developed nausea, vomiting, and upper abdominal pain 6 days prior on March 19. She was tested positive for COVID several days prior to admission (either the 22 or 23rd, patient not sure). On the morning admission, patient had significant worsening of shortness of breath and wheeze. Patient also became significantly more weak and fatigued, and was eventually brought to ED. Patient reported chills, but denied headaches, chest pain, or diarrhea. Patient admitted to the hospital on 3/25/21 with main diagnosis COVD-19 pneumonia and patient expired on 4/13/21.


VAERS ID: 1276708 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-24
Onset:2021-03-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Chest X-ray, Dyspnoea, Electrocardiogram, Fatigue, Feeding disorder, Hyperkalaemia, Myalgia, Pneumonia, Pyrexia, Respiratory failure, Septic shock, Troponin, pH body fluid
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: NORVASC; METOPROLOL; DEXAMETHASONE; LEVOTHYROXINE; LEXAPRO; LISINOPRIL; VITAMIN D NOS
Current Illness: Critical illness; Hypertension; Hypothyroidism; Penicillin allergy; Renal cell carcinoma (on chemotherapy); Type 2 diabetes mellitus
Preexisting Conditions: Comments: the concomitant product the patient had taken are Norvasc , vitamin D, Metoprolol , Dexamethasone , Levothyroxine, Lexapro ,Lisinopril. the patient had certain medical history : Renal Cell Carcinoma on Chemotherapy , Hypertension , Hypothyroidism and Type 2 Diabetes Mellitus
Allergies:
Diagnostic Lab Data: Test Date: 20210326; Test Name: Chest X-ray; Result Unstructured Data: Severe bilateral pneumonia; Test Date: 20210326; Test Name: ECG; Result Unstructured Data: ST depression on V2-V4; Test Date: 20210326; Test Name: PH; Result Unstructured Data: Abnormal; Test Date: 20210326; Test Name: troponin; Result Unstructured Data: High
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: NSTEMI; Septic shock; Hypoxic respiratory; Hyperkalemic; Bilateral pneumonia; Acute renal failure; Shortness of breath; Fever; Myalgia; Fatigue; Poor PO intake following the vaccine; This spontaneous case was reported by a health care professional (subsequently medically confirmed) and describes the occurrence of ACUTE MYOCARDIAL INFARCTION (NSTEMI), SEPTIC SHOCK (Septic shock), RESPIRATORY FAILURE (Hypoxic respiratory), HYPERKALAEMIA (Hyperkalemic), PNEUMONIA (Bilateral pneumonia) and ACUTE KIDNEY INJURY (Acute renal failure) in a 69-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. the concomitant product the patient had taken are Norvasc , vitamin D, Metoprolol , Dexamethasone , Levothyroxine, Lexapro ,Lisinopril. the patient had certain medical history : Renal Cell Carcinoma on Chemotherapy , Hypertension , Hypothyroidism and Type 2 Diabetes Mellitus. Concurrent medical conditions included Renal cell carcinoma (on chemotherapy), Hypertension, Hypothyroidism, Type 2 diabetes mellitus, Critical illness and Penicillin allergy. Concomitant products included AMLODIPINE BESILATE (NORVASC), METOPROLOL, DEXAMETHASONE, LEVOTHYROXINE, ESCITALOPRAM OXALATE (LEXAPRO), LISINOPRIL and VITAMIN D NOS for an unknown indication. On 24-Mar-2021 at 11:00 AM, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 24-Mar-2021, the patient experienced FEEDING DISORDER (Poor PO intake following the vaccine). On 25-Mar-2021 at 11:00 PM, after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced DYSPNOEA (Shortness of breath), PYREXIA (Fever), MYALGIA (Myalgia) and FATIGUE (Fatigue). On 26-Mar-2021, the patient experienced ACUTE MYOCARDIAL INFARCTION (NSTEMI) (seriousness criteria medically significant and life threatening), SEPTIC SHOCK (Septic shock) (seriousness criteria medically significant and life threatening), RESPIRATORY FAILURE (Hypoxic respiratory) (seriousness criteria medically significant and life threatening), HYPERKALAEMIA (Hyperkalemic) (seriousness criterion medically significant), PNEUMONIA (Bilateral pneumonia) (seriousness criterion medically significant) and ACUTE KIDNEY INJURY (Acute renal failure) (seriousness criterion medically significant). On 26-Mar-2021, ACUTE MYOCARDIAL INFARCTION (NSTEMI), SEPTIC SHOCK (Septic shock), RESPIRATORY FAILURE (Hypoxic respiratory), HYPERKALAEMIA (Hyperkalemic), PNEUMONIA (Bilateral pneumonia) and ACUTE KIDNEY INJURY (Acute renal failure) outcome was unknown. At the time of the report, DYSPNOEA (Shortness of breath), FEEDING DISORDER (Poor PO intake following the vaccine), PYREXIA (Fever), MYALGIA (Myalgia) and FATIGUE (Fatigue) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 26-Mar-2021, Chest X-ray: abnormal (abnormal) Severe bilateral pneumonia. On 26-Mar-2021, Electrocardiogram: abnormal (abnormal) ST depression on V2-V4. On 26-Mar-2021, Troponin: 8.496 (High) High. On 26-Mar-2021, pH body fluid: 7.12 (abnormal) Abnormal. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. The patient expired with in hours of arrival to the ER despite full attempts at resuscitation. Treatment for the events included resuscitation. Based on the current available information and temporal association between the use of the product and the events, a causal relationship cannot be excluded, although it is likely the patient''s underlying critical state caused or contributed to the events. The cause of death is not specifically reported and event of death retained separately, although likely caused by MI, septic shock, respiratory failure, or a combination of these events; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the events, a causal relationship cannot be excluded, although it is likely the patient''s underlying critical state caused or contributed to the events. The cause of death is not specifically reported and event of death retained separately, although likely caused by MI, septic shock, respiratory failure, or a combination of these events


VAERS ID: 1276773 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Minnesota  
Vaccinated:0000-00-00
Onset:2021-04-05
Submitted: 0000-00-00
Entered: 2021-05-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: USMODERNATX, INC.MOD20210

Write-up: Stroke; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of CEREBROVASCULAR ACCIDENT (Stroke) in a 45-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 05-Apr-2021, the patient experienced CEREBROVASCULAR ACCIDENT (Stroke) (seriousness criterion death). The patient died on 05-Apr-2021. The reported cause of death was Stroke. It is unknown if an autopsy was performed. Concomitant medications were not reported. The patient was not hospitalized prior to or during the stroke. The reporter mentioned that the organs were donated as the patient was on a ventilator.; Reported Cause(s) of Death: Stroke


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