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

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

Government Disclaimer on use of this data



Case Details

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VAERS ID: 1391500 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-05-15
Onset:2021-05-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure congestive, Death, Dyspnoea, Laboratory test, Mechanical ventilation, SARS-CoV-2 antibody test negative, SARS-CoV-2 test negative, Seizure, Thrombosis
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-25
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: obesity
Allergies:
Diagnostic Lab Data: Yes, extensive. You will need medical records. He had 3 covid tests and 1 antibody test all negative for Covid.
CDC Split Type:

Write-up: Patient had his 2nd Moderna vaccine at pharmacy at 2:00 and was struggling to breathe a few hours later. We were at the emergency room around 6:00pm and he was placed on a ventilator between midnight and 1:00am. He died 10 days later after experiencing clots that led to seizures and congestive heart failure. I have a death certificate if needed.


VAERS ID: 1391671 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Connecticut  
Vaccinated:2021-04-17
Onset:2021-05-19
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Surgery
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: 2021-05-20
   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:
Current Illness: Diabetes High blood pressure High cholesterol
Preexisting Conditions: Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Her surgery in the morning went very well according to her doctor. Later in the afternoon, pt. had a massive stroke. Next day pt. died at Hospital .


VAERS ID: 1391711 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Death, Hypertensive heart disease
SMQs:, Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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
Preexisting Conditions:
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Certificate 4/22/2021 Cause of Death - Hypertensive Cardiovascular Disease


VAERS ID: 1391995 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-04-26
Onset:2021-05-11
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA A-HRSA-043B2 / UNK LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-11
   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: Lisinopril, Colcrys
Current Illness: Hypertension, Hyperlipidemia, tobacco use, gout, sleep apnea
Preexisting Conditions: Hypertension, Hyperlipidemia, tobacco use, gout, sleep apnea
Allergies: Sertraline
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died of unknown cause 2 weeks after receiving vaccine.


VAERS ID: 1392054 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-06
Onset:2021-02-16
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 UN / -

Administered by: Private       Purchased by: ?
Symptoms: B-cell lymphoma, Computerised tomogram, Death, Fatigue, Full blood count, Lymphoma, Magnetic resonance imaging, Pain
SMQs:, Malignant lymphomas (narrow), Haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-01
   Days after onset: 104
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tikosyn Warfarin
Current Illness: Knee replacement surgery
Preexisting Conditions: A-fib
Allergies: None known
Diagnostic Lab Data: CBC, mri, CT, hematologists, oncologist etc etc
CDC Split Type:

Write-up: He died after being diagnosed with Lymphoma. Double hit , B cell. He was fatigued a couple weeks after vaccine, fatigue worsened, then developed severe pain. Diagnosis to death was 11 days.


VAERS ID: 1394058 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-17
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: This spontaneous case was reported by a patient family member or friend (subsequently medically confirmed) and describes the occurrence of DEATH (She passed away) and THROMBOSIS (Clots in her leg) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 037A21B) for COVID-19 vaccination. No Medical History information was reported. On 17-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced DEATH (She passed away) (seriousness criteria death, hospitalization and medically significant) and THROMBOSIS (Clots in her leg) (seriousness criteria hospitalization and medically significant). The patient died on an unknown date. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, THROMBOSIS (Clots in her leg) outcome was unknown. No concomitant medications reported. Description: The patient had clots in her leg and was hospitalized. There was talk of amputation, but she passed away before that occurred. No treatment information provided. Company Comment: Very limited information regarding these events have been provided at this time. Further information cannot be requested.; Sender''s Comments: Very limited information regarding these events have been provided at this time. Further information cannot be requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1394314 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-05-28
Onset:2021-05-31
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Anaemia, Blood lactic acid increased, Catheterisation cardiac abnormal, Chest pain, Confusional state, Coronary artery disease, Death, Dyspnoea, Echocardiogram, Epigastric discomfort, Feeling cold, Fibrin D dimer increased, Haemoglobin decreased, Hypoglycaemia, Hypokinesia, Hypotension, Hypoxia, Livedo reticularis, Malaise, Nausea, Pneumonia aspiration, Tachycardia, Vomiting, Wall motion score index abnormal
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Parkinson-like events (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (narrow), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-12
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: family reports had "severe" reaction to first moderna vaccine
Other Medications: glycopyrrolate (Robinul) 2 mg tablet Take 4 mg by mouth daily. hydrOXYzine (Vistaril) 25 mg capsule Take 25 mg by mouth 3 (three) times a day as needed for itching. lisinopriL (Zestril) 10 mg tablet Take 10 mg by mouth daily. metFORMIN (
Current Illness:
Preexisting Conditions: DM2 HTN GERD Chronic pain
Allergies: Latex Codeine
Diagnostic Lab Data: see above
CDC Split Type:

Write-up: 73 y.o. female with a past medical history of non-insulin-requiring diabetes type 2 and recent admission at Hospital (5/31-6/6/2021) who was transferred on 6/9 for chest pain with worsening EF with concerns for ischemic cardiomyopathy. Hospital course by dates 5/31?6/6/2021: Admitted for abdominal pain, nausea and vomiting thought to be secondary to ischemic colitis and severe constipation. Patient was found to be anemic during that hospitalization, but did not require blood transfusion. Patient''s hospital course was complicated by aspiration pneumonia requiring PICC placement and norepinephrine. She is no longer requiring supplemental oxygen was discharged home. 6/9: Return to hospital with increasing shortness of breath, confusion and generalized malaise. Repeat TTE with anterior wall motion abnormalities and decreased EF. Patient was transferred to bed for cardiology evaluation 6/10: Cardiac catheterization with moderate three-vessel coronary disease, wall motion abnormality does not correspond to coronary disease. Cardiology thinks findings are related to stress-induced cardiomyopathy. 6/11: Patient continues have downtrending hemoglobin, started to prep for colonoscopy on 6/12. 6/12: Rapid response was called at at approximately 4:40 AM, patient ultimately expired at 7:35 AM Patient was transferred from Hospital given new wall motion abnormalities and severe hypokinesis seen on repeat TTE. Fortunately, cardiac catheterization on 6/10 without coronary artery disease that corresponded to these wall motion abnormalities. Ultimately, it was thought to be stress induced cardiomyopathy. Patient was improving, but still complained of epigastric discomfort. Given her recent diagnosis of ischemic colitis and ongoing abdominal pain, GI was consulted for EGD/colonoscopy on 6/12 Rapid response was called at at approximately 4:40 AM. They were mottled appearing, hypotensive and cool to touch. Patient was found to be severely hypoglycemic and had wide-complex tachycardia. Multiple amps of D50 were given but remained hypoglycemic. Patient was also found to be hypoxemic and did not tolerate BiPAP. Eventually patient was transition to comfort measures only. After discussion with patient''s daughter, patient''s last 10 minutes of life consisted of "fluid pouring out of her mouth". Work-up also was positive for elevated lactic acid and elevated D-dimer. Given the abrupt change in patient''s clinical status, concern for embolic thrombosis is the most likely cause. Unclear if had pulmonary embolism or ischemia to gut. Interestingly, patient was visiting her from Indiana for her brother''s funeral. After discussion with family, patient''s brother had a similar unexplained death just a few weeks prior. The Family going back to the fact that she had her second Maderna vaccine 3 days prior to presenting to select hospital. Patient''s brother also had a Maderna vaccine before his recent demise. Given the unknown cause of death, an autopsy was discussed with family. They were agreeable to this. Highly concern for thrombotic event, but unable to confirm at this time without autopsy. Unknown if recent vaccine was related to her death, but could explain thrombosis leading to ischemic colitis prompting her last admission. Patient was noted to have a "severe" reaction to her first vaccine.


VAERS ID: 1394685 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-04-16
Onset:2021-05-13
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-06-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebrovascular accident, Myocardial infarction, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-13
   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: Felt very Lethargic the month prior after recieving the first dose on 3/16/21
Preexisting Conditions: No, very healthy, in shape, 5?11? 170 lbs, no health conditions. Recently seen by doctor and cleared. Had had routine physical
Allergies: NO Known Allergies
Diagnostic Lab Data: No a topsy was done
CDC Split Type:

Write-up: He died suddenly on May 13th. Had just had thorough physical prior to vaccines. Perfect health, weight perfect. No prior health concerns. Heart attack or stroke in his yard. After his first dose on March 16, 2021 he ceased his several mile walk each day stating he was tired and lethargic. He was a military man that rose each day of his life to that walk. His second dose was 04/16/21 he still did not continue the walks and on May 13, 2021 died suddenly of heart attack or stroke.


VAERS ID: 1394806 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-17
Onset:2021-03-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

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

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

Write-up: My father passed 2 days after vaccine


VAERS ID: 1394845 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-06-11
Onset:2021-06-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Death, Loss of consciousness, Malaise
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-11
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none listed
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received 2nd Moderna shot on 6/11/21 at 10:32am. Went home after the shot and didn''t feel well, so he laid down to rest. His wife checked on him and he was unconscious, so she called 911. Patient was taken to local hospital and died of Cardiac Arrest sometime between his vaccine and 7pm on 6/11/21.


VAERS ID: 1394899 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-30
Onset:2021-05-04
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-06-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019B21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Brain oedema, Brain operation, Cerebral haemorrhage, Cerebrovascular accident, Computerised tomogram head abnormal, Death, Electrocardiogram, Thrombolysis
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), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-01
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol, aspirin (daily), fish oil, multivitamin, vitamin C, Zinc, vitamin B-12.
Current Illness: None.
Preexisting Conditions: Pollen/grass allergies.
Allergies: None.
Diagnostic Lab Data: CT scans 5/4/21 thru 5/8/21 showing brain hemorrhage. EKG test
CDC Split Type:

Write-up: Stroke at approx 1:10 p.m. on 5/4/21. Taken to emergency room. CT scan and given clot-buster mediation shortly after arrival at emergency room. Transport to hospital on 5/4/21 at 5:45 p.m. and subsequent CT scan revealed intracerebral hemorrhage. Administer medication to reverse clot buster medication and airlifted at approx 7:30 p.m. on 5/4/21. At medial center CT scans and EKG testing. Continued brain bleeding. Brain surgery to relieve swelling. Death on 05/08/2021.


VAERS ID: 1395042 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-27
Onset:2021-03-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac arrest leading to death


VAERS ID: 1395420 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-02-10
Onset:2021-03-02
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 63
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: acidophillus/lactobacillus (FLORANEX) chew tablet alendronate (FOSAMAX) 70 MG tablet amLODIPine (NORVASC) 5 MG tablet ascorbic acid 250 MG tablet atorvastatin (LIPITOR) 10 MG tablet calcium-vitamin D (OSCAL-500+D) 500-200 MG-UNIT tablet cya
Current Illness: Patient was treated for a UTI on 2/8/2021. She was also being treated for lymphoma.
Preexisting Conditions: Bradycardia, dyspepsia, essential hypertension, hypercholesteremia, insomnia, lymphoma, seizure disorder
Allergies: No known drug allergies
Diagnostic Lab Data: COVID test positive on 3/3/2021, 4/8/2021, and 4/23/2021.
CDC Split Type:

Write-up: Patient presented to emergency department for increasing trouble breathing on 4/23/2021. She was previously diagnosed with COVID-19 infection on 3/3/2021. She was admitted to a different facility from 4/8/2021 to 4/20/2021 for management of COVID-19 infection where she also tested positive for COVID-19. She was admitted for further management of COVID-19 infection. Her symptoms did not improve and she was placed on comfort measures on 5/4/2021. Patient expired on 5/5/2021 due to complications from COVID-19 infection.


VAERS ID: 1395442 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Anticoagulant therapy, Brain stem infarction, Cardiac arrest, Cerebrovascular accident, Death, Magnetic resonance imaging abnormal, Magnetic resonance imaging head, Myocardial infarction, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin 81 mg, atorvastatin 40 mg, metformin 1000 mg BID, Onglyza 5 mg, amaryl 4 mg BID, ranitidine 150 mg BID, Claritin 10 mg, lyrica 75 mg BID, multivitamin
Current Illness:
Preexisting Conditions: CABG in 2004, HTN, DM, HLD
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: stroke and MI came in with symptoms of stroke but symptoms for 24 hours so did not receive tPa. MRI showed brainstem infarct. Statin was increased and started on plavix 75 mg daily for 3 weeks due to small stroke with low NIH. Patient came back in 3 days later due to STEMI and went into cardiac arrest. patient died after 1 hour of resuscitation


VAERS ID: 1395443 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-03-01
Onset:2021-03-05
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 AR / UN

Administered by: Public       Purchased by: ?
Symptoms: Aspiration, Death, Hiatus hernia, Intensive care, Mechanical ventilation, Oxygen saturation abnormal
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 28
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 30 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: alendronate, atenolol, calcium, B12, eliquis, klor-con, levothyroxine, metoclopramide, omeprazole, pravastatin, propafenone, tums, verapamil
Current Illness: none
Preexisting Conditions: A-fib; osteoporosis, recovering from an earlier bout of covid-19
Allergies: none
Diagnostic Lab Data: Various daily tests while in the emergency room, ICU, and room at hospital
CDC Split Type:

Write-up: Four days post-vaccination, she had a serious spell with a hiatal hernia which resulted in a possible gastric volvulus. Over the course of the episode, she ended up aspirating while vomiting. Within 24 hours she couldn''t hold her O2 sats at an acceptable level and was put on a ventilator in ICU. She recovered enough to extubate and go to a regular room but then ended up back on the vent and in ICU a second time. She was extubated again, but still could not maintain her O2 levels without medical intervention. She passed away on April 3, 2021. She did have covid-19 in late November 2020, with a mild case of pneumonia. She had been under the care of her primary doctor, as well as home health care and physical therapy, as part of her recovery. Her death may have been unrelated to the vaccine, but I have been told I should report anyway, as a precaution.


VAERS ID: 1395663 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-12
Onset:2021-05-02
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-03
   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: Massive heart attack and death


VAERS ID: 1395843 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Death, Discomfort, Feeling abnormal, Vomiting
SMQs:, Acute pancreatitis (broad), Dementia (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin Calcium, Bicalutamide, Finasteride, Furosemide, Metropolol, B-6, B-12, Potassium,
Current Illness: Prostate Cancer
Preexisting Conditions: Hip replacement, 5 way bypass in 2001, Esophageal replacement in 2014
Allergies: Penicillin,
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Dad woke up on January 29, 2021 with severe stomach pains and vomiting. He was very uncomfortable and ended up going back to bed. He was miserable all day. I called his physician and we decided to keep him comfortable at home and give him the BRAT diet which seemed to be helping with the pain and vomiting. Dad never got out of bed again. On February 4th, Dad was placed on Hospice and died on February 7, 2021.


VAERS ID: 1395844 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-13
Onset:2021-05-10
   Days after vaccination:117
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Endotracheal intubation, Malaise, Mechanical ventilation, SARS-CoV-2 test positive
SMQs:, Angioedema (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-14
   Days after onset: 35
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 27 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none
Preexisting Conditions: Lymphocytic Leukemia, Colon Cancer, GERD, High Cholesterol, HTN, Hyperuricemia, Hypothyroid, Iron deficiency Anemai, Leukocytosis, Chronic Macrocytic anemia, Macular degeneration of rt eye, Neuropathy, Neutropenia, thrombocytopenia, Ulcerative Colitis, Vitamin B12 deficiency,
Allergies: unknown
Diagnostic Lab Data: covid-19 positive 5/17/2021
CDC Split Type:

Write-up: pt had 2nd Moderna vaccine on 2/10/2021 lot # 013M20A. Pt became Ill on 5/10/2021, test covid-19 positive on 5/17/2021 and treated with BAM, Intubated on vent 6/1/2021 deceased 6/13/2021


VAERS ID: 1396353 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Abdominal pain, Arteriosclerosis, Autopsy, Bronchial irritation, Coronary artery disease, Death, Dyspnoea, Emphysema, Enteritis, Eosinophilia, Hypertension, Myocardial fibrosis, Myocarditis, Oedema, Respiratory viral panel, Resuscitation, SARS-CoV-2 test negative, Toxicologic test normal, Tryptase, Unresponsive to stimuli
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypertension (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Noninfectious diarrhoea (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-11
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Current medications included apple cider vinegar, atenolol, cinnamon bark, Lofibra, Glucotrol, Lisinopril, metformin, multivitamin, pioglitazone, potassium, nystatin cream.
Current Illness: Unknown
Preexisting Conditions: PMH includes cardiovascular disease, diabetes, severe obesity (BMI 45.3), prostate cancer.
Allergies: He had a history of allergies to Januvia and cephalexin.
Diagnostic Lab Data: Full autopsy performed on 3/12/2021. Findings included: lungs - emphysema with mild to focally moderate lymphoplasmacytic inflammation of bronchi, with rare to moderate eosinophils, with bronchial mast cells with associated tissue edema; heart - interstitial fibrosis, CAD with multiple areas of lymphoplasmacytic inflammation within the epicardium with rare eosinophils and scattered mast cells in myocardium and within epicardial fat near AV node; small intestine- intense eosinophilic enteritis and some areas of scattered eosinophilic inflammation; bone marrow - eosinophils identified, all cell lines present; cause of death hypertensive and atherosclerotic cardiovascular disease, contributing causes pending. Postmortem SARS-CoV-2 and respiratory pathogen panel negative; tryptase 11.11 ng/ml; toxicology negative.
CDC Split Type:

Write-up: Worsening abdominal pain and distention on 3/2/21 which progressed to include shortness of breath for which he did not seek medical care. He was found unresponsive on the couch on 3/11/21 and resuscitation was unsuccessful.


VAERS ID: 1396396 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-04-27
Onset:2021-05-12
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-12
   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: In assisted living facility
Preexisting Conditions: Unknown using nasal canula for oxygen
Allergies: None known
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient passed away on 5/12/2021 at assisted living facility


VAERS ID: 1396725 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-06-04
Onset:2021-06-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016C21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions:
Allergies: Not aware of any
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per daughter, patient died the next day after receiving the shot. Patient didn''t have any issues with 1st shot and she went to check on her and she was dead.


VAERS ID: 1397246 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-05-14
Onset:2021-06-03
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-06-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Albumin globulin ratio, Aspartate aminotransferase increased, Asthenia, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium decreased, Blood chloride increased, Blood creatine phosphokinase normal, Blood creatinine normal, Blood glucose normal, Blood lactic acid, Blood potassium normal, Blood sodium normal, Blood test, Blood urea decreased, Carbon dioxide normal, Dizziness, Echocardiogram normal, Electrocardiogram abnormal, Fatigue, Gait inability, Haematocrit decreased, Haemoglobin normal, Headache, Hypophagia, Nausea, Platelet count normal, Protein total normal, Pyrexia, SARS-CoV-2 test negative, Sinus rhythm, Supraventricular extrasystoles, Vomiting, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: LABORATORY DATA: Reviewed by me in ED. WBC 9.9, hemoglobin 14.4, hematocrit 41.8, platelets 177. CPK 114. Chemistry, sodium 139, potassium 4.3, chloride 108, carbon dioxide 25, blood glucose 114,BUN 7, creatinine 0.72, calcium 8.9, protein 7.9, albumin 3.8, A/G ratio 0.9, AST 72, ALT 74, alkaline phosphatase 42, bilirubin 0.5. Lactic acid 2. COVID-19 negative. EKG reviewed by me, sinus rhythm with premature atrial complexes.
CDC Split Type:

Write-up: HISTORY OF PRESENT ILLNESS: This is a 20-year-old male with past medical history of asthma, who was brought to ED by ambulance for nausea, vomiting, generalized weakness, and fever. The patient received his second dose of Moderna vaccine 10 days ago. The patient is experiencing symptoms of nausea, vomiting, fatigue, poor p.o. intake for the last few days. He was at ED 4 days ago and had a negative workup. The patient had a fever with T-max of 103 at home. He also had 2 episodes of emesis in the last few days. He denies any diarrhea, chest pain, abdominal pain. He complains of headache. He denies any blurred vision or neck stiffness. At hospital, the patient was given 4 L of fluid and had multiple blood tests. Even echocardiograms were unremarkable. The patient is unable to ambulate because of generalized weakness and dizziness.


VAERS ID: 1398476 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-17
Onset:2021-02-15
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Feeling abnormal, Movement disorder, Pain, Vital signs measurement
SMQs:, Dementia (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 18
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: ASPIRIN 81; CALCITRIOL; CLOPIDOGREL; FERROUS SULFATE [FERROUS SULFATE HEPTAHYDRATE]; FUROSEMIDE; ISOSORBIDE; LAMOTRIGINE; METFORMIN HYDROCHLORIDE; METOPROLOL; PANTOPRAZOLE; VITAMIN B12 NOS; VITAMIN D3 1000; LANTUS; ACITRETIN; DULOXETINE; AT
Current Illness: Atherosclerosis; Blood pressure high (stable); Diabetes; Heart attack (recovered)
Preexisting Conditions: Medical History/Concurrent Conditions: Stroke (recovered)
Allergies:
Diagnostic Lab Data: Test Name: Vitals; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; Felt like he was dying; Can''t move; Hurting pain over the whole body; Weak; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Death), FEELING ABNORMAL (Felt like he was dying), MOVEMENT DISORDER (Can''t move), PAIN (Hurting pain over the whole body) and ASTHENIA (Weak) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 016M20A and 028L20A) for COVID-19 vaccination. The patient''s past medical history included Coronary artery disease in 2000 and Stroke (recovered) in 1992. Concurrent medical conditions included Diabetes since 2000, Blood pressure high (stable) since 1964, Atherosclerosis since 2016 and Heart attack (recovered) since 2019. Concomitant products included PANTOPRAZOLE for Acid reflux (oesophageal), METOPROLOL for Blood pressure, DULOXETINE for Depression, METFORMIN HYDROCHLORIDE for Diabetes, FERROUS SULFATE HEPTAHYDRATE (FERROUS SULFATE [FERROUS SULFATE HEPTAHYDRATE]) for Iron deficiency, LAMOTRIGINE for Seizure, ACETYLSALICYLIC ACID (ASPIRIN 81) from 18-Jul-2017 to an unknown date, CALCITRIOL, CLOPIDOGREL, FUROSEMIDE, ISOSORBIDE, VITAMIN B12 NOS, COLECALCIFEROL (VITAMIN D3 1000), INSULIN GLARGINE (LANTUS), ACITRETIN, ATORVASTATIN, LOSARTAN POTASSIUM (COZAAR), DULAGLUTIDE (TRULICITY), METFORMIN HYDROCHLORIDE (METFORMINE HCL) and LAMOTRIGINE for an unknown indication. On 17-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 14-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 15-Feb-2021, the patient experienced FEELING ABNORMAL (Felt like he was dying) (seriousness criteria death and hospitalization), MOVEMENT DISORDER (Can''t move) (seriousness criteria death and hospitalization), PAIN (Hurting pain over the whole body) (seriousness criteria death and hospitalization) and ASTHENIA (Weak) (seriousness criteria death and hospitalization). The patient was treated with TRAMADOL for Pain, at a dose of 50 mg; LORAZEPAM for Anxiety, at a dose of 0.5 mg and MECLIZINE [MECLOZINE] for Dizziness, at a dose of 25 mg. The patient died on 05-Mar-2021. The reported cause of death was heart and kidney failure and Kidney failure. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Vital signs measurement: unknown (Inconclusive) Inconclusive. This is a case of sudden death in a 74-year-old male patient with a history of Coronary artery disease and Stroke, who died of heart and kidney failure 19 days after receiving last dose of vaccine. Very limited information has been provided at this time. Most recent FOLLOW-UP information incorporated above includes: On 04-Jun-2021: Follow up received, includes patient''s gender. On 07-Jun-2021: Follow up received, includes Patient information, historical conditions, batch number, cause of death, concomitant drugs.; Sender''s Comments: This is a case of sudden death in a 74-year-old male patient with a history of Coronary artery disease and Stroke, who died of heart and kidney failure 19 days after receiving last dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: Heart and kidney failure; kidney failure


VAERS ID: 1398495 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-28
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Ageusia, Anosmia, Chills, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Taste and smell disorders (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
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: No medical history information was provided.
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Myalgia; Chills; Taste loss; Smell loss; This spontaneous case was reported by a consumer and describes the occurrence of MYALGIA (Myalgia), CHILLS (Chills), AGEUSIA (Taste loss) and ANOSMIA (Smell loss) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 007M20A) for COVID-19 vaccination. No medical history information was provided. On 28-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 21-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On an unknown date, the patient experienced MYALGIA (Myalgia) (seriousness criterion death), CHILLS (Chills) (seriousness criterion death), AGEUSIA (Taste loss) (seriousness criterion death) and ANOSMIA (Smell loss) (seriousness criterion death). The patient died on 06-Mar-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No Concomitant medication information was provided. No treatment medication information was provided. Company Comment: This is a case of sudden death in a 74-year-old male patient with unknown medical history died after receiving vaccine. Very limited information has been provided at this time.; Sender''s Comments: This is a case of sudden death in a 74-year-old male patient with unknown medical history died after receiving vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1398528 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: heart attack; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of MYOCARDIAL INFARCTION (heart attack) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) unknown. On an unknown date, the patient experienced MYOCARDIAL INFARCTION (heart attack) (seriousness criteria death and medically significant). The reported cause of death was Myocardial infarction. It is unknown if an autopsy was performed. Concomitant medications were not reported. No treatment information was provided. Patient reported a family member died from a heart attack shortly after getting your vaccine. Very limited information regarding this event has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Myocardial infarction


VAERS ID: 1399352 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Montana  
Vaccinated:2020-12-30
Onset:2021-05-18
   Days after vaccination:139
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cataract operation, Death, Dyspnoea, Small cell lung cancer
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Lens disorders (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-07
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had cataract surgery in mid May, developed shortness of breath after, was seen in ER and admitted. Found to have stage 4 small cell lung cancer (not a smoker to my knowledge). Stayed in hospital until June 3rd when he was transferred home to medical center for end of life care. Died June 7th.


VAERS ID: 1399375 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-05-18
Onset:2021-06-03
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-03
   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: NONE
Current Illness: NONE
Preexisting Conditions: Heart Murmur
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Coroner stated that 3 weeks after patient received 2nd dose of COVID-19 Moderna vaccine, patient collapsed from cardiac arrest, which lead to death.


VAERS ID: 1399516 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-21
Onset:2021-05-12
   Days after vaccination:52
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 1 RA / SYR

Administered by: School       Purchased by: ?
Symptoms: Hyperhidrosis, Pain, Thrombosis, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-14
   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: Metformin, otc allergy meds
Current Illness: None
Preexisting Conditions: High blood pressure
Allergies: No
Diagnostic Lab Data: 5/12/2021 blood clot
CDC Split Type:

Write-up: Sweating, soreness, vomiting


VAERS ID: 1400093 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-05-04
Onset:2021-05-20
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Trazodone, certrizine, naproxen
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died suddenly, autopsy pending


VAERS ID: 1400218 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-05-19
Onset:2021-06-06
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-06-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix, Lisinopril, Coreg, Ferrous Sulfate, Norvasc, Atorvastatin, Cymbalta, Levothyroxine
Current Illness: UTI, Hypothyroidism, Hyperlipidemia, Hypertension, A-fib, GERD
Preexisting Conditions: COPD, Heart Failure
Allergies: Aspirin and Tape
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient CTB


VAERS ID: 1401705 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Pennsylvania  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac disorder
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: USMODERNATX, INC.MOD20212

Write-up: Cardiac problems after receiving either Pfizer or Moderna vaccine; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a nurse and describes the occurrence of CARDIAC DISORDER (Cardiac problems after receiving either Pfizer or Moderna vaccine) in an elderly patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. Unknown) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced CARDIAC DISORDER (Cardiac problems after receiving either Pfizer or Moderna vaccine) (seriousness criterion death). The reported cause of death was Cardiac disorder NOS. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Company Comment: Based on the current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Cardiac disorder NOS


VAERS ID: 1401722 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-25
Onset:2021-05-28
   Days after vaccination:64
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028A21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Disease recurrence, Gastritis, Ultrasound scan
SMQs:, Gastrointestinal nonspecific inflammation (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Heart disease, unspecified
Allergies:
Diagnostic Lab Data: Test Date: 20210601; Test Name: Ultrasound scan; Result Unstructured Data: confirmed gastritis.
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Died on the night of 05Jun2021 or Morning 06Jun2021 not Sure; Gastritis; The reaction came back with a vengeance; was doubling over; This spontaneous case was reported by an other health care professional (subsequently medically confirmed) and describes the occurrence of DEATH (Died on the night of 05Jun2021 or Morning 06Jun2021 not Sure) in a 53-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 007C21A and 028A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Heart disease, unspecified. On 25-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 22-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 28-May-2021, the patient experienced DISEASE RECURRENCE (The reaction came back with a vengeance) and CONDITION AGGRAVATED (was doubling over). On 01-Jun-2021, the patient experienced GASTRITIS (Gastritis). The patient died on 05-Jun-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, GASTRITIS (Gastritis), DISEASE RECURRENCE (The reaction came back with a vengeance) and CONDITION AGGRAVATED (was doubling over) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 01-Jun-2021, Ultrasound scan: abnormal (abnormal) confirmed gastritis.. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medications were not provided. Labs included electrocardiogram (EKG) whose results were not provided. It was reported that on 01-jun-2021 at Emergency room, gastritis was diagnosed and patient was sent home. Treatment information was not provided. Company comment: This is a case of sudden death in a 53-year-old male patient with a history of Heart disease, who died 1 month 14 days after receiving last dose of vaccine. Very limited information has been provided at this time. This case was linked to MOD-2021-211580 (Patient Link).; Sender''s Comments: This is a case of sudden death in a 53-year-old male patient with a history of Heart disease, who died 1 month 14 days after receiving last dose of vaccine. Very limited information has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1401732 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-04-16
Onset:2021-05-01
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Acute respiratory failure, Blood pressure measurement, Cardiac arrest, Cardiac failure acute, Dyspnoea, Gait disturbance, Glycosylated haemoglobin, Infection, Oxygen saturation, Pyrexia, SARS-CoV-2 antibody test, SARS-CoV-2 test, Seizure, Sepsis, Thrombosis
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-25
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Obesity
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210515; Test Name: Blood pressure; Result Unstructured Data: Twice normal; Test Date: 20210515; Test Name: HbA1c; Result Unstructured Data: High; Test Date: 20210515; Test Name: Oxygen saturation; Result Unstructured Data: Required intubation and was placed on ventilator.; Test Date: 20210515; Test Name: COVID Antibody test; Test Result: Negative ; Result Unstructured Data: 1 negative COVID antibody test; Test Date: 20210515; Test Name: COVID antigen test; Test Result: Negative ; Result Unstructured Data: 3 negative COVID antigen tests
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Seizures; Bood clots; Stuggling to breathe; Struggling to walk; ARDS; Acute hypoxic respiratory failure; Acute exacerbation of heart failure and sepsis; Acute exacerbation of heart failure and sepsis; Cardiac arrest; Blood infection; Fever; This spontaneous case was reported by a patient family member or friend (subsequently medically confirmed) and describes the occurrence of ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS), ACUTE RESPIRATORY FAILURE (Acute hypoxic respiratory failure), SEPSIS (Acute exacerbation of heart failure and sepsis), CARDIAC FAILURE ACUTE (Acute exacerbation of heart failure and sepsis), CARDIAC ARREST (Cardiac arrest), SEIZURE (Seizures), THROMBOSIS (Bood clots), DYSPNOEA (Stuggling to breathe) and GAIT DISTURBANCE (Struggling to walk) in a 53-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Obesity. On 16-Apr-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 15-May-2021 at 2:00 PM, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 15-May-2021, the patient experienced ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) (seriousness criteria death and medically significant), ACUTE RESPIRATORY FAILURE (Acute hypoxic respiratory failure) (seriousness criteria death and medically significant), DYSPNOEA (Stuggling to breathe) (seriousness criterion hospitalization prolonged) and GAIT DISTURBANCE (Struggling to walk) (seriousness criterion hospitalization prolonged). In May 2021, the patient experienced SEPSIS (Acute exacerbation of heart failure and sepsis) (seriousness criteria death and medically significant), CARDIAC FAILURE ACUTE (Acute exacerbation of heart failure and sepsis) (seriousness criteria death and medically significant), CARDIAC ARREST (Cardiac arrest) (seriousness criteria death and medically significant), INFECTION (Blood infection) and PYREXIA (Fever). On 17-May-2021, the patient experienced SEIZURE (Seizures) (seriousness criteria hospitalization prolonged and medically significant) and THROMBOSIS (Bood clots) (seriousness criteria hospitalization prolonged and medically significant). The patient was hospitalized from 15-May-2021 to 25-May-2021 due to DYSPNOEA, GAIT DISTURBANCE, SEIZURE and THROMBOSIS. The patient died on 25-May-2021. The reported cause of death was Cardiac arrest, Acute hypoxic respiratory failure, ards and acute exacerbation of heart failure and sepsis. It is unknown if an autopsy was performed. At the time of death, SEIZURE (Seizures), THROMBOSIS (Bood clots), DYSPNOEA (Stuggling to breathe), GAIT DISTURBANCE (Struggling to walk), INFECTION (Blood infection) and PYREXIA (Fever) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 15-May-2021, Blood pressure measurement: elevated (High) Twice normal. On 15-May-2021, Glycosylated haemoglobin: elevated (High) High. On 15-May-2021, Oxygen saturation: low (Low) Required intubation and was placed on ventilator.. On 15-May-2021, SARS-CoV-2 antibody test: negative (Negative) 1 negative COVID antibody test. On 15-May-2021, SARS-CoV-2 test: negatie (Negative) 3 negative COVID antigen tests. No concomitant medications were provided. It was reported that within few hours after second dose of vaccine patient was struggling to walk and to breathe. The reporter and her husband went to see the patient and took him to an emergency room (ER). In the ER his blood pressure was markedly elevated (twice normal) and his oxygen level was low and by midnight he required intubation and was placed on a ventilator. His HbgA1c was noted to be elevated. Two days after admission (17-May-2021), he developed seizures which the medical team believed to be due to blood clots and he was anti-coagulated. It was determined that he did not have blood clots on his heart valves as the source of the clots. The source of the blood clots was never identified. He later developed fever and was diagnosed with a blood infection and treated with antibiotics. At one point his oxygen requirement on the ventilator went down to 65% but later returned and remained at 100%. He ultimately died on 25-May-2021 and as per copy of his death certificate he had 4 causes of death as cardiac arrest, acute hypoxic respiratory failure, acute respiratory distress syndrome (ARDS) and acute exacerbation of heart failure and sepsis. Treatment included, anticoagulants, antibiotics, intubation and ventilator. Very limited information regarding these events has been provided at this time. Further information has been requested. This case was linked to MOD-2021-219410 (Patient Link).; Sender''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Cardiac arrest; Acute hypoxic respiratory failure; ARDS; Acute exacerbation of heart failure and sepsis


VAERS ID: 1402213 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 2 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Pruritus
SMQs:, Anaphylactic reaction (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), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-23
   Days after onset: 64
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Carotid artery narrowing
Preexisting Conditions: Carotid artery narrowing
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had severe itching started shortly after 2nd shot. MD stated pt having histamine response and Atarax started 3x/day to control itching symptoms. After several weeks pt stated atarax making her drowsy and requested to decrease to 2x/day. Pt started itching severely again after frequency decreased and pt requested to be put back to 3x/day. Shortly after pt had massive stroke which led to her death a couple of days later on 4/23/2021


VAERS ID: 1402355 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Cardiac ablation, Death, Gait inability, Intensive care, Movement disorder
SMQs:, Anticholinergic syndrome (broad), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-15
   Days after onset: 41
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: liver transplant in 2012 before liver transplant she had unknown liver failure 2000 she had a heart attack and she got stints in her heart 2015 she had a cabbage done on her heart
Allergies: dial soap
Diagnostic Lab Data: march the 7th she was rushed to er and was transferred to icu to a new hospital until she passed ran many test but husband wasnt sure of all because he wasnt allowed to be in the icu heart abalsion was one of them
CDC Split Type:

Write-up: day after vax she became weak, couldn''t walk, couldn''t move arms/legs


VAERS ID: 1402834 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-29
Onset:2021-03-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cerebrovascular accident, Condition aggravated, Myocardial infarction, Vomiting
SMQs:, Acute pancreatitis (broad), Myocardial infarction (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-06
   Days after onset: 38
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Baby Aspirin 81mg, Allopurinol 100mg, Atorvastatin, Buspirone 5mg, Clopidogrel, Ezetimibe 10mg, Finasteride 5mg, Insulin, Isosorbide Mononitrate 60 mg, Lisinopril 40mg, Melatonin 3mg only at night, Nifedipine, Sertraline 100mg.
Current Illness:
Preexisting Conditions: Heart failure, diabetes, strokes.
Allergies: Penicillin.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Strokes, very weak, vomiting, suffered mild heart attack.


VAERS ID: 1403424 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-15
Onset:2021-06-05
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adenocarcinoma of colon, Chest pain, Colectomy, Colonoscopy abnormal, Death, Endoscopy large bowel, Myocardial infarction, Stoma closure
SMQs:, Myocardial infarction (narrow), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific inflammation (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospital Course: Complicated. Patient was brought in for ostomy reversal, had a colonoscopy performed through his colostomy which revealed the patient to have a right colonic mass, mass was an adenocarcinoma. Had a right colectomy performed , had a massive myocardial infarction and died. Complicated 1 year, started with COVID 19 - patient was admitted prolonged amount of time due to complications of COVID 19 , developed a large decubitus ulcer which was not healing. Was being followed by Dr wound care center. Multiple debridements. Failure to heal. Referred to me for a diverting colostomy to facilitate healing of the large decubitus ulcer. Diverting colostomy was performed September 2nd 2020. Patient had plastic surgery, flap surgeries, in December 2020 and January 2021. finally healed. Brought for a ostomy reversal, found large mass in the cecum attempted endoscopic removal, with micro perforation, taken to the operating room immediately from endoscopy suite had a right colectomy. Colostomy started functioning, patient was recovering, suddenly started having chest pain and had a massive myocardial infarction.


VAERS ID: 1403521 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-03-26
Onset:2021-04-19
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Asthenia, COVID-19, Decreased appetite, Pneumonia, SARS-CoV-2 test positive
SMQs:, Interstitial lung disease (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-05
   Days after onset: 16
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: UNK
Current Illness: none reported
Preexisting Conditions: DEMENTIA, HIGH CHOLESTEROL, PREVIOUS SMOKER
Allergies: UNK
Diagnostic Lab Data: test positive for COVID-19 4/19/2021
CDC Split Type:

Write-up: weak, loss of appetite, pneumonia, ARDS


VAERS ID: 1403750 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-02
Onset:2021-03-20
   Days after vaccination:46
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J220A / 1 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Angiogram peripheral abnormal, Autopsy, Confusional state, Death, Embolism, Headache, Iliac artery stenosis, Malaise, Pain in extremity, Paranoia, Peripheral arterial occlusive disease, Peripheral artery occlusion, Peripheral artery stenosis, Peripheral coldness, Peripheral ischaemia, Pulmonary artery thrombosis, Pulmonary embolism, Pulse absent, Refusal of treatment by patient, Renal infarct, Skin discolouration, Urinary tract infection, Urine analysis abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Renovascular disorders (narrow), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None, only longstanding chronic conditions as stated in item 12
Preexisting Conditions: 1. Arteriosclerosis 2. Severe osteoarthritis (bilateral shoulders, bilateral hips and bilateral knees) 3. Chronic bilateral rotator cuff arthropathy 4. Chronic pain syndrome 5. History Atrial fibrillation with RVR on chronic anticoagulation 6. History of cardiac pause as long as 7 seconds worsened by metoprolol 7. Hypertension 8. Prediabetes 9. Vitamin B12 insufficiency 10. History of hyperuricemia 11. Malnutrition 12. History of hyponatremia 13. Dysphagia status post esophageal dilatation 14. GERD 15. Diverticulosis 16. Internal hemorrhoids 17. Constipation 18. BPH status post Urolift implants x 2 19. Urinary retention status post Foley catheter placement 20. Anemia 21. Dementia 22. Decubitus ulcer, stage 3, sacro-coccyx 23. Onychomycosis 24. Acute on chronic debility with impaired gait and functional mobility
Allergies: None
Diagnostic Lab Data: On 3/20/21, he had a CTA which showed as per radiology: "Occlusion of the right superficial femoral artery beginning just beyond the origin. Occluded right popliteal, anterior tibial, tibioperoneal, peroneal, and posterior tibial arteries without reconstitution on arterial and delayed phases. Patent right deep femoral artery with minimal luminal stenosis in the proximal segment. Patent mid and distal right external iliac artery with up to mild luminal stenosis."
CDC Split Type:

Write-up: Patient complained of feeling unwell and having headaches after his second dose of Moderna vaccine on 2/2/2021. He became increasingly confused, paranoid and started occasionally refusing medications. On early March 2021, he started refusing all medications. Around 3/17/21, his increasing confusion and paranoia prompted suspicion for UTI which was confirmed with a urinalsis. Unfortunately, he refused antibiotic treatment. On 3/20/2021, nursing staff noted that patients right lower extremity was purple from toes to mid-calf, cold to touch and pedal pulse were not present. He complained of right leg pain. He was evaluated and diagnosed with probable thromboembolic event, since patient refused his oral anticoagulant for weeks prior to these event. Patient was sent to the local Emergency Department (ED) and diagnosed with acute critical right limb ischemia. At the local ED, he had a CTA which showed as per radiology: "Occlusion of the right superficial femoral artery beginning just beyond the origin. Occluded right popliteal, anterior tibial, tibioperoneal, peroneal, and posterior tibial arteries without reconstitution on arterial and delayed phases. Patent right deep femoral artery with minimal luminal stenosis in the proximal segment. Patent mid and distal right external iliac artery with up to mild luminal stenosis." Per discharge summary, "vascular surgery evaluated patient in the ED and did not feel operative revascularization with fasciotomy would provide any benefit; recommended continued anticoagulation with amputation/palliative management." He was admitted to the general medicine service which consulted orthopedic, infectious diseases and palliative care. Medicine Service also contacted patient''s daughter who is his next of kin who opted for comfort care. He was discharged to facility on 3/25/2021 and started in the Comfort Care Program. He was pronounced dead on March 27, 2021 at 0807 hours. His autopsy showed that he also had thrombi on: 1. Pulmonary embolism, Left pulmonary artery 2. Left renal infarct


VAERS ID: 1405284 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-28
Onset:2021-03-06
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Ageusia, Anosmia, Chills, Death, Pain
SMQs:, Taste and smell disorders (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: loss sense of taste; Lost sense of smell; pain in body; chills; Patient died; This spontaneous case was reported by a patient family member or friend and describes the occurrence of DEATH (Patient died) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 007M20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 28-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 21-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient experienced AGEUSIA (loss sense of taste), ANOSMIA (Lost sense of smell), PAIN (pain in body) and CHILLS (chills). The patient died on 06-Mar-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, AGEUSIA (loss sense of taste), ANOSMIA (Lost sense of smell), PAIN (pain in body) and CHILLS (chills) was resolving. Concomitant medications were not reported. No treatment information was provided. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. This case was linked to MOD-2021-201255 (Patient Link).; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown casue of death


VAERS ID: 1405294 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Pennsylvania  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac disorder
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Cardiac problems after receiving either Pfizer or Moderna vaccine; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a health care professional and describes the occurrence of CARDIAC DISORDER (Cardiac problems after receiving either Pfizer or Moderna vaccine) in an elderly patient of an unknown gender who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. Unknown) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On an unknown date, the patient experienced CARDIAC DISORDER (Cardiac problems after receiving either Pfizer or Moderna vaccine) (seriousness criteria death and life threatening). The reported cause of death was cardiac disorder. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. No relevant concomitant medications were reported. It was reported that the reporter has seen that patients above 60 years of age who developed Cardiac problems after receiving either Pfizer or Moderna vaccine. Two patients even passed away post cardiac problems after vaccination. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Cardiac disorder


VAERS ID: 1406845 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-29
Onset:2021-04-13
   Days after vaccination:74
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Dyspnoea, Full blood count, Laboratory test
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 57
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ketotifen O/S 0.025%, Sodium Chloride Nasal Spray, Multivitamin with Fe, Puralube Ophthalmic Ointment 85-15%, Calcium Carb 500mg chew, Meclizine HCL 12.5mg , Senna 8.6mg, Albuterol HFA 90 mcg inhaler, Aspirin EC 81mg, Atorvastatin 40mg
Current Illness:
Preexisting Conditions: COPD, Hyperlipidemia
Allergies: PCN
Diagnostic Lab Data: 4/30/21: Diagnostic Profile Labs, CBC
CDC Split Type:

Write-up: Evaluated in Health Services for complaints of SOB on 4/13/21, states he felt ''winded and weak after the 2nd moderna vaccine."


VAERS ID: 1406851 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-17
Onset:2021-04-17
   Days after vaccination:90
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, Atrial fibrillation, COVID-19, Chronic respiratory failure, Condition aggravated, Death, Decubitus ulcer, Dyspnoea, Endotracheal intubation, Fatigue, Hypercapnia, Hypoxia, Mental status changes, Pneumonia, Pulmonary embolism, Shock, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-10
   Days after onset: 23
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: Hypothyroidism Hypertension GERD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 5/10/2021 Patient died. 5/3/2021 Patient is a 91 y.o. female with a history of afib, PE/DVT, hypothyroidism, GERD, htn, colon resection 206 and HTN who presented to the ED with AMS and difficulty breathing. Patient unresponsive in the ED and was intubated for airway protection. CTA chest with extensive acute pulmonary embolism with findings of right heart strain. Patient intubated and sedated, information is obtained from her son, medical staff and medical records. Patient was hospitalized with Covid 2 weeks ago, following discharge she seemed to slowly be improving until Saturday prior to admission Per son was more tired but she had worked with physical therapy and HH on Friday. Sunday she was having difficulty breathing and was brought to the hospital. 4/17/2021 Altered mental status, unspecified altered mental status type; Pneumonia of left lower lobe due to infectious organism; Atrial fibrillation with rapid ventricular response (HCC); Acute pulmonary embolism without acute cor pulmonale, unspecified pulmonary embolism type (HCC); Acute hypoxemic respiratory failure (HCC); Chronic respiratory failure with hypoxia (HCC); Pressure injury of sacral region, stage 3 (HCC); SOB (shortness of breath); Palliative care encounter; Shock (HCC); Chronic atrial fibrillation (HCC); Acute respiratory failure with hypoxia and hypercapnia (HCC)


VAERS ID: 1407804 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-12
Onset:2021-04-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Candida infection, Cardiac disorder, Condition aggravated, Death, Malaise, Mobility decreased, Myocardial infarction, Resuscitation, Seizure, Thrombosis
SMQs:, Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Convulsions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Thrombophlebitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: As per wife''s account, patient died approximately 9 days after receiving vaccine on 4/21 of massive, unknown (suspected cardiac) event. Wife explained that patient was diagnosed with Wolff-Parkinson-White (WPW) syndrome prior to being vaccinated. PCP unaware of diagnosis, and patient did not disclose that on vaccine consent form. Patient reported to his wife that he was feeling unwell after receiving vaccine including unable to move legs well. Patient later diagnosed with thrush and supposedly treated by physician. Patient did not discuss concerns regarding vaccine or WPW with physician. Patient called his wife the day of death and asked her to bring him to the doctor the following day. Wife reported that patient experienced seizures but not concerned as it was similar to childhood seizure. Wife was done at work and drove home after phone call, arriving at house approximately 10-15 minutes after call. Patient supposedly dead when wife arrived. Wife performed CPR for ~15 minutes until EMS arrived, and EMS attempted for another 40 minutes for any electrical activity. Wife declined full autopsy from ME, suspecting that it was massive MI or clot. Wife and patient unaware that WCW could place patient at risk of clots and wondering if the vaccine was partially responsible.


VAERS ID: 1407818 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-04-14
Onset:2021-04-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 210414-015 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-12
   Days after onset: 55
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 55 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had an ED visit and/or hospitalization within 6 weeks of receiving COVID vaccine.


VAERS ID: 1407833 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-04-21
Onset:2021-04-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Asiprin 81 mg QD, Atorvastatin 20 mg QD, Bumetanide 2 mg 1 1/2QD, Calcitriol 0.5 mcg 1 tab 5xweek, carvedilol 6.25 mg BID, clobidogrel 75 mg QD, Flovent Diskus 50 mcg/actuation powder inhale qd. Gentamicin 0.3% drops for catheter exit site
Current Illness: ESRD on Peritoneal dialysis daily, Anemia in CRD
Preexisting Conditions: ESRD On daily peritoneal dialysis
Allergies: Penicillins
Diagnostic Lab Data: no official death certificate is available to facility. Not known cause of death.
CDC Split Type:

Write-up: Patient was found dead next day at home during sleep.


VAERS ID: 1407929 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: California  
Vaccinated:2021-05-21
Onset:2021-05-29
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033C1A / 2 UN / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test, Death, Toxicologic test
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: diabetes mellitus type I, inactive TB
Allergies: unknown
Diagnostic Lab Data: Blood and vitreous toxicology
CDC Split Type:

Write-up: Decedent passed away from causes not yet determined


VAERS ID: 1407938 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-04-13
Onset:2021-04-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037B21A / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Abdominal distension, Abdominal pain upper, Amnesia, Cardiac monitoring, Computerised tomogram, Diarrhoea, Dyspnoea, Fatigue, Immobile, Incoherent, Laboratory test, Nausea, Pathology test, Skin exfoliation, X-ray
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Dementia (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-31
   Days after onset: 46
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 31 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Breo, Pro-Air, Alprazolam, Centrum, Aspirin and Warfin
Current Illness: Skin Cancer, lower left ankle
Preexisting Conditions: COPD
Allergies: None
Diagnostic Lab Data: Clinical Lab, Pathology, X-rays, Nuclear medical tests, CT scans, respiratory services, occupational/speech PT, and cardiac monitoring services
CDC Split Type:

Write-up: Intense diarrhea, stomach cramps and bloating. nausea, fatigue, memory loss, incoherent, skin peeling over entire body including face, immobile and labored breathing (over and above her COPD).


VAERS ID: 1407967 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-04-23
Onset:2021-06-08
   Days after vaccination:46
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 1 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019B21A / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: unknown
CDC Split Type:

Write-up: Patient was vaccinated with the Moderna Covid-19 vaccine on 3-26-21 and 4-23-21. He was admitted to Hospital on 06-08-2021. He tested positive for Covid-19 on 06-11-2021. He passed away on 06-12-2021. It is unknown whether or not Covid-19 contributed to the case''s illness, hospitalization, possible adverse vaccine reaction or death.


VAERS ID: 1408027 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-06-08
Onset:2021-06-15
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-06-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Blood ethanol, Cardiac arrest, Cardiomyopathy, Ejection fraction decreased, Electrocardiogram abnormal, Fatigue, Hyperkalaemia, Lactic acidosis, Left ventricular dysfunction, Leukocytosis, Liver function test increased, Mitral valve incompetence, Myocarditis, Pallor, Respiratory arrest, Resuscitation, Troponin increased, Vaccination complication
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Naltrexone, Trazodone, Fioricet
Current Illness: Unknown
Preexisting Conditions: Von Willebrand''s Disease, nerve damage (unspecified), Opioid addiction
Allergies: NKDA
Diagnostic Lab Data: AKI with severe hyperkalemia, mildly elevated troponin, elevated LFT, leukocytosis, lactic acidosis, presence of EtOH. ECG indicates markedly reduced systolic function of Left ventricle, estimated EF of 15 - 20%. Right ventricle shows moderately reduced systolic function. Mitral and Tricuspid valves show mild mitral regurgitation.
CDC Split Type:

Write-up: Per family, patient reported to have been experiencing fatigue for several days after receiving Covid vaccine. On 6/15/21, patient''s significant other discovered patient in bed, not breathing, with ashen appearance, uncertain how long it had been since patient was last breathing. EMS was contacted, CPR was given and patient was transferred to Emergency Department at the hospital. Diagnosis of Cardiologist is cardiac arrest, NSTEMI (suspects type 2). Per cardiologist, patient appears to exhibit cardiomyopathy, etiology difficult to ascertain (patient''s family/acquaintances have endorsed periodic use by patient of anabolic steroids in the past, making it more difficult to rule out source of cardiomyopathy. ). Physicians involved are reporting this case in the event that this may be a case of vaccine-induced myocarditis, although no diagnosis as such has been made.


VAERS ID: 1409932 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-04-01
Onset:2021-04-23
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Death, Dizziness, Feeling abnormal, Myocardial infarction, Pyrexia, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-27
   Days after onset: 34
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: We were unaware that he had an undiagnosed heart condition
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: The evening of his second shot, he collapsed. He said he became light headed, but I believe he may have lost consciousness briefly. He rand a low fever for 12 hours. Afterwards, he complained that he had "not felt right" since the second shot. He died of a heart attack on May 27, roughly one month after his second shot.


VAERS ID: 1410139 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-01
Onset:2021-04-12
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Joint swelling, Peripheral swelling
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient received the first dose of vaccine on March the 1st and the 2nd dose of the vaccine on March 28th. Patient had difficulty breathing with swelling feet and ankles that did not begin until April 12th. Patient had no history of breathing problems. Cardiovascular history is unknown at the pharmacy as we had only ever performed vaccinations on the patient. Patient was discovered in his house deceased. Exact date is unknown. The pharmacy was contacted by the patient''s prescriber which requested we file this report. I apologize for the lack of precise information.


VAERS ID: 1410203 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-05-01
Onset:2021-05-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-14
   Days after onset: 44
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: blood pressure meds, doesnt know the name
Current Illness:
Preexisting Conditions:
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt developed pulmonary embolism and passed away 6/14/2021


VAERS ID: 1410369 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-10
Onset:2021-06-10
   Days after vaccination:120
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute kidney injury, Auscultation, COVID-19, Chest X-ray abnormal, Crepitations, Death, Intensive care, Respiratory failure, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amiodarone, Furosemide, Risperidone, Pantoprazole, Atorvastatin, Sertraline, Apixaban, Trazodone, Ibuprofen, Acetaminophen, Aspirin , Docusate Sodium, Memantine, Multivitamin (Thera M Plus), Metoprolol
Current Illness:
Preexisting Conditions: Chronic renal disease, Heart disease, Dementia
Allergies:
Diagnostic Lab Data: Real-Time Reverse Transcriptase PCR for SARS-CoV-2 via Nasopharyngeal Swab - Positive 6/11/21
CDC Split Type:

Write-up: Patient received 2nd dose of the COVID-19 vaccine on 2/10/21 and was considered fully vaccinated two weeks later on 2/24/21. On 6/10/21 patient was hospitalized with a possible upper GI bleed. Overnight the patient began to have increased oxygen needs and crackles on auscultation. She was transferred to the ICU, had an abnormal chest x-ray, and tested PCR positive for COVID-19. The patient had acute kidney failure and respiratory failure with a DNR and DNI. She expired on 6/11/21.


VAERS ID: 1410676 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A 030L20 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arteriosclerosis coronary artery, Asthenia, Bone pain, Chest pain, Condition aggravated, Cough, Death, Fatigue, Feeling abnormal, Hypoglycaemia, Lethargy, Myocardial infarction, Myocardial ischaemia, Pain, Resuscitation, Rhinorrhoea, Seizure
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Dementia (broad), Convulsions (narrow), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Osteonecrosis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 73
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: birth control
Current Illness: With her first vaccine on 12-31-2020, she experienced a runny nose, sniffles, and cough. Felt a little tired.
Preexisting Conditions: After her second vaccine, she became weaker and very fatigued. She just kept saying she felt funny that something wasn''t right. On April 12, 2020 she had a hypoglycemic attack at work and they gave her a glucose tablet along with a soda and snack but her sugar came up to normal. After getting home from work, she laid down for a while because she was tired and said she just needed a nap. after a while, she got up and cooked. afterwards she was going to hunt for mushrooms but came back after about half an hour and tired and not feeling right once again. Her fianc´┐Ż called me at 11:33 p.m. saying that I needed to get over here right away that patient was in bad shape. Once I got over there I checked her blood sugar level and it was good. As she began to tell me by motioning that she was hurting from her color bone and over chest she then proceeded to tell us that her right arm and thumb felt weird. She then went into a seizure. We called 911 and reported her that she had a hypoglycemic attack earlier in the day and that she had just seized and now was having a heart attack and CPR was being performed. The ambulance came 40 minutes later telling us that dispatch messed up the call. They pronounced our daughters'' death at 0121 on April 13, 2021 due to ischemic heart disease due to coronary artery atherosclerosis.
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: ACHE, RUNNY NOSE, COUGH, LETHARGIC


VAERS ID: 1410797 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-06
Onset:2021-05-30
   Days after vaccination:113
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025AZ1A / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood glucose decreased, COVID-19, COVID-19 pneumonia, Death, Decreased appetite, Depressed level of consciousness, Diarrhoea, Fatigue, Hypertension, Hypoglycaemia, Ischaemic stroke, SARS-CoV-2 test positive
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-13
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Combivent Respimat, Lactobacillus acidophilus, Mucinex, acetaminophen, azithromycin, bisacodyl , calcium carbonate, cholecalciferol , ferrous sulfate, finasteride, furosemide, hydralazine, ipratropium-albuterol, lidocaine [Lidoderm], losart
Current Illness: Anemia, COVID-19, Dementia, Diabetes Mellitus type II, heart failure. hypertension, radiculopathy
Preexisting Conditions: see item 11
Allergies: Adhesive tape
Diagnostic Lab Data:
CDC Split Type:

Write-up: Initially had fatigue, diarrhea, and loss of appetite. Tested positive for COVID 19 on 5/28/21 , during surveillance testing related to a facility COVID Outbreak. He went to ED 5/28/21 for decrease level of consciousness, high blood pressure, low blood sugar, anorexia. Once stabilized, transferred back to facility. On 6/7/21, transferred to ED for COVID pneumonia and hypoglycemia, treated with Dexamethasone and oxygen. Discharged back to facility 6/10/2021. On 6/12/2021, went to ED for ischemic stroke. Died 6/13/2021.


VAERS ID: 1410799 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: California  
Vaccinated:2021-05-26
Onset:2021-05-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Marijuana
Current Illness: None known
Preexisting Conditions: Schizophrenia
Allergies: None known
Diagnostic Lab Data: Coroner autopsy 2021-06
CDC Split Type:

Write-up: After first dose of vaccine on 4/23 complained of fatigue and tiredness. After second dose on 5/26 complained of fatigue, dizziness, nausea and body aches. Expired on 5/28.


VAERS ID: 1410930 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-06-10
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004C21A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Eliquis
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: death, June 14, 2021


VAERS ID: 1410986 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-04-01
Onset:2021-04-16
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-06-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Urinary tract infection
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was admitted to hospital from hospice care with UTI on 4/16/21 after receiving 2nd dose of vaccine on 4/1/21. Patient passed on 4/21/21. Per guidelines, all hospitalizations are reported.


VAERS ID: 1412293 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-02-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chills, Fatigue, Lymphadenopathy, Malaise, Myocardial infarction, Nausea
SMQs:, Acute pancreatitis (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 46
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: COVID-19
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: not well after the vaccination; Died of a massive heart attack; substantial swelling on her lymph node on the left side on the neck/jaw area; Chills; Nausea; Felt very tired; This spontaneous case was reported by a consumer and describes the occurrence of MYOCARDIAL INFARCTION (Died of a massive heart attack) in an 82-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 015M20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included COVID-19 in January 2021. On 11-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 11-Feb-2021, the patient experienced CHILLS (Chills), NAUSEA (Nausea) and FATIGUE (Felt very tired). On 02-Mar-2021, the patient experienced LYMPHADENOPATHY (substantial swelling on her lymph node on the left side on the neck/jaw area). On 30-Mar-2021, the patient experienced MYOCARDIAL INFARCTION (Died of a massive heart attack) (seriousness criteria death and medically significant). On an unknown date, the patient experienced MALAISE (not well after the vaccination). The patient was treated with NAPROXEN SODIUM (ALEVE) for Lymph nodes enlarged, at a dose of 1 dosage form. The patient died on 30-Mar-2021. The reported cause of death was massive heart attack. It is unknown if an autopsy was performed. At the time of death, MALAISE (not well after the vaccination), CHILLS (Chills), NAUSEA (Nausea) and FATIGUE (Felt very tired) outcome was unknown and LYMPHADENOPATHY (substantial swelling on her lymph node on the left side on the neck/jaw area) had not resolved. Concomitant medications were not reported. Company Comment ; Very limited information regarding this events has been provided at this time. Further information has been requested. Most recent FOLLOW-UP information incorporated above includes: On 30-Apr-2021: Follow up telephone contact report (TCR) upgraded case to serious, new event added, action taken updated; new reporter added.; Sender''s Comments: Very limited information regarding this events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Massive heart attack


VAERS ID: 1412755 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-06-17
Onset:2021-06-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003C21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, amlodipine, aspirin, buprenorphine patch, carvedilol, diclofenac sodium gel, docusate sodium, gabapentin, heparin, hydralazine, insulin lispro, levetiracetam, insulin glargine, lidocaine cream, atorvastatin, ondansetron, Rena
Current Illness: sepsis, pneumonia
Preexisting Conditions: atherosclerosis, type 2 diabetes mellitus, diabetic neuropathy, pressure ulcer of sacral region, chronic kidney disease, hypertension, hyperlipidemia, anxiety disorder, pain, unspecified convulsion, history of COVID-19, dependence on renal dialysis
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient found in respiratory arrest at 4:20am on 6/19/21. CPR initiated and continued by EMS, along with IV fluids and intubation, remained in asystole throughout course of CPR. CPR terminated by EMS.


VAERS ID: 1413325 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-04-05
Onset:2021-04-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

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

Write-up: He said he felt bad and fell over and died.


VAERS ID: 1413849 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-05-18
Onset:2021-05-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Arteriosclerosis, Chronic obstructive pulmonary disease, Death, Dyspnoea, Resuscitation
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-18
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Yes
Current Illness: COPD She was a resident at the Senior Living facility. My mother received the vaccine on Tuesday, May 18, 2021 at approximately 11:00 a.m. She was left by herself and called around at 11:32 to say she got the vaccine and she was having a hard time breathing. Around 1:40, the nursing home called to let me know CPR was being performed. My sister rushed to the site and she was pronounced dead around 2:10. p.m.
Preexisting Conditions: COPD The death states she died of Atherosclerotic Heart Disease
Allergies: No
Diagnostic Lab Data: Death certificate
CDC Split Type:

Write-up: COPD She was a resident at the Senior Living facility. My mother received the vaccine on Tuesday, May 18, 2021 at approximately 11:00 a.m. She was left by herself and called around at 11:32 to say she got the vaccine and she was having a hard time breathing. Around 1:40, the nursing home called to let me know CPR was being performed. My sister rushed to the site and she was pronounced dead around 2:10. p.m.


VAERS ID: 1414045 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-28
Onset:2021-02-02
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / UNK UN / ID

Administered by: Senior Living       Purchased by: ?
Symptoms: SARS-CoV-2 test negative, Vital functions abnormal
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg, Lasix 20 mg, Plavix 75 mg, Temazepam 30 mg.
Current Illness: Unknown.
Preexisting Conditions: Stroke, PEG, bed ridden.
Allergies: Unknown.
Diagnostic Lab Data: Covid-19 PCR lab test, not detected.
CDC Split Type:

Write-up: Unstable vital signs.


VAERS ID: 1414259 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-03-01
Onset:2021-03-18
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016420A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Heart rate decreased, Oxygen saturation decreased
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulosima, Prozac, Synthroid, Amaryl, Risperidone, Famotidine, Januvia, Isosorbide, Furosemide, Carvedidol, Atorvastatin.
Current Illness: Unknown.
Preexisting Conditions: Hyperthyroidisms, Hypertension, CHF, Hospice.
Allergies: Unknown.
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: Low heart activity and low oxygenation.


VAERS ID: 1414536 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-06-10
Onset:2021-06-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Patient was homeless. Self-reported history of seizures; self-report of not walking well or being able to stand for more than 15 minutes at a time; shortness of breath
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This patient was homeless. Partner was with patient on the night of 6/12 when patient complained of not feeling well and attributed it to side effects of his COVID vaccine, which he received two days prior. Patient declined to go to the hospital. When partner woke up the morning of 6/13, the patient was found dead. A coroner''s report is expected sometime within the next 4-6 weeks.


VAERS ID: 1414703 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-05
Onset:2021-02-17
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / UNK UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Hypertension, Oxygen saturation decreased, SARS-CoV-2 test negative, Urinary tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Hypertension (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: Metformin, Carvedilol, Plavix, Folic Acid, Levoxin, Paxin, Prednisone, Lipitor, Temazepam.
Current Illness: Unknown.
Preexisting Conditions: Heart problems, Diabetes, Osteoporosis.
Allergies: Unknown.
Diagnostic Lab Data: Covid-19 Molecular test, negative result.
CDC Split Type:

Write-up: High blood pressure, low oxidation, urine infection. cardiac arrest.


VAERS ID: 1414947 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-02
Onset:2021-06-05
   Days after vaccination:95
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Back pain, Computerised tomogram abdomen, Computerised tomogram thorax, Death, Deep vein thrombosis, Dysphagia, Dysphonia, Dyspnoea, Electrocardiogram, Full blood count, Guillain-Barre syndrome, Metabolic function test, Muscular weakness, Peripheral swelling, Vena cava filter insertion
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Peripheral neuropathy (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, venous (narrow), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Norco 5/325mg 1 tab every 4 hours as needed, caltrate plus vitamin D-1 tablet daily, Fenofibric acid daily, Metformin 500 mg BID, Zyloprim 100 mg daily Synthroid 0.05mg daily, Vitamin D3 BID, Fish oil 1,200 mg daily, Claritin 10 mg QD, lipi
Current Illness: unknown was seen in the ER not a normal pt here at the Clinic
Preexisting Conditions: Acute Kidney injury, BPH, Type 2 diabetes, DVT, Gout, arthritis, HLD, Hypothyroidism ,renal rupture
Allergies: Warfarin, Lisinopril, Phenylbutazone
Diagnostic Lab Data: Consults-GI, Palliative care, rehab medicine, urology, IR and neuromuscular. Procedure: IVC filter placed on 6/11. CBC, CMP, CT chest,abd,pelvis, EKG all done on 6/5/2021
CDC Split Type:

Write-up: Pt showed up to the ER via EMS on 6/5/2021 with low back pain and weakness, bilateral leg swelling, shortness of breath. On 6/6/2021-developed bilateral upper and lower weakness that progressed to dysphagia and dysphonia. Transferred to ER on 6/8/2021 for Gillian Barre Syndrome On 6/11 had bilateral DVTS He was placed on palliative care and passed away on 6/19/2021


VAERS ID: 1414988 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-04-17
Onset:2021-05-15
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain upper, Blood glucose normal, Cardiac arrest, Death, Pulse absent
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), 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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-17
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not that report source is aware of
Current Illness: none
Preexisting Conditions: none
Allergies: not that report source is aware of
Diagnostic Lab Data:
CDC Split Type:

Write-up: After receiving the 2nd vaccine on 5/15/21, on 5/16 patient had a "stomach ache", on 5/17 he went to work. At 9:30am, the camera''s show him going into the women''s restroom to service it, a lady tried to go into the restroom and could not go in, she called the supervisor, when the supervisor arrived there was no pulse. Report source believes he goes into work around 7:00AM. Report sources states she was told " his blood sugar was not elevated". Report source states that the death certificate states he had a cardiac arrest.


VAERS ID: 1414999 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-08
Onset:2021-04-22
   Days after vaccination:73
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / UNK UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dementia Alzheimer's type
SMQs:, Dementia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin, Zoloft, Losartan, Aricept, Multivitamins, Ferrous Sulfate, Folic Acid, Lasix.
Current Illness: Unknown.
Preexisting Conditions: Hyperthyroidism, Type 2 Diabetes, Alzheimer, Nasogastric, Prostate Cancer, Hospice.
Allergies: Unknown.
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: Dies due to Alzheimer complications.


VAERS ID: 1415021 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-30
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

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

Write-up: Cardiac arrest, death


VAERS ID: 1415083 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chills, Death, Malaise, Pain, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-21
   Days after onset: 87
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 35 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Warfarin, Bystolic, Losartan, allopurinol
Current Illness: none
Preexisting Conditions: heart valve replacement from a birth defect in his heart when he was born
Allergies: none
Diagnostic Lab Data: the file is too large to attach.
CDC Split Type:

Write-up: My husband fell ill within hours of getting the first dose of the vaccine, he started running fever, chills, body aches-within 7 days he was admitted to the hospital and 12 hours after admission to the hospital he was diagnosed with Covid Pneumonia. or they thought- his lungs were showing signs of being attacked. He had no illness, no fever, no underlying health concerns, no allergies, he was not over weight, he was not diabetic, he was still young and within 6 weeks of getting the vaccine he was dead. Doctors could do nothing to save his life. The Moderna vaccine killed my husband and it is killing other perfectly healthy people.


VAERS ID: 1415200 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-22
Onset:2021-03-31
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Atrial fibrillation, Death
SMQs:, Supraventricular tachyarrhythmias (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-26
   Days after onset: 56
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented to the ED and was subsequently hospitalized for atrial fibrillation within 6 weeks of receiving COVID vaccination. She died on 5/26/2021.


VAERS ID: 1415239 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-05-13
Onset:2021-05-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022C21A / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Angiogram, Anticoagulant therapy, Bilevel positive airway pressure, Blood cortisol, Blood creatinine increased, Blood lactic acid, C-reactive protein increased, Deep vein thrombosis, Fasciectomy, Fibrin D dimer, Intestinal ischaemia, Myocarditis, Myoglobin blood increased, N-terminal prohormone brain natriuretic peptide increased, Respiratory failure, SARS-CoV-2 test negative, Thrombosis, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (narrow), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Ischaemic colitis (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-19
   Days after onset: 35
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 34 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ALPRAZOLAM (XANAX) 0.5 MG TABLET TAKE ONE-HALF TO ONE TABLET BY MOUTH THREE TIMES A DAY AS NEEDED FOR ANXIETY AMLODIPINE (NORVASC) 10 MG TABLET TAKE ONE TABLET BY MOUTH EVERY DAY ASPIRIN 81 MG CHEWABLE TABLET Take 1 tab
Current Illness: SOB after first covid shot.
Preexisting Conditions: ? Cholelithiases ? Clostridium difficile infection ? Diabetes mellitus (CMS/HCC) ? Enterocolitis ? Epistaxis ? Fracture of right hip (CMS/HCC) ? Hemoglobin A1c less than 7.0% 01/14/2018 6.2 ? History of bone density study unknown ? History of colonoscopy 04/03/2017 repeat 3 years ? Hypertension ? Myocardial infarction (CMS/HCC)
Allergies: Iodine Anaphylaxis Other reaction(s): see contrast passed out Severity: Unknown ? Sulfamethoxazole Hives Severity: Moderate ? Trimethoprim Hives Severity: Moderate ? Clopidogrel ? Codeine Nausea And Vomiting Severity: Severe ? Cyclobenzaprine Hcl ? Sulfamethoxazole-Trimethoprim ? Latex Rash
Diagnostic Lab Data: 6/18 - lactic acid 4.6 , CRP 13 6/16 -proBNP 19,000 6/15 - ddimer 5,513 6/10 - cortisol 145 5/18 Cr 2.58 5/17 myoglobin 1574 5/15 high sensitivity troponin 18,046, covid antigen rapid negative
CDC Split Type:

Write-up: Myocarditis in 2 days - diuretics, Respiratory Failure in 2 days Bipap and Airvo, Clotted off leg in a few weeks Angiogram and Fascitomy, Ischemic gut weeks - comfort care orders, DVT in arm in weeks could have been due to PICC also - Elquis


VAERS ID: 1415288 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-02-24
Onset:2021-02-28
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / IM

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

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

Write-up: client died. Client had other underlining health conditions.


VAERS ID: 1415368 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-03-30
Onset:2021-05-28
   Days after vaccination:59
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None.
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Autopsy performed by county coroner''s office.
CDC Split Type:

Write-up: Patient died of a sudden heart attack at age 70, just 2 months after receiving his 2nd dose of the vaccine. His parents lived well into their mid-eighties and patient spent the last 17 years of his working years as a door to door, getting lots of cardio exercise every day. At the time of his death he was a very low stress person and taking good care of himself.


VAERS ID: 1415733 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: California  
Vaccinated:2021-06-13
Onset:2021-06-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Cyanosis, Death, Fatigue, Impaired work ability, Injection site erythema, Injection site pain, Lethargy, Somnolence
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-14
   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: None
Current Illness: None
Preexisting Conditions: None
Allergies: No allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The pt received his 2nd Moderna covid vaccine on 6/13/21 at 10:45 am (approximately). Starting at 5pm he c/o pain, redness and tenderness in the injection site, chills, and lethargy . The next day he did not go to work b/o he felt tired and he stayed home with his 7 y/o daughter while his wife went to work. His wife spoke with him in the am and he reports he was making breakfast for their daughter and he was going to lie down and sleep afterward. He made lunch for daughter about 1 pm and he went to lie down in his chair. His brother called his wife at about 4:30 pm stating he was blue. 911 was called and they were unable to revive him.


VAERS ID: 1416338 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-02-04
Onset:2021-02-07
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Arteriosclerosis, Cardiac failure congestive, Coronary artery disease, Death, Immediate post-injection reaction, Malaise, SARS-CoV-2 test negative
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypersensitivity (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Covid 19 test was negative. Cause of death was ruled to be Acute and Chronic congestive heart failure with atherosclerotic coronary artery disease.
CDC Split Type:

Write-up: My dad died on February 19th after having been visibly sick immediately after being vaccinated until the day he died, according to his friends. Was told by a friend that he dropped something he was holding while hanging out with friends and they called an ambulance but he refused the ambulance. I do not know that exact date of that incident only that it was following vaccination. Was also told by numerous others that he seemed "sick". No other details are known.


VAERS ID: 1416476 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-04-21
Onset:2021-05-14
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-14
   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:
CDC Split Type:

Write-up: Patient died at home 3 weeks after receiving first dose of vaccine.


VAERS ID: 1416488 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Texas  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: USMODERNATX, INC.MOD20212

Write-up: Passed away; Had seizures 2 days after receiving his first dose; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Passed away) and SEIZURE (Had seizures 2 days after receiving his first dose) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced DEATH (Passed away) (seriousness criteria death and medically significant) and SEIZURE (Had seizures 2 days after receiving his first dose) (seriousness criterion medically significant). The patient died on an unknown date. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, SEIZURE (Had seizures 2 days after receiving his first dose) outcome was unknown. No concomitant medication information was provided. No treatment medication information was provided. Reporter stated she knows of someone and is not totally sure which vaccine was taken, but says Moderna. Action taken with respect to mRNA-1273 was not applicable. This is a case of a sudden death of a Male patient who reportedly had seizures 2 days after receiving his vaccine. Reporter is unsure of vaccine that patient received and this can be a confounding factor. Very limited information has been provided regarding these events. Most recent FOLLOW-UP information incorporated above includes: On 18-Jun-2021: Sender''s Comments: This is a case of a sudden death of a Male patient who reportedly had seizures 2 days after receiving his vaccine. Reporter is unsure of vaccine that patient received and this can be a confounding factor. Very limited information has been provided regarding these events.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1416721 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-01
Onset:2021-04-01
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac death, Cardiac disorder, Chest pain, Circulatory collapse, Decreased appetite, Dehydration, Dyspnoea, Electrocardiogram, Fatigue, Thirst
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-10
   Days after onset: 9
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: CHLORTHALIDONE; LOSARTAN POTASSIUM; MELOXICAM; METOPROLOL SUCCINATE; PANTOPRAZOLE SODIUM; TAMSULOSIN HCL; XARELTO; AMLODIPINE BESYLATE; TADALAFIL
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: ECG; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive; Test Name: ECG; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Dehydrated; Collapsed; Cardiac death/the patient woke up and then grab it''s chest and collapsed; Started having heart issues; Chest pain; Lose it''s appetite; Thirsty; Short of breath/got very winded; Fatigue/ very tired; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of CARDIAC DEATH (Cardiac death/the patient woke up and then grab it''s chest and collapsed), DEHYDRATION (Dehydrated) and CIRCULATORY COLLAPSE (Collapsed) in a 66-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concomitant products included CHLORTHALIDONE, LOSARTAN POTASSIUM, MELOXICAM, METOPROLOL SUCCINATE, PANTOPRAZOLE SODIUM SESQUIHYDRATE (PANTOPRAZOLE SODIUM), TAMSULOSIN HYDROCHLORIDE (TAMSULOSIN HCL), RIVAROXABAN (XARELTO), AMLODIPINE BESILATE (AMLODIPINE BESYLATE) and TADALAFIL for an unknown indication. On 01-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 01-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. In April 2021, the patient experienced DEHYDRATION (Dehydrated) (seriousness criterion hospitalization), CARDIAC DISORDER (Started having heart issues), CHEST PAIN (Chest pain), DECREASED APPETITE (Lose it''s appetite), THIRST (Thirsty), DYSPNOEA (Short of breath/got very winded) and FATIGUE (Fatigue/ very tired). On an unknown date, the patient experienced CIRCULATORY COLLAPSE (Collapsed) (seriousness criterion medically significant). The patient died on 10-Apr-2021. The reported cause of death was Cardiac death. An autopsy was not performed. At the time of death, DEHYDRATION (Dehydrated), CIRCULATORY COLLAPSE (Collapsed), CARDIAC DISORDER (Started having heart issues), CHEST PAIN (Chest pain), DECREASED APPETITE (Lose it''s appetite), THIRST (Thirsty), DYSPNOEA (Short of breath/got very winded) and FATIGUE (Fatigue/ very tired) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Electrocardiogram: inconclusive (Inconclusive) Inconclusive and inconclusive (Inconclusive) Inconclusive. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Action taken with the mRNA-1273 vaccine due to the events was not applicable. The reporter informed that the patient had received both doses of mRNA-1273 vaccine. He first lost his appetite and started feeling thirsty on the following day after vaccination, which worsened progressively for the next five days. The patient then started having chest pain, was short of breath and experienced fatigue. He got very winded when he went to the bathroom and felt very tired for the next two days, When he went to the hospital, the doctor said that he would need to be admitted if he doesn''t feel well. On a Wednesday, the patient went to the hospital and an ECG was done. The reporter informed that when the doctor compared it with an ECG from few days before, he could not believe it was of the same patient''s. The patient was taken to the ER (emergency room) and was them transferred to ICU (intensive care unit) as he was dehydrated. Dehydration was treated and at the time the patient started having heart issues. By Friday, the patient started doing better and the doctor discussed discharging him. On Saturday, when the patient woke up he grabbed his chest and collapsed. The reporter informed that they were not able to get an autopsy but the death was assumed to be cardiac death. It was reported that the patient passed away approximately nine days after receiving the second dose of the vaccine. The reporter further informed that the patient was in good health and had a full ''cardiac work'' prior to his vaccination. Company comment: Very limited information regarding this event has been provided at this time. Details regarding medical history and course in the hospital is required for further evaluation.; Sender''s Comments: Very limited information regarding this event has been provided at this time. Details regarding medical history and course in the hospital is required for further evaluation.; Reported Cause(s) of Death: Cardiac death


VAERS ID: 1416982 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-22
Onset:2021-01-29
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspepsia, Respiratory disorder, SARS-CoV-2 test negative
SMQs:, Acute central respiratory depression (broad), Gastrointestinal nonspecific dysfunction (narrow), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown.
Current Illness: Unknown.
Preexisting Conditions: Pacemaker, heart problems, doesn''t pacify.
Allergies: Unknown.
Diagnostic Lab Data: Covid-19 PCR lab test on February 11, 2021, negative.
CDC Split Type:

Write-up: Burning sensation in the stomach, died of respiratory problems.


VAERS ID: 1417056 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-04-22
Onset:2021-04-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048B21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Death, Gastrointestinal disorder, Mass
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-03
   Days after onset: 39
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s wife reported that patient died a couple of days after second Moderna vaccine. About 2 days after vaccine, patient presented with lumps all around body and doctor''s could not figure out what was wrong. His digestive tract started to deteriorate and he passed away at home. Autopsy was performed but could not confirm cause of death.


VAERS ID: 1417063 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-05-28
Onset:2021-06-20
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Metoprolol
Current Illness: Atrial Fibrillation
Preexisting Conditions:
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 6/20/2021. Cause of death unknown.


VAERS ID: 1417109 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-05-18
Onset:2021-05-25
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-15
   Days after onset: 21
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Not known
CDC Split Type:

Write-up: Patient received first dose of Moderna on May 18, 2021. Spouse came to the pharmacy and informed us that the patient passed away in the hospital on June 15, 2021. She was diagnosed with COVID-19 during her stay at the hospital.


VAERS ID: 1417223 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-04-29
Onset:2021-05-14
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 005C21A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Cardiac arrest, Death, Ischaemic skin ulcer, Peripheral arterial occlusive disease, Peripheral ischaemia, Respiratory failure, SARS-CoV-2 test positive, Vascular graft
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), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-05
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: Pre-Existing Conditions: OTHER CHRONIC DISEASES, CARDIOVASCULAR DISEASE, DIABETES MELLITUS, CHRONIC LUNG DISEASE (ASTHMA/EMPHYSEMA/COPD)
Allergies: unknown
Diagnostic Lab Data: PCR + 5/14
CDC Split Type:

Write-up: I am the epidemiologist reporting on behalf of patient who tested positive for COVID-19 via PCR on 5/14/21 after the completion of a full Moderna vaccine series (Dose 1 on 4/1 and Dose 2 on 4/29). The patient later died on 6/5/21 . Cause of Death is listed as cardiac arrest; hypoxic RF; Extensive PAD and ischemic leg/foot ulcers s/p bypass surgery. Pre-existing conditions listed as: OTHER CHRONIC DISEASES, CARDIOVASCULAR DISEASE, DIABETES MELLITUS, CHRONIC LUNG DISEASE (ASTHMA/EMPHYSEMA/COPD)


VAERS ID: 1417278 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-11
Onset:2021-04-22
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-13
   Days after onset: 21
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: + PCR 4/22
CDC Split Type:

Write-up: I am the epidemiologist reporting on behalf of patient who tested positive for COVID-19 via PCR on 4/22/21 after the completion of a full Moderna vaccine series (Dose 1 on 2/11 and Dose 2 on 3/11). The patient later died on 5/13/21 . Cause of Death is listed as ?Intestinal Obstruction?.


VAERS ID: 1417642 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-05-24
Onset:2021-06-07
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-08
   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: vimpat Depakote dr
Current Illness:
Preexisting Conditions: epilepsy learning disabilities
Allergies: clindamycin topamax
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient father reported he passed away in his sleep the night of 06-07-21 and was pronounced diseased on 6-8-21


VAERS ID: 1417729 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-03-12
Onset:2021-04-22
   Days after vaccination:41
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Areflexia, Cardiac arrest, Catheterisation cardiac normal, Chest pain, Death, Dyspnoea, Electrocardiogram ST segment elevation, General physical health deterioration, Intra-aortic balloon placement, Mydriasis, Pulmonary embolism, Pulse absent, Pulseless electrical activity, Pupil fixed, Respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This was very unfortunate 51 years old male with past medical history of hypertension, hyperlipidemia, obesity. Patient presented with chief complaint of shortness of breath and chest pain. EMS reported that the patient has been complaining of some shortness of breath and chest pain intermittent for couple of weeks. 12 leads EKG showed evidence of anterior ST elevation myocardial infarction. Code heart was called. Patient developed PEA arrest in the Cath Lab. CPR ACLS was initiated. ROSC was achieved initially after 30 minutes of CPR. Intra-aortic balloon pump was placed. Coronary arteries were essentially clean. Due to high suspicion for massive PE-TPA was given 100 mg without meaningful clinical improvement. CPR was continued for more than an hour. Despite all aggressive measures patient continued to deteriorate. At 3:26 PM patient has no spontaneous breathing, no peripheral pulses, no heartbeats by auscultation or by monitor. Pupils were fixed and dilated. No cough no gag reflexes . patient was pronounced dead.


VAERS ID: 1417870 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-08
Onset:2021-03-20
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / UNK AR / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Colonoscopy, Intensive care, Magnetic resonance imaging, Rectal haemorrhage, Thrombosis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal haemorrhage (narrow), Thrombophlebitis (broad), Ischaemic colitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None
Preexisting Conditions: Coronary artery disease, arthritis, peripheral vascular disease, abdominal aortic aneurism
Allergies: None
Diagnostic Lab Data: Hospitalized in ICU, colonoscopy, MRI
CDC Split Type:

Write-up: Profuse rectal hemorrhaging and blood clots


VAERS ID: 1417918 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-06-18
Onset:2021-06-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-06-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043821A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, acetaminophen, fish oil, garlic
Current Illness: Aortic stenosis, coronary artery disease COPD
Preexisting Conditions: Aortic stenosis, coronary artery disease COPD
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1419805 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-20
Onset:2021-03-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Chills, Fall, Haemorrhage, Myocardial infarction, Pyrexia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-23
   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: Diabetes (was on anti-diabetic medicine.)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Died due to heart attack; Lot of blood was on the floor; He fell on bathroom tiles; Feeling weakness/Could not coming out of bed; Fever; Chills; This spontaneous case was reported by a consumer and describes the occurrence of MYOCARDIAL INFARCTION (Died due to heart attack) and HAEMORRHAGE (Lot of blood was on the floor) in a 42-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Diabetes (was on anti-diabetic medicine.). On 20-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 20-Mar-2021, the patient experienced ASTHENIA (Feeling weakness/Could not coming out of bed), PYREXIA (Fever) and CHILLS (Chills). On 23-Mar-2021, the patient experienced MYOCARDIAL INFARCTION (Died due to heart attack) (seriousness criteria death and medically significant), HAEMORRHAGE (Lot of blood was on the floor) (seriousness criterion medically significant) and FALL (He fell on bathroom tiles). The patient died on 23-Mar-2021. The reported cause of death was Heart attack. It is unknown if an autopsy was performed. At the time of death, HAEMORRHAGE (Lot of blood was on the floor), FALL (He fell on bathroom tiles), ASTHENIA (Feeling weakness/Could not coming out of bed), PYREXIA (Fever) and CHILLS (Chills) outcome was unknown. Concomitant medication included was anti-diabetic medicine. The treatment information was not provided. Very limited information regarding this events has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: heart attack


VAERS ID: 1419824 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Died; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Died) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medications were provided. It was reported that a person died after receiving a COVID-19 vaccine. No further details were provided. Very limited information regarding this event has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1419839 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-16
Onset:2021-04-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-26
   Days after onset: 33
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: Surgery (Bladder surgery on 25 Feb.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20212

Write-up: Stated going downhill; He died; Got a little sick,he stated going downhill; This spontaneous case was reported by a patient family member or friend and describes the occurrence of DEATH (He died) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Surgery (Bladder surgery on 25 Feb.). On 16-Apr-2021, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 23-Apr-2021, the patient experienced ILLNESS (Got a little sick,he stated going downhill). On an unknown date, the patient experienced FEELING ABNORMAL (Stated going downhill). The patient died on 26-May-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, ILLNESS (Got a little sick,he stated going downhill) and FEELING ABNORMAL (Stated going downhill) outcome was unknown. Treatment and concomitant information was not provided by the reporter. Patient had the modera shot on 16-Apr-2021 and he was recovering from a bladder surgery. Very limited information regarding this events has been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding this events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1420121 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-03-31
Onset:2021-03-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Inappropriate schedule of product administration, Vaccination site pain
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   Days after onset: 70
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20211

Write-up: passed away; received second vaccine 44 days after receiving the first dose; Pain the injection site from the first dose; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (passed away) in a 91-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 31-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 14-May-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 31-Mar-2021, the patient experienced VACCINATION SITE PAIN (Pain the injection site from the first dose). On 14-May-2021, the patient experienced INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (received second vaccine 44 days after receiving the first dose). On 05-Apr-2021, VACCINATION SITE PAIN (Pain the injection site from the first dose) had resolved. On 14-May-2021, INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (received second vaccine 44 days after receiving the first dose) had resolved. The patient died on 09-Jun-2021. The cause of death was not reported. It is unknown if an autopsy was performed. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) and mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. No concomitant medication were reported. No treatment information was reported. Company comment: This report refers to a case of Inappropriate schedule of product administration for mRNA-1273, with associated Adverse Events of Vaccination site pain and Death in a 91-year-old female subject who died 25 days after receiving second dose of vaccine. Very limited information regarding these events has been provided at this time. Further information has been requested. This case was linked to US-MODERNATX, INC.-MOD-2021-132760 (Linked Report). Most recent FOLLOW-UP information incorporated above includes: On 14-Jun-2021: Case upgraded to Serious due to death.; Sender''s Comments: This report refers to a case of Inappropriate schedule of product administration for mRNA-1273, with associated Adverse Events of Vaccination site pain and Death in a 91-year-old female subject who died 25 days after receiving second dose of vaccine. Very limited information regarding these events has been provided at this time. Further information has been requested. US-MODERNATX, INC.-MOD-2021-132760:Son; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1420192 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-07
Onset:2021-01-30
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: Ferrous Sulfate, Folic Acid, Lorazepam, Temazepam.
Current Illness: Unknown.
Preexisting Conditions: Dementia and Alzheimer.
Allergies: Unknown.
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: Died do to unknown reasons, did not present symptomology.


VAERS ID: 1420208 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-18
Onset:2021-04-04
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol Tid, Atrovent, Losartan, Galantamine, Remeron, Aricef, Vitamin D.
Current Illness: Unknown.
Preexisting Conditions: Keratosis, Respiratory failure, Stroke, Alzheimer''s, Aricept.
Allergies: Unknown.
Diagnostic Lab Data: Covid-19 Antigen test. In April, 4 2021.
CDC Split Type:

Write-up: Died, unknown reasons, no symptomology reported.


VAERS ID: 1420517 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Connecticut  
Vaccinated:2021-05-27
Onset:2021-05-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Atrial fibrillation, Bandaemia, Blood urea increased, C-reactive protein increased, Cough, Death, Dyspnoea, Hypoxia, Leukocytosis, Lung consolidation, Pneumonia, Red blood cell count decreased, Septic shock, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Supraventricular tachyarrhythmias (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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-06
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: chronic Hepatitis C Subarachnoid hemorrhage
Allergies: Penicillin
Diagnostic Lab Data: WBC = 10.4 at 14:35 6/5, 26.2 at 22:00 6/5, 30.9 at 06:40 6/6 RBC = 2.98, 2.8, 2.47 CRP = 19.9 at 14:35 6/5 BUN = 71, 66, 62
CDC Split Type:

Write-up: 1 week history of shortness of breath and nonproductive cough beginning shortly after receipt of second dose. Patient became hypoxic and had diffuse consolidation through left lung with wedge-shapes consolidation involving the right upper and midlateral lungs. Leukocytosis and bandemia noted and acute renal failure. Developed atrial fibrillation and rapid ventricular response. Multilobal pneumonia, septic shock, non-q-wave myocardial infarction, acute renal failure. Patient expired.


VAERS ID: 1420707 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-01-13
Onset:2021-01-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Flonase, Amlodipine, Atenolol, HCTZ, Losartan, Metformin, Simvastatin, Vitamin D3
Current Illness: Unknown
Preexisting Conditions: Diabetes Type II Diastolic Dysfunction Hypertension Obesity Hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: 01/18/2021
CDC Split Type:

Write-up: Patient presented to ER on 01/18/2021 and stated respiratory symptoms began on 01/14/2021. Positive Covid test that day. Patient was released from ER and admitted as inpatient to the hospital on 01/23/2021 and expired of Covid related symptoms on 02/02/2021.


VAERS ID: 1421090 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-19
Onset:2021-06-09
   Days after vaccination:82
Submitted: 0000-00-00
Entered: 2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Angiopathy, Chronic obstructive pulmonary disease, Coronary artery disease
SMQs:, Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-09
   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: Advanced coronary artery disease, Arteriovascular risk factors, Chronic obstructive lung disease.COVID-19 2/10/2021, Recurrent GI bleed with iron deficiency


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