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From the 9/10/2021 release of VAERS data:

Found 14,925 cases where Vaccine is COVID19 and Patient Died



Case Details

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VAERS ID: 936805 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-22
Onset:2021-01-11
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: See Continuation Field
Current Illness: Whiplash injury to neck. Sprain of ligaments of cervical spine
Preexisting Conditions: Septal defect (heart), chronic sinusitis
Allergies: Ceftriaxone
Diagnostic Lab Data: None associated.
CDC Split Type:

Write-up: Patient received the vaccine on 12/22/20 without complication. It was reported today that the patient was found unresponsive and subsequently expired at home on 1/11/21.


VAERS ID: 937127 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: Mirtazapine, Fentanyl Patch,
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had positive cases of COVID when we were able to begin vaccinating residents. Within about a week of vaccination, patient was tested positive for COVID. He was 91 years old and his immune system did not have the time to allow the vaccine to begin working before exposure. His age was a major contributing factor to his death.


VAERS ID: 937152 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol, Cephalexin, Brimonidine, Donepezil, Losartan, Latanoprost, Timolol
Current Illness: High blood pressure, pain, eye issues
Preexisting Conditions: Blood pressure, pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had positive cases for COVID 19 when the vaccine was received and administered to patient. With her advanced age and chronic conditions, she did not have time to build immunity between the time of vaccination and her testing positive.


VAERS ID: 937186 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrocodone-Acetamenaphin, Lidocaine, Cefritriaxone, Citalopram
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The facility had a number of positive COVID 19 cases prior to patients vaccination. Due to her advanced age, chronic condition, and exposure, patient did not have the time to build immunity after exposure before becoming positive.


VAERS ID: 937434 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-01-07
Onset:2021-01-11
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None known
Preexisting Conditions: only had 1 lung
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related.


VAERS ID: 937444 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-11
Onset:2021-01-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Brain bleed, sleep apnea, htn
Preexisting Conditions: Brain bleed, sleep apnea, htn
Allergies:
Diagnostic Lab Data: The county coroner declared her death was related to a heart attack
CDC Split Type:

Write-up: Resident was found deceased at approximately 6pm in her apartment


VAERS ID: 937527 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2020-12-23
Onset:2021-01-04
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown, not reported
CDC Split Type:

Write-up: unsure if related to vaccine, but was notified by her next of kin that she died on 1/4/2021. No reports of side effects or hospitalization were reported to the facility prior to the notification of death.


VAERS ID: 937569 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-01-02
Onset:2021-01-07
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient reported expired 1/7/2021


VAERS ID: 937773 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-02
Onset:2021-01-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Haematuria
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19 positive on 11/30/2020
Preexisting Conditions: Parkinson''s Disease, Diabetes, Heart disease, A-fib, Hypothyroidism
Allergies: Baclofen, PCN, Ambien, Singulair
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was sent to the ED due to significant hematuria. He was afebrile.


VAERS ID: 938097 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021017780

Write-up: died; This is a spontaneous report from a non-contactable consumer via a Pfizer-sponsored program. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, via an unspecified route of administration on an unspecified date at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. It was reported the patient was a doctor, died after the vaccine with no apparent disease. It was not reported if an autopsy was performed. No follow-up attempts are possible. Information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 938118 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Abdominal X-ray, Aneurysm, Angiogram cerebral, Arteriogram carotid, Cerebellar haemorrhage, Cerebrovascular accident, Chest X-ray, Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram pelvis, Computerised tomogram spine, Computerised tomogram thorax
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: multivitamin; vitamin D
Current Illness: none mentioned
Preexisting Conditions: no significant past medical history
Allergies: latex
Diagnostic Lab Data: CT brain head; CT cervical spine; chest xray; CT chest, abdomen, pelvis; abdominal xray; CT angiogram neck & brain
CDC Split Type:

Write-up: on 1/8/2021 17:30 patient taken to ER, cerebellar hemorrhage, stroke, aneurysm


VAERS ID: 938974 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-06
Onset:2021-01-11
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Diarrhoea, Haematemesis, Haematochezia, Haemoglobin decreased, Vomiting
SMQs:, Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hospice
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data: Labs contacted facility with critical lab, Hemoglobin 4.8, at 9:45am after resident passed
CDC Split Type:

Write-up: Hospice Resident received first Covid 19 vaccine dose on 1/6/21. 1/7/21 resident had decreased appetite noted in am but ate 100% of meal at dinner. 1/9/21 resident had decreased appetite with emesis x 2, loose BM x 2. Call placed to hospice. 1/10/21 5:44 am resident able to take HS meds, ingest 2 cups of shake. No emesis or loose stool noted. 12PM nurse noted resident not eating meals but ingesting milkshake and medications without any problems. Hospice contacted for change in condition. 1:00 pm hospice ordered Phenergan 12.5 mg Q 6 hrs PRN. Labs to be drawn 1/11/21. Hospice notified POA. 1/11/21 12:24am Resident had blood in stool. Resident denies any pain, on 2L of O2 for comfort.


VAERS ID: 939050 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: New York  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, Cough, Death, Endotracheal intubation, Hemiparesis, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), 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: 2021-01-04
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Morbid obesity and hypothyroidism
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient vaccinated on 12/28. Approximately one day later, develops cough and on azithromycin x 1 week. On 1/3, patient develops left-sided weakness and aphasia. Taken to the hospital, tested COVID+, required intubation -- acute hypoxic respiratory failure secondary to COVID - on H&P. Patient died on 1/4/21 at 7:20am.


VAERS ID: 939270 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2020-12-22
Onset:2020-12-31
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden cardiac death


VAERS ID: 963163 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-01-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative:


VAERS ID: 939845 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-11
Onset:2021-01-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Oxygen saturation decreased
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), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHF
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Three hours after receiving COVID 19 vaccination, Patient oxygen level decreased to a critical level and went into cardiac arrest. Staff performed full code but was unable to bring back patient from cardiac arrest.


VAERS ID: 940602 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-08
Onset:2021-01-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K209 / 5 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Injection site pain, Myocardial infarction, Pain, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: see attached
Current Illness: None reported
Preexisting Conditions: HTN, Type II DM, High cholesterol
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 1/8/2021. On 1/9/2021 I checked on patient via phone for symptoms or problems and he reported none but mild soreness at injection site. On 1/10/2021 family friend called me to tell me that patient had expired at about 8:00 pm. Patient reportedly complained of "pain" unspecific and collapsed at home. Hospital reportedly told family that it appeared to be a "heart attack".


VAERS ID: 940822 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK RA / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: None
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021015752

Write-up: patient passed away after receiving the Covid vaccine; This is a spontaneous report from a contactable nurse. An 81-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE), intramuscular into the right arm on 07Jan2021 at 0.3 mL, single for covid-19 immunization. There was no medical history and no concomitant medications. On 08Jan2021, the patient passed away after receiving the COVID vaccine. The patient died on 08Jan2021. An autopsy was not performed. Investigations indicate that unspecified labs were done, but nothing two weeks prior; no further details were provided. The patient received the first dose the day prior. The reporting nurse discussed it with the medical director, and he thought that he potentially passed away from the COVID vaccine. The relatedness of the event to the suspect vaccine was reported as related by the reporting nurse per The Agency. The batch/lot number for the vaccine, BNT162B2, was not provided and will be requested during follow-up .; Sender''s Comments: Based on the limited information available, it is medically not possible to make meaningful causality assessment, it is unlikely the vaccine could have contributed to the death of the patient based on the known safety profile. However case will be reevaluated when additional information is received during the follow-up The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Stated that the patient passed away after receiving the Covid vaccine


VAERS ID: 940855 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.


VAERS ID: 940866 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-01-07
Onset:2021-01-09
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Cardiac arrest, Cardio-respiratory arrest, Death, Pulse absent, 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), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr
Current Illness: None
Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia
Allergies: Loxapine, Thioridazine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest.


VAERS ID: 940955 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-11
Onset:2021-01-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Death, Pulse absent, Respiratory arrest, SARS-CoV-2 test negative
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ; ; EFFEXOR; ; ABILIFY; ; CRANBERRY; ; TYLENOL; ; LASIX [FUROSEMIDE]; IPRATROPIUM/ALBUTEROL; ; SENNA [SENNA ALEXANDRINA LEAF]; POLYETHYLENE GLYCOL 3350;
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Prior to vaccination, the patient was diagnosed with COVID-19); Diastolic heart failure; Epilepsy; Morbid obesity; Pulmonary hypertension; Spinal stenosis
Allergies:
Diagnostic Lab Data: Test Date: 20210111; Test Name: pulseless; Result Unstructured Data: Test Result:pulseless; Test Date: 20210111; Test Name: breathless; Result Unstructured Data: Test Result:breathless; Test Date: 20210106; Test Name: Covid-19 PCR; Result Unstructured Data: Test Result:Negative (Nasal Swab)
CDC Split Type: USPFIZER INC2021018488

Write-up: Cardiac Arrest; Patient was found pulseless and breathless 20 minutes following the vaccine administration.; Patient was found pulseless and breathless 20 minutes following the vaccine administration.; This is a spontaneous report from a contactable other healthcare professional (HCP). A 66-year-old female patient (pregnant at the time of vaccination: no) received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL1284) via intramuscular at left arm on 11Jan2021 12:15 PM at single dose for COVID-19 immunization. Medical history included diastolic CHF, spinal stenosis, morbid obesity, epilepsy, pulmonary hypertension and COVID-19 (Prior to vaccination, the patient was diagnosed with COVID-19). The patient received medication within 2 weeks of vaccination included amiodarone, melatonin, venlafaxine hydrochloride (EFFEXOR), ibuprofen, aripiprazole (ABILIFY), lisinopril, cranberry capsules, diltiazem, paracetamol (TYLENOL), famotidine, furosemide (LASIX [FUROSEMIDE]), ipratropium bromide, salbutamol sulfate (IPRATROPIUM/ALBUTEROL), buspirone, senna alexandrina leaf (SENNA [SENNA ALEXANDRINA LEAF]), polyethylene glycol 3350 and morphine. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Patient used took Penicillin, propranolol, quetiapine, topiramate, Lamictal and had allergy to them. Patient used took the first dose of BNT162B2 (lot number: EJ1685) via intramuscular at right arm on 21Dec2020 12:00 PM at single dose for COVID-19 immunization. Since the vaccination, the patient been tested for COVID-19 (Sars-cov-2 PCR) via nasal swab on 06Jan2021, covid test result was negative. Patient was found pulseless and breathless 20 minutes following the vaccine administration (11Jan2021 12:30 AM). MD found no signs of anaphylaxis. Patient died on 11Jan2021 12:30 AM because of cardiac arrest. No treatment received for the events. Outcome of pulseless and breathless was unknown. the autopsy was performed, and autopsy remarks was unknown. Autopsy-determined cause of death was unknown. It was reported as non-serious, not results in death, Life threatening, caused/prolonged hospitalization, disabling/Incapacitating nor congenital anomaly/birth defect.; Sender''s Comments: Based on the available information this patient had multiple underlying medical conditions including morbid obesity, diastolic CHF, epilepsy, pulmonary hypertension and COVID-19 diagnosed prior to vaccination. All these conditions more likely contributed to patients cardiac arrest resulting in death. However, based on a close temporal association ("Patient was found pulseless and breathless 20 minutes following the second dose of BNT162B2 vaccine administration, contributory role of BNT162B2 vaccine to the onset of reported events cannot be completely excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Cardiac arrest; Autopsy-determined Cause(s) of Death: autopsy remarks was unknown. Autopsy-determined cause of death was unknown


VAERS ID: 941215 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-01-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Aortic valve replacement (Verbatim: Aortic valve replacement)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021018269

Write-up: Actual event and cause of death were unknown; This is a spontaneous report from a non-contactable consumer. A 90-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 06Jan2021 at single dose for COVID Prevention. The relevant medical history included aortic valve replacement from Nov2019. Concomitant medications were not reported. The consumer stated that she was taking the reporting responsibilities to report that a friend of hers, informed that the patient passed away on Friday, and had received the COVID vaccine on Wednesday. The consumer stated that it was unknown to her at this time, if the friend had called to complete a report herself, regarding the incident. Their conversation was very brief. The patient was 90 years old, and it was her friend''s mother that was the patient. Actual event and cause of death were unknown. The patient had her vaccine on Wednesday 06Jan2021, and then the patient collapsed in front of the reporter at Friday night on 08Jan2021 and passed away that same day. The autopsy was unknown. The outcome of the event was fatal. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Actual event and cause of death were unknown


VAERS ID: 941561 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Decreased appetite, Grip strength decreased, Hemiplegia, Hypotonia, Speech disorder, Weight decreased
SMQs:, Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (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), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram Oxalate, Metformin ER, Systane balance, Colace, Refresh tears, Milk of Magnesia, Diltiazem
Current Illness: Resident was on hospice for Alzheimer''s disease.
Preexisting Conditions: Alzheimer''s Disease, Type II diabetes, Major depression disorder, Elevated B/P readings with Hypertension, history of stroke (7/22/2019 - Acute Lacunar Stroke)
Allergies: No known Allergies
Diagnostic Lab Data: Resident was declining for some time. He normally had a high heart rate. Appetite was poor with a significant weight loss noted.
CDC Split Type:

Write-up: Staff walked into resident''s room around 10:00am and noted resident''s left side of his face was flaccid. Nurse was called and upon assessment resident noted to have an unequal hand grasp with left worse. He was able to talk but was mumbled and hard to understand. Physician, hospice, and family were notified. Resident had a stroke at 10:06 am on 1/8/2020. He lost all ability to use his left side. Resident passed away on 1/11/2020.


VAERS ID: 941607 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anal incontinence, Death, Hypotonia, Unresponsive to stimuli
SMQs:, Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 325mg, Lasix 20mg, Senna 8.6mg, Aspirin 81mg, Levothyroxine 75mcg
Current Illness: N/A
Preexisting Conditions: End stage dementia, cerebro vascular disease, Hx left vertebral artery aneurysm
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: The patient passed away today, 1/13/2021. She was a hospice patient. She showed no adverse effects after receiving the vaccine on 1/12/2021. This morning she woke up as normal and during her morning shower she had a bowel movement, went limp and was non-responsive. The patient passed away at 7:45 am.


VAERS ID: 941743 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amitiza, Anastrozole, Calcium Carbonate, Levemir, Novolog, Docusate, Fiber Lax, Fluvoxamine Maleate, Gavilax, Glucerna, Ketoconazole, levetiracetam, loratadine, Selenium sulfide lotion, vimpat, vitamin D3, Prolia AS needed medications: fle
Current Illness: None
Preexisting Conditions: Benign polycythemia, Type II DM, Anxiety, Epilepsy, Blepharitis (bilateral), cataract (not specified), Allergic rhinitis, constipation, scoliosis, osteoporosis, dyspahgia, urinary incontinence, Dermatitis, breast cancer (right breast lumpectomy), history of respiratory infection, DNR AND MOLST were in place at time of death
Allergies: No known drug or food allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This person was found to be deceased on routine rounds during the night, 3am. No symptoms of reaction noted post vaccine. No injection site reaction. No reports of any allergic reaction.


VAERS ID: 941811 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-04
Onset:2021-01-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Albumin urine present, Bacterial test positive, Chest X-ray abnormal, Death, Hypoxia, Lung infiltration, Pyrexia, Respiratory distress, Respiratory failure, SARS-CoV-2 test negative, Sepsis, Urine leukocyte esterase positive, White blood cell count normal, White blood cells urine positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Haldol 2mg TWICE DAILY, DEPAKENE 750MG THREE TIMES
Current Illness: NONE
Preexisting Conditions: HUNTINGTON''S CHOREA, HTN, HLP, HYPOTHYROID, DEPRESSION, CONSTIPATION, AND DYSPHAGIA
Allergies: NKDA & NO FOOD ALLERGIES
Diagnostic Lab Data: CXR on 1/11/21: Suspicion of minimal infrahilar infiltrates bilaterally. U/A on 1/11/21: Leuk Esterase 3+, Albumin 2+, Few Bacteria, White cells 10 CBC on 1/11/21: WBC 8.9
CDC Split Type:

Write-up: Resident began having fever on 1/11/21 @0600. VS= T-102 B/P- 100/57 P- 112 RR- 24 O2 Sat 92% on RA. MD called. Rapid COVID Test was negative. CBC,CMP, U/A were ordered as well as CXR. Resident''s condition declined. At 3:00pm resident started having respiratory distress and hypoxia O2 Sat 89%. Supplemental O2/mask @ 5LPM. Neb TX, EKG, and Rocephin 1 GM ordered. Condition worsened. Resident sent to nearest ER for evaluation. Later in the evening the staff AT Medical Center called to inform staff that resident had expired @ 2230 as a result of Respiratory Failure and Sepsis.


VAERS ID: 942040 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dizziness, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none
Preexisting Conditions: yes
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: little bit of a reaction light headed after 5 minutes. vitals were low, so observed for 30 minutes after being light headed. Patient was found unresponsive and pronounced dead later that day.


VAERS ID: 942072 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Vermont  
Vaccinated:2021-01-02
Onset:2021-01-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Death, Dementia, SARS-CoV-2 test negative
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   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: Tramadol, risperidone, fluoxetine, cyanocobalamin, colchicine, torsemide, levothyroxine
Current Illness: aspiration pneumonia- completed treatment prior to vaccination.
Preexisting Conditions: Advanced dementia with severe violent behavioral symptoms. Progressive decline and frailty due to late stage dementia with likely terminal aspiration after completion of treatment for previous aspiration pneumonia. Death attributed to complications of her advanced dementia. No evidence of acute reaction to vaccine (rash, dyspnea, swelling, redness). Chronic kidney disease, hypothyroidism, type 2 diabetes, gout, B12 deficiency
Allergies: No known allergies
Diagnostic Lab Data: COVID-19 PCR neg on 12/31/20 and 1/3/21
CDC Split Type:

Write-up: Death occurred 3 days after vaccine receipt; attributed to complications of her chronic advanced dementia with aspiration at age 87. No evidence of acute vaccine reaction.


VAERS ID: 942085 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-01-02
Onset:2021-01-08
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Dyspnoea, Livedo reticularis, Pain, Pulse absent, Tremor, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ativen, Butrans Patch, Tylenol, Potassium Citrate-Citric Acid
Current Illness: Medical diagnosis: quadriplegia, Atherosclerotic heart disease
Preexisting Conditions: see #11.
Allergies: Amoxicillin, Clavulanic Acid, Codeine, Morphine, Pencillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse effects from vaccination seen on 1/2/21. On 1/6/21 resident was seen by Dr and her baclofen pump was refilled with 20 ml Baclofen 4,000mcg/ml. ITB Rate increased by 6% to 455.5 mcg/day simple continuous rate over 3 days. On 1/8/21 at 0615 resident was shaking, lower extremities mottled, Sa02 70%, pulse 45. Oxygen started at 2 L/m per NC. At 0715 her primary physician was notified as well as her daughter. Oxygen increased to 4 L/min, sats at 83%. SOA noted, reported all over pain. At 0850 when they attempted to reposition the resident, she was not responsive. Licensed nurse assessed her and no heartbeat heard or pulse found.


VAERS ID: 942106 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Cardiac arrest, Chest pain, Pain, Pulse absent, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 54 y/o M with PMH of HTN, HLD, Alcoholic Cirrhosis, Aortic Valve Stenosis, and angina BIBA as a Medical Alert for cardiac arrest noted PTA. Per EMS, the patient called because he was having constant, diffuse abdominal pain x 1 day that radiated to his chest. On scene, the patient had a witnessed arrest with EMS starting CPR. He was given 3 rounds of epi without ROSC. Pt had no associated shockable rhythm. Of note, pt''s wife, had noted pt had received covid vaccine the prior day.


VAERS ID: 942290 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-04
Onset:2021-01-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Crepitations, Death, Decreased appetite, Dizziness, Dyspnoea, Fall, Hospice care, Hyperhidrosis, Lethargy, Leukaemia, Nausea, Pyrexia, SARS-CoV-2 test negative, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), 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), Cardiomyopathy (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Haematological malignant tumours (narrow), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Influenza Virus Vaccines - Unknown date/type or brand
Other Medications: Tylenol, tylenol with codeine, Artificial Tears, ASA, Cal-Mag-Zinc, Claritin, Sertraline, Melatonin, MOM, Latuda, Estradiol, Gabapentin, Alendronate, Atorvastatin, Multi-Vit
Current Illness:
Preexisting Conditions: Glaucoma, Low back pain, restless leg syndrome, Osteoporosis, Compression Fx-Lumbar
Allergies: Dilaudid; Morphine Sulfate; Sulfonamides; Influenza Virus Vaccines
Diagnostic Lab Data: Resident has allergy to Influenza Virus Vaccines, pharmacists were informed of this prior to resident receiving the vaccine and both pharmacists stated that was not a risk factor.
CDC Split Type:

Write-up: Resident received 1st dose on 1/4/2021. On 1/6/2021 resident having SOB, increased weakness with O2 sats at 91% RA. On 8th resident sustained a fall, O2 sats 88-92, dizzy, weakness. Rapid COVID test performed with negative results. Evening of 8th resident was lethargic and diaphoretic with fever of 99.9. Resident transferred to ER, on 5lt of oxygen. Resident returned from the ER on 1/9/2021 with new diagnosis of Leukemia and orders for hospice. Continued with fever, crackles and N/V and loss of appetite from the 9th and 10th of January. Resident expired at 820am on 1/11/2021.


VAERS ID: 943266 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cerebral haemorrhage, Coma, Craniotomy, Death, Endotracheal intubation, Headache, Intracranial aneurysm, Magnetic resonance imaging brain abnormal, Vomiting
SMQs:, Acute pancreatitis (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Losartan, Levothyroxine, Carvedilol
Current Illness:
Preexisting Conditions: Arthritis, high blood pressure
Allergies: Penicillin, Sulfa, Gluten
Diagnostic Lab Data:
CDC Split Type:

Write-up: Initial pain in back of head and extreme headache. Some vomiting. At emergency, went into coma and was intubated. Hole drilled in skull to relieve pressure. MRI taken. Lot of bleeding in brain - anuerism lead to death approximately 14 hours after initial symptoms.


VAERS ID: 943362 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown none reported
Current Illness: none known
Preexisting Conditions: none
Allergies: none reported
Diagnostic Lab Data: currently undergoing preliminary autopsy
CDC Split Type:

Write-up: Pt collapsed at home approx 5:30 pm and died


VAERS ID: 943397 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2020-12-23
Onset:2021-01-11
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1862 / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Ceclor, Penicillin, Sulfa
Diagnostic Lab Data: No labs or tests.
CDC Split Type:

Write-up: On day due for 2nd dose, Patient was found unresponsive at work in the hospital. Patient pupils were fixed and dilated. Full ACLS was initiated for 55 minutes with multiple rounds of bicarb, calcium chloride, magnesium, and epinephrine. Patient was intubated. Patient continued into V. Fib arrest and was shocked multiple times.


VAERS ID: 943442 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Georgia  
Vaccinated:2020-12-30
Onset:2020-12-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM

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

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

Write-up: Systemic: reported by staff patient expired under suspicious circumstnces after receiving vaccine. Patient was on hospice, reported not expected to pass this soon; symptoms lasted 0 days


VAERS ID: 943889 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Other       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: 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: Alvesco, Amiodarone, Lipitor, Atrovent, Coreg, Cymbalta, Guaifenesin, Keppra, Levothroid, Megace, Protonix, Potassium, Prednisone, Rifampin, Carafate, Bactrim, Flomax
Current Illness: Rigth femur fracture, GI bleed
Preexisting Conditions: Hypertension, seizure, hypothyroidism, CHF
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reactions observed after administration of medication. Patient starting complaining of shortness of breath around 0500 the following morning. SP02 checked in the 80s. Patient expired 01/09/2021;


VAERS ID: 944282 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-05
Onset:2021-01-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Congestive heart failure; Heart failure; Open wound; Type 2 diabetes mellitus; Wound infection
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021016129

Write-up: resident coded on 09Jan at 8am and expired; This is a spontaneous report from a contactable Other Health Professional. A 70-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Batch/lot number: EL0140), intramuscularly in left arm on 05Jan2021 15:15 at single dose for COVID-19 immunization. Medical history included DM2(Type two diabetes mellitus), CHF(congestive heart failure), open wound, wound infection, heart failure. Allergies to medications, food, or other products: none. Concomitant medications included unspecified products (List of any other medications the patient received within 2 weeks of vaccination: yes). If the patient received any other vaccines within 4 weeks prior to the COVID vaccine: Unknown. Facility where the most recent COVID-19 vaccine was administered: Nursing Home/Senior Living Facility. The resident coded on 09Jan2021 at 8 AM and expired. The patient died on 09Jan2021. An autopsy was not performed. AE resulted in: patient died. Death cause: unknown at this time. Was treatment received for the adverse event: Unknown. Prior to vaccination, was the patient diagnosed with COVID-19: No. Since the vaccination, has the patient been tested for COVID-19: No. Serious: Yes. Seriousness criteria-Results in death: Yes. Seriousness criteria-Life threatening: No. Seriousness criteria-Caused/prolonged hospitalization: No. Seriousness criteria-Disabling/Incapacitating: No. Seriousness criteria-Congenital anomaly/birth defect: No.; Sender''s Comments: The old patient had diabetes mellitus, congestive heart failure, open wound complicated by infection, all these pre-existing medical conditions contribute to the patient death. More information including complete medical history, concomitant medications and event term details especially death cause and autopsy results are needed for a full assessment of the case. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate; Reported Cause(s) of Death: resident coded on 09Jan at 8am and expired


VAERS ID: 944365 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2020-12-26
Onset:2020-12-30
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Diazepam, Levothyroxine, Magnesium Oxide, Olanzapine, Omeprazole, Sertraline, and Vitamin D3
Current Illness: None
Preexisting Conditions: Schziophrenia
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident expired on 12/30/20, dx cardiac arrest.


VAERS ID: 944439 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2020-12-26
Onset:2021-01-03
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Keppra, Levothyroxine, Miralax, Olanzapine, Trazadone, Risperidone, and Lorazepam
Current Illness: Receiving hospice services
Preexisting Conditions: Stage 4 kidney function
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident expired on 1/2/21.


VAERS ID: 944595 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: losartan, spironolactone, carvedilol
Current Illness: No known new illnesses,
Preexisting Conditions: Cardiomyopathy
Allergies: nkda
Diagnostic Lab Data: mulitple Full ER code and then ICU support for 2 days
CDC Split Type:

Write-up: Cardiac arrest within 1 hour Patient had the second vaccine approximately 2 pm on Tuesday Jan 12th He works at the extended care community and was in good health that morning with no complaints. He waited 10-15 minutes at the vaccine admin site and then told them he felt fine and was ready to get back to work. He then was found unresponsive at 3 pm within an hour of the 2nd vaccine. EMS called immediately worked on him 30 minutes in field then 30 minutes at ER was able to put him on life support yet deemed Brain dead 1-14-21 and pronounced dead an hour or so later


VAERS ID: 944641 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin 80mg daily, biotin 2500mg daily, Calcium-Mag-Zinc tab daily, Restasis eye drop q12hr, ezetimibe 10mg qhs, gabapentin 100mg bid, lysine 1000mg daily, metoprolol tart 50mg bid, fish oil 1000mg daily, prilosec 20mg daily, ranola
Current Illness: CAD, angina, coronary bypass in 1990''s, Cardiac Cath on 12/28/2020
Preexisting Conditions: CAD
Allergies: Sulfa
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient died on 1/21-2021


VAERS ID: 944732 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K2OA / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (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: 2021-01-14
   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: Cholecalciferol, furosemide, metoprolol tartrate, tamsulosin, amlodipine, finasteride
Current Illness: Covid-19 infection from 12/31-01/10/2021
Preexisting Conditions: CHF, atrial fibrilation, Dysphagia, macular degeneration, Vitamin D deficiency, impaired fasting glucose, benign prostatic hyperplasia, osteoporosis, retention of urine, anemia
Allergies: hydrocodone
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Resident found unresponsive and without pulse at 05:45am.


VAERS ID: 944998 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-04
Onset:2021-01-12
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Headache, Malaise, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: Resident in skilled nursing facility. Please contact facility if needing all medications.
Current Illness:
Preexisting Conditions: Asthma, hypothyroidism, essential hypertension, atherosclerotic heart disease of native coronary artery, spinal stenosis, fibromyalgia, dementia. Please contact nursing facility for further needed information.
Allergies: Phenazopyridine, Demerol, Pyridium, Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/11/21 noted with headache, nausea/vomiting, severe melaise. On 1/12/21 resident expired.


VAERS ID: 945241 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Exposure to SARS-CoV-2, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: UNK
Current Illness: UNK
Preexisting Conditions: UNK
Allergies: UNK
Diagnostic Lab Data:
CDC Split Type:

Write-up: 71yo female resident who died after receiving Pfizer BioNTech vaccine. On 1/14/2021, VS taken at 10am, B/P 99/60, O2 sats, 95% (trach w/O2). At 11:30am, Patient showed no s/sx of distress, A&Ox3. At 11:50am, a nurse went to perform a COVID test and assessment (the facility is experiencing an outbreak), and found the patient unresponsive on the bathroom floor. CPR was immediately started; no shock advised per AED; 12:15pm EMS arrived and took over. At 12:38pm, EMT called time of death.


VAERS ID: 945247 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2020-12-29
Onset:2021-01-05
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Chest X-ray normal, Death, Dysphagia, Hemiparesis, Urinary tract infection, Urine analysis abnormal
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: depakote, lexapro, lisinopril, multiple vitamin, senna, seroquel, tylenol
Current Illness: Nothing acute prior
Preexisting Conditions: dementia, hypertension, depression, delusions, anxiety
Allergies: aricept, namenda, penicillin, actonel, erythromycin, niacin
Diagnostic Lab Data: Urinalysis did show a UTI and CXR was negative for aspiration pneumonia. Family did not want her sent to the hospital. She died on 1/13/21
CDC Split Type:

Write-up: Has underlying dementia and often with difficulty eating. 1 week after immunization she developed a stroke with left sided weakness and difficulty swallowing. Comfort measures instituted. Not sure if this is related to the vaccine, but thought I should report


VAERS ID: 945253 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Feeling abnormal, Nausea, Pulse absent, Respiratory arrest, Restlessness, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Akathisia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: UNK
Current Illness: UNK
Preexisting Conditions: UNK
Allergies: UNK
Diagnostic Lab Data: UNK
CDC Split Type:

Write-up: 83yo female resident who died after receiving Pfizer BioNTech vaccine. On 1/14/2021, the patient reportedly got up in the middle of the night with c/o feeling "blah", restlessness, and nausea. VS normal, no other s/sx. At 4:15am, the patient was asked to go back to bed, assisted by a nurse and GNA. At 6am, GNA was going to do morning VS and found the patient unresponsive, no pulse, no respirations. GNA notified the nurse. At 6:03am, CPR started and EMS called. At 6:15am, EMS arrived and took over. At or around 6:30am, EMT called time of death


VAERS ID: 945578 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-01-02
Onset:2021-01-10
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Hyporesponsive to stimuli, Livedo reticularis, Skin discolouration
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic 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: 2021-01-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg, metformin, namenda, effexor XR, donepezil, potassium chloride, Vitamin B12, Brillinta, clonzepam, flomax, ultram, oxybutynin chloride, sucralfate, ferrous sulfate, protonix, percocent, metoprolol succinate ER, senna Colace, n
Current Illness: Had a tooth extraction done on 1/6/21. Was on amoxicillin for 7 days and it caused diarrhea. Changed to Keflex.
Preexisting Conditions: Dementia, COPD, Type 2 DM, Atherosclerotic Heart Disease, Depression, Hypertensive Heart disease without heart failure GI hemorrhage, calculus of ureter, systolic CHF, Peripheral vascular disease, GERD, anxiety.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reactions immediately after vaccine was given. Resident has dementia, has had multiple hospitalizations related to a renal stone recently. Had a tooth that was bothering her, went to see her dentist and it was extracted on 1/6/21. On 1/10 they noted feet and ankles are dark purple with white splotches appears to be mottling. Minimally responsive to voice and touch. Not eating. Compassionate visit with family. Family did not want hospice, did not feel it was needed, said, what more could they do for her than you''re already doing? On 1/11 at 1950 was determined to be deceased.


VAERS ID: 945603 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-02
Onset:2021-01-08
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0412 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac pacemaker evaluation, Cyanosis, Metabolic function test, Pulse absent
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Verapamil ER, Pepcid, Norco, Vit D3, synthroid, flecainide Ace acetate, mucinex, lisinpril, amitriptyline, eliquis, atorvastatin, furosemide, acetaminophen, Coenzyme Q-10, metoprolol succinate ER
Current Illness: Hospitalized for abnormal heart rhythm 12/18/20.
Preexisting Conditions: anemia, hypothyroidism, BPH, paroxysmal atrial fib, HTN, atherosclerotic heart disease, Chronic Kidney dz stage 3, CHF
Allergies: NKA
Diagnostic Lab Data: 1/5/21 BMP drawn
CDC Split Type:

Write-up: Had no immediate issues with the vaccine. He had returned from the hospital on 12/21 and had some concerns about his weight which were shared with his physician on 1/4/21. On 1/5/21 had a visit with his cardiologist for a pacemaker check. On 1/8/21 staff were called to his room, he was on the floor, bluish skin color. No vital signs found, no heart rhythm heard at 2200.


VAERS ID: 963167 (history)  
Form: Version 1.0  
Age: 88.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-01-02
Onset:2021-01-04
   Days after vaccination:2
Submitted: 2021-01-08
   Days after onset:4
Entered: 2021-01-14
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE


VAERS ID: 967754 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-21
Onset:2021-01-05
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death - unknown cause, no reported side effects Narrative: Unknown cause of death


VAERS ID: 1349711 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2020-12-22
Onset:2021-01-07
   Days after vaccination:16
Submitted: 2021-01-11
   Days after onset:4
Entered: 2021-01-14
   Days after submission:3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD039K20A / 2 RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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: Symptoms: & cardiopulmonary arrest Treatment: EPINEPHRINE 8 MG Unknown during code


VAERS ID: 1349910 (history)  
Form: Version 1.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 2021-01-08
   Days after onset:1
Entered: 2021-01-14
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Symptoms: & Death


VAERS ID: 946225 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Death, Rash, Respiratory tract congestion
SMQs:, Anaphylactic reaction (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 1
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: CloZAPine 550 mg QD, Clozaril 150 mg QD, Ergocalciferol Capsule 1.25 MG (50000 UT) QD, MiraLax Powder 17 gram QD, Multivitamin QD, Remeron 45 MG QD, Sertraline HCl 200 mg QD, Simvastatin 20 MG QD, Synthroid Tablet 75 MCG QD, Tricor 14
Current Illness:
Preexisting Conditions: Dx with Covid-19 on 12/11/2020, PERIPHERAL VASCULAR DISEASES, SCHIZOAFFECTIVE DISORDER, BIPOLAR DISORDER, EPILEPSY, HYPERLIPIDEMIA, SECONDARY PARKINSONISM, MAJOR DEPRESSIVE DISORDER, ANXIETY DISORDER, HYPOTHYROIDISM, HYPERTENSION, OBESITY, and UNSPECIFIED CHRONIC BRONCHITIS,
Allergies: Lithium
Diagnostic Lab Data: No testes were done at the facility. Unsure what was performed in the ER.
CDC Split Type:

Write-up: At approximately 10:30pm on 1/14/2021, resident was noted to have a rash on her face, hands, arms, and chest. VS:100.2, 113, 20,108/59, 84% room air. applied nasal cannula at 4-L, telephoned Physician orders 6mg Decadron one time order, a second set of Vitals , reads 99.3, 110, 20, 106/60, 90% on 4-L N/C. On coming shift advised. At approximately 2:00am on 1/15/2021, resident congested and coughing. BP 151/70, pulse 124, temp 98.1 forehead, resp 20 and pulse oc 79% on 3L. At approximately 2:30am PRN cough syrup and breathing tx. Resident''s condition began to worsen with breathing tx. This LPN updated at 0248 doctor on resident''s condition. Doctor gave permission for resident to go to hospital. At 4:19am the Er called to say resident passed away.


VAERS ID: 946293 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alvesco inh, Mepron susp, Coreg, Zetia, Tricor, Umeclidinum, Cellcept, Zyprexa, Prilosec, paxil, Miralax, prednisone, trazodone, xopenex inh
Current Illness: Pulmonary fibrosis on O2
Preexisting Conditions: COPD,Severe pulmonary fibrosis,HTN,GERD
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: 51 year old M with h/o O2 dependent COPD, Severe pulmonary fibrosis became increasingly hypoxic around 1800hours 1/7/2021. He was transported to hospital for acute on chronic hypoxia respiratory failure. On 1/12/2021 he decompensated further, and after discussing with family and palliative care, He was changed to comfort care. He expired on 1/12/2021@2325 at medical center.


VAERS ID: 946959 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-14
Onset:2021-01-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Post COVID-19 complications, A-fib, CHF
Preexisting Conditions: Diabetes,
Allergies: None
Diagnostic Lab Data: Unsure, autopsy pending
CDC Split Type:

Write-up: Sudden death 18 hours post vaccine .


VAERS ID: 947129 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Georgia  
Vaccinated:2020-12-23
Onset:2020-12-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 AR / IM

Administered by: Private       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: 2021-01-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Digoxin, Diltiazem CR, Namenda CR, Toprol XL, Acetaminophen, Vitamin D, Zyrtec
Current Illness: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Preexisting Conditions: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received Moderna vaccine on 12/23/2020 around 5 pm. At approximately 3:35 am on 12/25/2020, resident had a CVA and died on 1/1/2021 at 3:00 am.


VAERS ID: 947642 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-07
Onset:2021-01-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021025817

Write-up: died two days after receiving the vaccine; Fever; This is a spontaneous report from a contactable consumer (patient''s stepchild). A 66-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, on 07Jan2021 (at the age of 66-years-old) as a single dose for COVID-19 immunization. The patient''s medical history was not reported. Concomitant medications included an unspecified statin. The patient experienced fever on 08Jan2021. The patient died two days after receiving the vaccine on 09Jan2021, which was reported as fatal. The clinical course was reported as follows: The patient had a fever the day after getting the vaccine and then he just died in the middle of night. It was reported that it was not clear what exactly happened, but they are looking into this. The clinical outcome of fever was unknown and of died two days after receiving the vaccine was fatal. The patient died on 09Jan2021. The cause of death was not reported. An autopsy was not performed (was reported to be taking place soon). The batch/lot number for the vaccine, BNT162B2, was not provided and has been requested during follow up.; Reported Cause(s) of Death: died two days after receiving the vaccine


VAERS ID: 947662 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2020-12-30
Onset:2021-01-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, Hypophagia, Hyporesponsive to stimuli, Somnolence
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (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: 2021-01-06
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC Split Type:

Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death


VAERS ID: 947841 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: unknown.
CDC Split Type:

Write-up: Patient had no immediate effects from the vaccine, but died approximately 8 hours after receiving first dose of vaccine.


VAERS ID: 948150 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LL / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Blood pressure decreased, Breath sounds abnormal, Death, Dyskinesia, Fatigue, Hyperhidrosis, Incontinence, Loss of consciousness, Muscular weakness, Oxygen saturation decreased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dyskinesia (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: MANTOUX; ACIDOPHILUS; ALPHA LIPOIC ACID; ASPIRIN EC; BUMETANIDE; C-GEL; ESCITALOPRAM; PROSCAR; KRILL OIL; LEVOTHYROXINE; MAGOX; K-DUR; FLOMAX; VITAMIN B-12; VITAMIN D3; LIORESAL; CALCIUM CITRATE; COCONUT OIL; CURCUMIN; PROAMATINE; PRESERVIS
Current Illness: pneumonia,
Preexisting Conditions: A-FIB; HYPERCHOLESTEROLEMIA; CKD 3; BPH; DEPRESSION; CERVICAL DISC DISORDER; SPINAL STENOSIS; BLADDER; COPD
Allergies: ibuprofen,sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: increase weakness and fatigue, weakness in extremities, incontinent, jerky arm movements, within first 24 hours, continue to decline sent to hospital returned weaker, within 24 hrs hours BP dropped, low pulse oximeter reading, diaphoretic, lung sounds diminished, loss consciousness and passed away. 01-12-2021


VAERS ID: 948164 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-06
Onset:2021-01-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 02SL20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Chest X-ray, Chest pain, Computerised tomogram, Computerised tomogram abdomen, Confusional state, Decreased appetite, Full blood count, Headache, Hepatic enzyme increased, Metabolic function test
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Multivitamin, Zinc, Doxycycline, Ultram, Xanax, Pepcid, Nitroglycerin, Tylenol, Simethicone, Metoprolol Succinate ER, Loperamide, Levothyroxine,
Current Illness: UTI and Sinus infection
Preexisting Conditions: Encephalopathy, Type 2 diabetes, Morbid obesity, hypothyroidism, CKD, HTN, iron deficiency anemia, Atrial fibrillation, IBS,
Allergies:
Diagnostic Lab Data: CT- 1/14/21, chest x-ray 1/14/21 & 1/15/21, abdomen CT 1/14/21; CBC, CMP, Liver panel 1/14/21
CDC Split Type:

Write-up: Abdominal pain, Headaches, chest pain, loss of appetite, confusion, elevated liver enzymes 1/8-1/15/21


VAERS ID: 948181 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Michigan  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Heart rate irregular
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (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: ANORA, Albuterol, Flovent, Bumex, Carvediol; omeprazole
Current Illness:
Preexisting Conditions: COPD, CHF, renal; ASCVD; MI hx
Allergies: 0
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Chest pain; irreg heart rhythm; evening of vaccine; death on toilet on 1/13/21


VAERS ID: 948228 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL 1284 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reportedly expired the day following receipt of the vaccine.


VAERS ID: 948418 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-01-07
Onset:2021-01-12
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / UNK LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: Unknown
Current Illness: Received 1st Covid vaccine 12/18/2020; 2nd 1/7/2021. This patient is now deceased 1/12/2021.
Preexisting Conditions: Per patient health history: hearing loss, asthma, bronchiolitis, chronic cough, anemia, depression
Allergies: No known
Diagnostic Lab Data: Autopsy pending;
CDC Split Type:

Write-up: Expired on 1/12/2021; unknown cause of death


VAERS ID: 948428 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / SYR

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

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

Write-up: We got a call from a home health nurse Brandu Talamo, stating that the patient passed away.


VAERS ID: 949474 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Respiratory arrest, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: Melatonin 3mg PO QHS Amlopidine Besylate 5mg PO QD Atorvastin Calcium 20mg PO QHS Carbidopa-Levodopa 25-100mg PO TID Multiple Vitamin 1 PO QD Senna 8.6mg PO BID Calcium-Vitamin D 600mg PO BID Metformin HCl 500mg PO BID Rivastigmine patch 9
Current Illness: None but he has History of COVID-19 previously when initially admitted to the facility.
Preexisting Conditions: Parkinson''s Disease, Diabetes Mellitus Type 2, Hyperlipidemia, Dementia, ASHD, Psychosis, Hypertension, Dysphagia, Acute Sinusitis
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident had lunch on 01/14/21 and after lunch around 2:00pm, he vomited and stopped breathing. We coded the resident and 911 paramedics came. They pronounced him dead at 2:18pm.


VAERS ID: 949523 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-13
Onset:2021-01-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Ascorbic Acid Tablet 500 MG GT QD Multi-Vite Liquid (Multiple Vitamins-Minerals) 15 ml GT QD Famotidine Tablet 20 MG GT BID Memantine HCl Tablet 10 MG GT BID Polyethylene Glycol 3350 Kit 7gm GT QD Senna Tablet 8.6 MG (Sennosides) 2 tablets
Current Illness: None
Preexisting Conditions: History of Stroke, Diabetes Mellitus Type 2, Dementia, Dysphagia, Depression, Pressure Injuries Sacral and Left Heel
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Around 00:50am on 01/15/21, C.N.A. reported that the resident looked different and not responding. Initiated Code Blue and started CPR. 911 arrived and pronounced resident dead at 1:01 am.


VAERS ID: 949630 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-01-02
Onset:2021-01-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure decreased, Death, Hypophagia, Hypotension, Hypoxia, Oxygen therapy, Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Senna-S, cranberry pills
Current Illness: Redness to left foot about 1 week prior to vaccination that resolved a few days prior
Preexisting Conditions: Advanced Dementia, Seizure disorder, CAD, prior stroke, HTN
Allergies: Simvastatin
Diagnostic Lab Data: None as she was under hospice care
CDC Split Type:

Write-up: This patient has been under hospice care for over 2 years at the nursing home. She has had a steady decline with gradual weight loss. She was totally dependent in her care needs. She received the vaccine on 1/2/2021 as part of the facility vaccination campaign. No adverse events noted initially. On 1/3/2021 at 6:06 pm, she was noted on vital sign checks (done every 4 hours for first 72 hours after vaccination) with BP 64/52 but otherwise asymptomatic. Subsequent BP improved. On 1/4/2021 at 4:45 am, pt found with respiratory rate of 30 with otherwise normal vital signs. Tachypnea persisted, so she received liquid morphine 2.5 mg without improvement. Supplemental oxygen was applied. Tachypnea persisted. She had poor oral intake after that point had persistent tachypnea and worsening hypoxemia despite clear lungs on exam. She remained under hospice care and comfort measures were continued. No blood testing or imaging tests were done. She required increasing amounts of oxygen, became hypotensive, and died peacefully on 1/8/2021 at 7:45 pm.


VAERS ID: 949657 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: D.C.  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Posture abnormal, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dystonia (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: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xarelto ,topical lidocaine patch
Current Illness:
Preexisting Conditions: Atrial fibrillation, Congestive heart failure, Anterior ischemic optic neuropathy of right eye
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Veteran was found by family slumped over and unresponsive at the breakfast table on 1/13/21, had expired


VAERS ID: 949965 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-01-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood culture negative, Bradycardia, Chest X-ray normal, Culture urine negative, Death, Hypotension, Hypothermia, Laboratory test normal, Respiratory viral panel, Unresponsive to stimuli, Viral test, Viral test negative
SMQs:, Anaphylactic reaction (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), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No cause of death found on labs/cxr including cultures (blood and urine) that are now growth to date and viral respiratory pcr that was negative.
CDC Split Type:

Write-up: Patient 101 years old, nursing home resident, received vaccine 1/11, on 1/13 found on floor without obvious trauma, unresponsive. Brought to ED and was bradycardic, hypotensive, hypothermic and refractory to aggressive medical management. No obvious cause of death found on exam or labs, cxr. Unknown if event could be related to vaccine or not. Medical Examiner accepted case although initially unknown that patient had recently received vaccine. ME updated with that information today as soon as discovered.


VAERS ID: 950057 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hydrocephalus with ventricular shunting Prior history of leukemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient suffered a cardiac arrest and was unable to give details about her symptoms. Per husband, patient did not complain of any symptoms after vaccine administration. She began seizing without warning which was complicated by cardiac arrest of uncertain etiology


VAERS ID: 950073 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Death, Headache, Lethargy, Mycobacterium tuberculosis complex test negative, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Arthritis (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC Split Type:

Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21.


VAERS ID: 950108 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-12
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Catheterisation cardiac abnormal, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 3
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: Unknown
Current Illness: Pt. stated she was not ill at the time of vaccination.
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: "Moderna COVID-19 Vaccine EUA" It has been reported to me that pt. had gone into hospital for a heart catheterization on 1/12/2021. It was found during this procedure that pt. had suffered a MI. She was release to home the following day and passed away at her residence on 1/15/2021.


VAERS ID: 950441 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-15
Onset:2021-01-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adjusted calcium, Alanine aminotransferase increased, Albumin globulin ratio, Anion gap, Aspartate aminotransferase increased, Band neutrophil percentage decreased, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride decreased, Blood creatinine normal, Blood glucose normal, Blood magnesium increased, Blood potassium decreased, Blood sodium decreased, Blood urea nitrogen/creatinine ratio, Blood urea normal, Carbon dioxide normal, Cardiac arrest, Death, Differential white blood cell count abnormal, Echocardiogram abnormal, Eosinophil count normal, Eosinophil percentage, Full blood count abnormal, Globulin, Glomerular filtration rate, Haematocrit normal, Haemoglobin normal, Immature granulocyte percentage increased, Lymphocyte count normal, Lymphocyte percentage increased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume increased, Mean platelet volume increased, Mechanical ventilation, Metabolic function test abnormal, Monocyte count normal, Monocyte percentage, Neutrophil count normal, Neutrophil percentage decreased, Neutrophil toxic granulation present, Platelet count normal, Protein total normal, Pupil fixed, Red blood cell count normal, Red blood cell nucleated morphology present, Red cell distribution width normal, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), 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), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Hypokalaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide Toprol XL spironolactone prasugrel furosemide Vit D3 albuterol inhaler sildenafil aspirin 81mg Crestor nitroglycerin SL singulair testosterone gel levothyroxine
Current Illness: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris
Preexisting Conditions: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris lower extremity edema
Allergies: Walnuts
Diagnostic Lab Data: 1/15/2021 CBC WITH AUTO DIFF - Abnormal Result Value WBC 8.8 RBC 5.1 Hgb 15.7 Hematocrit 49.5 MCV 97.1 (*) MCH 30.8 MCHC 31.7 (*) Red Cell Distribution Width 14.3 Platelets 173 Mean Platelet Volume 11.4 COMPREHENSIVE METABOLIC PANEL - Abnormal Glucose 167 (*) Blood Urea Nitrogen 14 Creat, Serum 1.2 Sodium 134 (*) Potassium 3.1 (*) Chloride 93 (*) CO2 25 Anion Gap 16 (*) Calcium 9.9 Total Bilirubin 1.0 Alkaline Phosphatase 126 AST 62 ALT (SGPT) 41 Total Protein 6.7 Albumin 3.6 Globulin, Total 3.1 A/G Ratio 1.16 BUN/Creatinine Ratio 11.67 Corrected Calcium 10.2 eGFR $g60.00 Narrative: Specimen slightly hemolyzed, K, AST & ALK may be affected. MAGNESIUM - Abnormal Magnesium 2.4 (*) Narrative: Specimen slightly hemolyzed, Mg may be affected. DIFFERENTIAL, MANUAL - Abnormal Total Counted 100 Nucleated Red Blood Cell 1.0 Neutrophils Relative 45 Band Neutrophils Relative 0 Lymphocytes Relative 46 Monocytes Relative 5 Eosinophils Relative 1 Basophils Relative 1 Immature Granulocytes Relative 2 Neutrophils Absolute 4.0 Lymphocytes Absolute 4.0 (*) Monocytes Absolute 0.4 Eosinophils Absolute 0.1 Basophils Absolute 0.1 Toxic Granulation Present Platelet Estimate Normal
CDC Split Type:

Write-up: Pt had witnessed arrest by wife. Pt wife started CPR and called EMS. CPR started at 15:12. Continued by EMS. Pt arrived to medical center asystole with CRP in progress and ventilated via igel device. He was in refractory ventricular fibrillation and continued CPR for a total of 1 hour. At that point, we checked a bedside ultrasound which showed his heart at a standstill. He was unresponsive to verbal and tactile stimulus and had fixed unreactive pupils. He was pronounced at 16:13.


VAERS ID: 950893 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-03
Onset:2021-01-07
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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: Ask the nursing home,
Current Illness: Diabetes dementia, cll, trigeminal neuralgia
Preexisting Conditions: Diabetes dementia cll trigeminal neuralgia
Allergies: Shellfish, other
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death


VAERS ID: 967747 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: Pt passed away evening of 1/13 - unknown reason currently Narrative:


VAERS ID: 967749 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Brain natriuretic peptide increased, Cardiac arrest, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (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), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Jan 11, 2021@15:111 NASOPHARYNX COVID-19 MONT (VELA): DETECTED Jan 11, 2021@10:51 PLASMA BNP: 403 H pg/mL 0 - 100
CDC Split Type:

Write-up: Cardiac Arrest Narrative:


VAERS ID: 950935 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated:2021-01-12
Onset:2021-01-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired


VAERS ID: 950979 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: allopurinol -Zyoprim 3000 mg amlodipine Norvasc 5 mg Lispro 100/unit /ml ups us to 150 unit daily per insulin scale Levemir U-100 - 100/unit/ml - (3ML) 55 units nightly Levothryoxine -Synthroid - 137 mcg - daily Simvastatin 25 mg - d
Current Illness:
Preexisting Conditions: IPF - Idoipathic Pulmonary Fibrosis Diabetic
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache after dose was given at 10:00 a.m Died at after 7:30 pm the same night the dose was given.


VAERS ID: 951101 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Colorado  
Vaccinated:2020-12-31
Onset:2021-01-03
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abnormal behaviour, Acute kidney injury, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Cerebral infarction, Cerebrovascular accident, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Influenza like illness, Liver function test abnormal, Malaise, Movement disorder, Nausea, Speech disorder, Troponin increased, Vomiting, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (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), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: metoprolol tartrate, furosemide
Current Illness:
Preexisting Conditions: hypertension, dementia, osteoarthritis, diverticulosis
Allergies: tramadol
Diagnostic Lab Data: CREATININE = 4.73 AST= 410 ALT= 579 WBC= 25.95 TROPONIN = 0.174 CT SCAN OF HEAD PER THE RADIOLOGIST = ACUTE LEFT PCA DISTRIBUTION INFARCT. NO HEMORRHAGICE CONVERSION. NO MIDLINE SHIFT. BASILAR CISTERNS ARE PATENT. CT OF CHEST= NEGATIVE
CDC Split Type:

Write-up: PATIENT GOT HER FIRST COVID PFIZER VACCINE AT 12/31 IN THE AM. HAD GOTTEN FLU LIKE SYMPTOMS AND HAD BEEN SICK FOR A COUPLE OF DAYS. HAD NAUSEA AND VOMITTING DURING THIS TIME AS WELL. ON 1/3 THE CARE GIVER WENT TO CHECK ON HER PT AT HER LTC FACILITY WHERE SHE LIVES AND SHE WASN''T ACTING RIGHT. SHE WAS UNABLE TO DO A STROKE EXAM. PT HAD NO MOVEMNET IN ARMS OR LEGS AND WAS UNABLE TO SPEAK. PT WAS VITALLY STABLE AT THE TIME. EMS RECORDED THAT THEY THOUGHT DIAGNOSIS WOULD BE STROKE, PNEUMONIA OR SEPSIS. AFTER ARRIVAL AT THE HOSPITIAL DETERMED THAT SHE HAD A STORKE, ACUTE KIDNEY INJURY, ABNORMAL LFTS.


VAERS ID: 951678 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-13
Onset:1921-01-17
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / -

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: 2021-01-17
   Days after onset: 36525
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Crestor 20 mg, Claritin-D 24 hour, Zaria 10 mg, baby aspirin, replatha,valsart hits 160-12.5mg Fish oil, wheat germ oil, D3 1000 mg, testosterone 8% gel, CO Q 10, weirder prime , eye drops
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Heart attack death medical test
CDC Split Type:

Write-up: Heart attack death medical test


VAERS ID: 951688 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-01-02
Onset:2021-01-17
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: Diclofenac Sodium Gel 1 %, Atorvastatin Calcium Tablet 40 MG, Acetaminophen Tablet 325 MG, Melatonin Tablet 3 MG, Vitamin D3 Tablet 25 MCG, Iron Tablet 325, Multivital-M Tablet, Eliquis Tablet 5 MG, metFORMIN HCl Tablet 500 MG, NIFEdipine
Current Illness: 11/25/20 Lower mid back abscess 11/4/20 toenail removal
Preexisting Conditions: CEREBRAL INFARCTION DUE TO UNSPECIFIED OCCLUSION OR STENOSIS OF LEFT MIDDLE CEREBRAL ARTERY, PRESENCE OF AUTOMATIC (IMPLANTABLE) CARDIAC DEFIBRILLATOR, UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE, APHASIA, DYSPHAGIA, UNSPECIFIED, WEAKNESS, COVID-19, OTHER REDUCED MOBILITY, URINARY TRACT INFECTION, SITE NOT SPECIFIED, ABNORMAL WEIGHT LOSS, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, VITAMIN DEFICIENCY, UNSPECIFIED, VITAMIN D DEFICIENCY, UNSPECIFIED, ANEMIA, UNSPECIFIED, CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE, CHRONIC KIDNEY DISEASE, STAGE 2 (MILD), ESSENTIAL (PRIMARY) HYPERTENSION, GOUT, UNSPECIFIED, INSOMNIA, UNSPECIFIED
Allergies: No Known Allergies
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Resident expired 1/17/21


VAERS ID: 955256 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-16
Onset:2021-01-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Immediate post-injection reaction, Muscle contractions involuntary, Pulse absent, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

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

Write-up: Patient was vaccinated in right arm. Within 5 to 10 seconds after vaccination, patient started clinching his hands tightly and became unresponsive. Patient was lowered to the floor and did not exhibit a pulse. CPR was initiated and 911 was called. An AED was used and healthcare professionals onsite continued compressions until the paramedics arrived.


VAERS ID: 952204 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Florida  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH PFIZERER9201 / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Autopsy, Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-01
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amoxicillin 500mg
Current Illness: None: Clean bill of health and a full cardiac exam was performed 2 months prior.
Preexisting Conditions: None.
Allergies: None
Diagnostic Lab Data: A full autopsy was done but results are pending.
CDC Split Type:

Write-up: Patient became sick 3 hours after the vaccine and was found deceased 1 day after his vaccination. He passed away in his sleep.


VAERS ID: 952704 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-01-14
Onset:2021-01-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Abnormal behaviour, Agitation, Anxiety, Completed suicide, Confusional state, Dementia, Dyspnoea, Panic disorder, Pyrexia, SARS-CoV-2 test negative, Tremor, Vaccination complication
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Suicide/self-injury (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Daughter does not know all medications to list at time of reporting
Current Illness: Pneumonia 12/20 not Covid19 related
Preexisting Conditions: COPD, Curvature of Spine pressed against lung, High blood pressure, Diabetes
Allergies: N/A
Diagnostic Lab Data: Covid 19 : negative and pt lungs clear, all else unknown to reporter -- Daughter
CDC Split Type:

Write-up: Daughter call in for VAERS report to file for father whom committed suicide 1/16/2021 in the AM after reportable ae of COVID 19 vaccine administered 1/14/2021. Patient sought care twice at ER; first visit by ambulance around 5PM and Friday 1/15/2021 Medical Center: Emergency Room. 1st Discharge summary diagnosis: adverse reaction to COVID shot; 2nd Discharge summary diagnosis: adverse reaction to COVID shot, fever, Panic Disorder-- ER. Medical Center Discharge summary diagnosis: Adverse reaction to the vaccine, acute anxiety. Reportable patient symptoms at, 1st visit : fever, shaking stomach cramps, breathing issues. Medical Center -- No fever, confusion and dementia type, patient would not stay in patient bed; patient would get up and sit down again repeatedly, agitated and anxious. Attempted to urinated hospital bed. Patient committed suicide in home.


VAERS ID: 952713 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Missouri  
Vaccinated:2020-12-30
Onset:2021-01-12
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes, Parkinson Disease
Allergies: PCN, Zithromax, Flomax
Diagnostic Lab Data: PCR and antigen test
CDC Split Type:

Write-up: Weakness, Low O2, death. Positive for COVID on 1/12/21, dies on 1/16/21


VAERS ID: 952799 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-05
Onset:2021-01-17
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Apnoeic attack, Death, Pulse absent
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: 2021-01-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/17/2021 at 4:35 am resident found apneic and pulseless, at 4:40am death confirmed


VAERS ID: 952881 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-10
Onset:2021-01-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Blood albumin decreased, Blood chloride decreased, Blood potassium normal, Blood sodium decreased, Blood urea normal, Brain natriuretic peptide increased, Carbon dioxide increased, Death, Dyspnoea, Glomerular filtration rate, Haematocrit decreased, Haemoglobin decreased, Lymphocyte count decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Neutrophil count normal, Oedema, Red blood cell count decreased, Red cell distribution width increased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Lasix, Timolol Maleate, Benefiber, Pravastatin, Multivitamin, Carbidopa ER 50-Levodopa 200 daily; Carbidopa ER 50-Levodopa 200 2 tabs daily, I-vite, Lactobacillus; Metoprolol Succinate; Tamsulosin, Finasteride, Oxubytynin
Current Illness: Edema, Hypokalemia, Hypertensive heart with heart failure
Preexisting Conditions: Parkinson''s Disease; COPD; Heart failure unspecified; Old myocardial infarction, Overactive bladder, Hyperlipidemia, Adult Failure to thrive, Urinary retention, Constipation unspecified, Unspecified urinary incontinence, Benign prostatic hyperplasia, other seasonal allergies rhinitis, unspecified glaucoma, mild cognitive impairment, Pressure ulcer of right heel, history of falling, dependence in wheelchair, COVID-19 on 11/23/2020
Allergies: No known allergies
Diagnostic Lab Data: RBC 3.72; HGB 9.8; HCT 32.7; MCH 26.3; MCHC 30; RDW 15.2; Neut # 7.18; Lymph # 0.97; NA 135; K 5.0; CL 97; CO2 34; BUN 11; CRT 0.76; ALB 1.9; ALT/SGPT 6; GFR $g60; BNP 415
CDC Split Type:

Write-up: Resident was seen by MD on 1/11/2021 due to increasing in edema and shortness of breath. Lasix 40 mg STAT given. New orders to get a STAT CBC, CMP, and BNP. Resident has been dependent on Oxygen since his diagnosis of COVID-19 on 11/23/2020. Labs were abnormal. Continued on the lasix 40 mgs. Resident remained short of breath with exertion and on oxygen. He was assisted to the toilet on 1/15/2021 in the morning where he subsequently passed away.


VAERS ID: 953129 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-09
Onset:2021-01-18
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known
Preexisting Conditions: hypertension; colon cancer (recovered); smoker
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient presented to our Emergency Department via EMS in full code status; asystole. Patient expired. Per nursing, husband stated patient awoke this AM and reported pain in back between shoulders and in bilateral shoulders. Patient then went unresponsive and husband called EMS.


VAERS ID: 953183 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-05
Onset:2021-01-11
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Oxygen saturation decreased, Pyrexia, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1/11/21 at 8:57 Resident with fever and at 11 am saturation down to 83 O2 to 10 liters. Resident continued to decline until CTB on 1/14/2021 at 1325


VAERS ID: 953348 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2020-12-22
Onset:2020-12-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Ibuprofen, Oxybutinin, Morphine Sulfate
Current Illness:
Preexisting Conditions: Chronic pain, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was living in a nursing home with positive cases when administered. His age and chronic condition was such that he did not have time after the vaccination to avoid exposure or develop immunity.


VAERS ID: 953590 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-05
Onset:2021-01-11
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Culture negative, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Arthritis; Chronic kidney disease; COPD; Dementia; Diabetes mellitus; Failure to thrive; Hyperlipidemia; Metabolic encephalopathy; Weakness
Allergies:
Diagnostic Lab Data: Test Date: 20210109; Test Name: Nasal Swab; Test Result: Negative
CDC Split Type: USPFIZER INC2021025371

Write-up: resident expired; This is a spontaneous report from a contactable healthcare professional. An 82-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot number: EL0140), intramuscular in the left arm on 05Jan2021 15:00 at a single dose for COVID-19 immunization. Medical history included metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia. Known allergies was none. The patient took unspecified concomitant medication. On 11Jan2021, the resident expired. The patient underwent lab tests and procedures which included nasal swab: negative on 09Jan2021. There was no treatment given for the event. The patient died on 11Jan2021. An autopsy was not performed.; Sender''s Comments: Lacking information on the cause of patient''s demise, the Company cannot completely exclude a causal relationship between COVID 19 vaccine, BNT162B2, and patient''s death of unknown cause, as a cautionary measure and for reporting purposes. The patient''s pre-existing medical condition of metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia may have provided the contribution to the event in this 82-year-old male patient. The impacts of this report on the benefit/risk profile of the product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: resident expired


VAERS ID: 953754 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-01-06
Onset:2021-01-13
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not provided by facility
Current Illness:
Preexisting Conditions: COVID-19 4/24/2020, hyperlipidemia, type 2 diabetes, generalized idiopathic epilepsy, chronic gingivitis, paranoid schizophrenia, extrapyramidal movements (G25.9), BMI 29, major depressive disorder, hypertensive heart disease, GERD
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient suddenly developed pneumonia 7 days after vaccination and died the evening of developing pneumonia


VAERS ID: 953785 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-07
Onset:2021-01-16
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Hypersensitivity/ anaphylaxis to standard flu vaccine (egg containing) ~ 20 years ago. Of note, did tolerate FluBlok this past
Other Medications: No scheduled medications Tylenol and Zyrtec as needed
Current Illness: None
Preexisting Conditions: None Known
Allergies: Egg (anaphylaxis) Chicken
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Death


VAERS ID: 953858 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-08
Onset:2021-01-13
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Seroquel, ibandronate, atenolol, Lexapro, simvastatin, acetaminophen, estradiol, famotidine, calcium citrate, antacid, donepezil, ferrous sulfate, Probiotic Pearls Complete, memantine, Antifungal cream, potassium chloride, Creon, bisacodyl
Current Illness: COVID-19, ARDS, enterocolitis, Sepsis, UTI, Acute renal failure
Preexisting Conditions: Chronic kidney disease, dementia with lewy bodies, COPD, GERD, anxiety, anemia, osteoarthritis, unspecified heart failure, paroxysmal atrial fibrillation
Allergies: nka
Diagnostic Lab Data: general decline starting 1/10/2021 - patient deceased 1/13/2021
CDC Split Type:

Write-up: patient started to decline 1/10/2021, patient seen at facility by medical professional - patient deceased 1/13/2021


VAERS ID: 953865 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-01-14
Onset:2021-01-17
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Breath sounds abnormal, Death, Hypoxia, Pulmonary congestion, SARS-CoV-2 test negative
SMQs:, Cardiac failure (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: FINASTERIDE 5MG QD, FAMOTIDINE 20 MG DAILY, FOLIC ACID 400 MCG QD, SENNA 8.6 DAILY
Current Illness: NONE
Preexisting Conditions: HYPOTHYROIDISM, DEMENTIA, SCHIZOPHRENIA, HTN, DYSPAGIA, INTELLECTUAL DISABILITIES, CKD MACULAR DEGENERATION
Allergies: NKA
Diagnostic Lab Data: RAPID COVID-19 TEST ON 1/17 NEGATIVE NO OTHER TESTS
CDC Split Type:

Write-up: REPORTING ONLY AS RESIDENT EXPIRED ON 1/17/2021 3 DAYS AFTER. S/S HYPOXIA/CONGESTED LUNG SOUNDS


VAERS ID: 953922 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2020-12-26
Onset:2020-12-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anxiety, Chest discomfort, Death, Dyspnoea, Myocardial infarction, Oropharyngeal discomfort, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 4
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:
Current Illness: Diabetes, COPD, Chrone''s Disease, DJD, OSA, PTSD, GERD, HLD, Depression, HTN, lobectomy 3/4/2019, cancer
Preexisting Conditions: See above
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: The day following the vaccine, the patient complained of throat issues and anxiety. This was not new... however . That evening he reported difficulty breathing and was placed on oxygen; a COVID test was performed and was negative. On 12/30/2020, patient complained of sternal pressure and was transferred to the hospital. The patient died 12/31/2020 and records obtained from the hospital indicated the patient died from a massive myocardial infarction.


VAERS ID: 954251 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-12
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Confusional state, Death
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Cirrhosis of the liver, asthma, heart condition
Preexisting Conditions: Cirrhosis of the liver, asthma, heart condition
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 71 year old woman at rehabilitation center for physical therapy with history of cirrhosis of the liver, asthma, and heart condition was tested for COVID-19 on 01/07/21, received 1st dose of Pfizer COVID-19 vaccine on 01/08/21, positive test result for COVID-19 received on 01/09/21. She was sent to the hospital and admitted on 01/12/21 after O2 was 70% and was in a confused state. Patient passed away on 01/17/21.


VAERS ID: 954780 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-05
Onset:2021-01-13
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Vomiting
SMQs:, Acute pancreatitis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D
Current Illness: None
Preexisting Conditions: Essential Hypertension Anxiety Disorder Unspecified Convulsions Pulmonary Candidiasis Paroxysmal atrial fibrillation Occlusion and stenosis of carotid arteries Congestive Heart Failure Left below the knee amputation Peripheral Vascular Disease Hypokalemia Urinary Retention
Allergies: Shellfish/Seafood
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: On 1/13/2021, resident had sudden emesis. Immediately following emesis he was noted without a pulse and pronounced deceased. No acute symptoms noted prior to this episode. Resident does have a significant cardiac history.


VAERS ID: 954812 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-15
Onset:2021-01-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Cardiac arrest, Chest discomfort, Headache, Heart rate irregular, Nausea, Pulseless electrical activity, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: apixaban, levothyroxine, prednisone, diltiazem, (cont page 2)
Current Illness: Unknown
Preexisting Conditions: non stentable distal occlusive disease, coronary heart disease, stroke, heart failure, diabetes mellitus, (cont. p 2)
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: She had the first dose of Pfizer vaccine at the Campus on Friday 1/15 at 4:30 pm. After the vaccine, she had no new symptoms or signs of vaccine reaction and MD friend reports that he checked her pulse which was not elevated from baseline. On 1/16, she awakened and continued to feel at her recent baseline. However, in the early afternoon, she complained of headache, nausea/epigastric pain, and chest heaviness. These apparently were not unusual symptoms for her to feel intermittently. Per her niece, who has a home O2 sat device, her 02 sat that morning was 97 with a HR of 87 irregularly irregular. She was afebrile. (continue on page 2)


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