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From the 6/11/2021 release of VAERS data:

Found 5,993 cases where Vaccine is Covid19 and Patient Died



Case Details

This is page 31 out of 60

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VAERS ID: 1212489 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-09
Onset:2021-04-13
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: CARDIAC ARREST Death


VAERS ID: 1212567 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-04-10
Onset:2021-04-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute cardiac event, Autopsy, Coronary artery disease, Death
SMQs:, Myocardial infarction (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: clonidine; gabapentin; beet powder
Current Illness: none
Preexisting Conditions: none
Allergies: ibuprofen
Diagnostic Lab Data: autopsy 4-14-2021
CDC Split Type:

Write-up: he died while on his routine daily run; medical examiner agreed he should have an autopsy which showed coronary artery disease/likely an acute cardiac event


VAERS ID: 1212771 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-04-08
Onset:2021-04-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Agonal respiration, Bacteraemia, Cardiac arrest, Computerised tomogram abdomen normal, Computerised tomogram pelvis, Computerised tomogram thorax normal, Condition aggravated, Dyspnoea, Endotracheal intubation, Gastrointestinal disorder, Gastrointestinal haemorrhage, Hepatobiliary disease, Intensive care, Pulseless electrical activity, Resuscitation, Scan with contrast, Sepsis, Systemic candida
SMQs:, Torsade de pointes/QT prolongation (broad), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Biliary tract disorders (narrow), Pulmonary hypertension (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (narrow), Sepsis (narrow), Opportunistic infections (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 100 mg Oral Tablet Sig: TAKE 1/2 TABLET BY MOUTH DAILY budesonide/formoterol (SYMBICORT) 160-4.5 mcg/actuation Inhalation HFA Aerosol Inhaler Sig: Inhale by mouth. clopidogrel 75 mg Oral Tablet Sig: Take 7
Current Illness: ESRD on PD, pAfib, CAD, HTN, HLD, hypothyroidism, who was brought in after a witness cardiac arrest.
Preexisting Conditions: above
Allergies: ASA
Diagnostic Lab Data: ICU admission post PEA arrest. Pt was septic: per ID notes: It remains uncertain what happened. The polymicrobial bacteremia and candidemia favors GI/hepatobiliary sepsis. However contrast-enhanced CT of the abdomen and pelvis yesterday does not show any obvious indication of anatomic abnormality. CT of the chest does not reveal any evidence of pneumonia. He has not improved despite aggressive polymicrobial therapy. He is not making urine and is building up acid. His chance of survival is minimal. In retrospect it does not appear that this is a side effect of COVID-19 vaccination as he is found to have multiple organisms in the blood. Vancomycin is no longer indicated and can be stopped. He also does not need any further tobramycin. Zosyn and anidulafungin are all that is required here based on the culture results.
CDC Split Type:

Write-up: an 87 year old male with ESRD on PD, pAfib, CAD, HTN, HLD, hypothyroidism, who was brought in after a witness cardiac arrest. Patient apparently received the first dose of the Covid vaccine (pfizer) at around 11 am. He was doing fine the rest of the day until later in the evening when he had shortness of breath without chest pain, abdominal pain, nausea, vomiting. Upon EMS arrival, the patient appeared to have some agonal breathing and then went down, was in PEA arrest, received CPR with 1 dose of calcium, 1 dose of bicarbonate, and 3 doses of epinephrine with return of spontaneous circulation. Upon arrival in the ED, patient had an intraosseous line, on dopamine for soft blood pressure. Patient has been successfully intubated.


VAERS ID: 1212788 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-23
Onset:2021-03-30
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / N/A LA / IM

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: 2021-03-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown to pharmacy
Allergies: no allergies reported on vaccine consent form
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s wife notified our corporate office on 4/15/21 that her husband received a J&J COVID vaccine from our pharmacy on 3/23/2021 and that he passed away one week later, 3/30/2021, in their yard after having a heart attack. Phone number provided is the wife''s.


VAERS ID: 1212820 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: California  
Vaccinated:2021-04-10
Onset:2021-04-13
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None known
Current Illness: COVID
Preexisting Conditions: Drug abuse, unknown type
Allergies: None known
Diagnostic Lab Data: Postmortem COVID test is positive.
CDC Split Type:

Write-up: Unexpected death 3 days after vaccination


VAERS ID: 1212869 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-19
Onset:2021-04-03
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Refusal of treatment by patient
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASPIRIN 81 MG TABLET, ENTERIC COATED (Aspirin) ONE TAB Oral DAILY SEVELAMER CARBONATE 800 MG TABLET FERROUS SULFATE 325 MG TABLET, ENTERIC COATE TAMSULOSIN HCL 0.4 MG CAPSULE POTASSIUM CHLORIDE 10 MEQ TABLET, EXTENDED RELEASE
Current Illness: DM Type 2 Chronic Kidney Disease stage 5- refusing dialysis
Preexisting Conditions: DM Type 2 Chronic Kidney Disease stage 5
Allergies: Januvia Metformin
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient expired on 4/3/2021 after refusing dialysis x 2 weeks


VAERS ID: 1212969 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-19
Onset:2021-04-13
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Septic Shock
Preexisting Conditions: DM Type 2 Alzheimer''s dementia
Allergies: Penicillin
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient Expired


VAERS ID: 1213035 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: New York  
Vaccinated:2021-04-07
Onset:2021-04-12
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

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

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

Write-up: MY MOTHER, PATIENT, HAD BEEN MANAGING HYPERTENSION AND DIABETES FOR NEARLY 30 YEARS VERY WELL. SHE RECEIVED THE J&J VACCINE ON 4/7. PEOPLE WHO SAW HER AND SPOKE TO HER DAYS AFTER REPORTED SHE FELT GOOD AND LOOKED GOOD. ON 4/12, 5 DAYS LATER, PATIENT, WAS DEAD. SHE WAS FOUND DECEASED IN HER APARTMENT ON 4/13 SLUMPED IN A CHAIR. SHE HAD EATEN BREAKFAST, GOTTEN DRESSED AND APPEARED TO BE ON HER WAY OUT THE DOOR TO AN EYE DOCTOR APPT WHEN SHE SAT IN A CHAIR TO TAKE A REST. THE MEDICAL EXAMINER''S OFC REFUSED TO DO AN AUTOPSY, STATING HER PRE-EXISTING CONDITIONS, DESPITE HER RECENTLY GETTING THE J&J SHOT.


VAERS ID: 1213047 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-03-02
Onset:2021-03-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 1 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Ageusia, Anosmia, Arthralgia, COVID-19, Chills, Cough, Fatigue, Intensive care, Oropharyngeal pain, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Taste and smell disorders (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Arthritis (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 40
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 30 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Calcium 500, Cromolyn 4%, Levothyroxine, Meclizine, Metoprolol Tartrate, Nasonex, Pravastatin
Current Illness: None
Preexisting Conditions: Hypothyroidism, High Blood Pressure, High Cholesterol, Vertigo (intermittent), Seasonal Allergies
Allergies: Augmentin, Cipro, Sulfa
Diagnostic Lab Data: Too many to list. Patient was in ICU for 29 days.
CDC Split Type:

Write-up: This is the patient''s spouse reporting. The day following the vaccination, wife began to suffer mild, common vaccination symptoms such as fatigue, hills, and joint pain. In the days following, in addition to those symptoms, she began to cough and had a sore throat. By March 8th, she had lost her sense of taste and sense of smell. We realized we needed to have her tested for COVID-19. We went to a testing area. She was seen and tested. She tested positive for COVID-19 (as did I). The belief was that our illness was uncomplicated and we were sent home with instructions to monitor our symptoms. On 03/14/2021, I took her to the hospital because her condition was worsening.


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

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

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

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


VAERS ID: 1213085 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-05
Onset:2021-04-02
   Days after vaccination:56
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose, Death, Dementia, Full blood count, General physical health deterioration, Metabolic function test
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, aspirin, ativan, insulin glargine, gabapentin, divalproex, fluoxetine, ocuvite, metformin, levothyroxine, topiramate, potassium chloride, lasix
Current Illness: anemia, heart failure
Preexisting Conditions: Depression, heart failure, dementia, diabetes, htn, cardiac pacemaker, aphasia, osteoarthritis
Allergies: ACE inhibitors, codeine sufate
Diagnostic Lab Data: 2/8/2021 CMP, CBC w/diff, Blood sugars BID
CDC Split Type:

Write-up: End Stage dementia, overall decline, hospice care, expired


VAERS ID: 1213115 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: New York  
Vaccinated:2021-04-10
Onset:2021-04-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036B21A / 2 LA / IM

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

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

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


VAERS ID: 1213131 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-03-11
Onset:2021-03-29
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / UNK RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death, Fall, Hip fracture, Spinal fracture, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (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? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Diabetic Medications (Pills)
Current Illness: broke 3 back bones and hip chip due to fall 3/22/2021 a store parking lot
Preexisting Conditions: Diabetic
Allergies: none
Diagnostic Lab Data: AUTOPSY PERFORMED AND CONFIRMED
CDC Split Type:

Write-up: PATIENT DIED FROM BLOOD CLOT 3/29/2021 - AUTOPSY PERFORMED AND CONFIRMED


VAERS ID: 1213138 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-03-26
Onset:2021-04-06
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   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: unknown
Current Illness: none
Preexisting Conditions: diabetes type 2, hypertension
Allergies: PCN (anaphylaxis)
Diagnostic Lab Data:
CDC Split Type:

Write-up: The day after vaccination had a terrible headache. Stroke on 4/6/21. Died on 4/11/21


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

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

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

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


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

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

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

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


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

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

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

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


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

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

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

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


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

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

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

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


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

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

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

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


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

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

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

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


VAERS ID: 1213302 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-02
Onset:2021-03-18
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Chest X-ray abnormal, Death, Decreased insulin requirement, Dyspnoea, Fall, Hypoglycaemia, Lung opacity, Mobility decreased, Neutropenia, Pleural effusion, Pneumonia, Pulmonary mass, Sepsis
SMQs:, Anaphylactic reaction (broad), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   Days after onset: 22
Permanent Disability? Yes
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin, carboplatin, gabapentin, ibuprofen, insulin glargine, insulin regular human, lidocaine-prilocaine cream, lorazepam, magnesium, paclitaxel, pancrelipase, simvastatin, trazodone
Current Illness: worsening hypoglycemic to hyperglycemic swings/events, bruising, insomnia
Preexisting Conditions: type 2 diabetes on insulin, peripheral arterial disease, hyperparathyroidism, esophageal cancer, hx of pancreatic tumor, insomnia
Allergies: no known drug allergies
Diagnostic Lab Data: CXR 3/18: patchy airspace disease CXR 3/25: multifocal pneumonia CT angio of chest 3/29: multifocal pneumonia, pleural effusions, 3rd spacing CXR 4/3: diffuse bilateral lung opacities with disseminated nodular morphology, possible superimposed pneumonia
CDC Split Type:

Write-up: He received his first COVID19 shot (Pfizer) reportedly on 3/2/21, then began a new chemotherapy regimen on 3/10/21. On 3/18, he fell to the floor and could not get up. He was admitted to the hospital for sepsis, pneumonia, and chemotherapy-induced neutropenia, treated on IV antibiotics and discharged on PO antibiotics. His home insulin was also decreased but continued to have hypoglycemic to hyperglycemic events. Insulin was decreased in clinic afterward and was compliant on antibiotics. Returned to hospital again a few days later for sepsis and pneumonia/effusion. He later went to a nursing facility / on hospice. He ultimately required supplemental oxygen and breathing increasingly became labored. Patient ultimately died on 4/9/21.


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

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

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

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


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

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

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

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


VAERS ID: 1213431 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-01
Onset:2021-03-16
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Infection, Platelet count decreased, Portal vein thrombosis
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Embolic and thrombotic events, venous (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   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: albuterol HFA (PROVENTIL HFA) 108 (90 Base) MCG/ACT Aerosol Solution inhaler Ammonium Lactate (LAC-HYDRIN) 12 % Lotion ibuprofen 600 MG Tablet
Current Illness: na
Preexisting Conditions: Mild intermittent asthma without complication
Allergies: Ciprofloxacin-ciproflox Hcl ErNausea/GI Upset Peanut
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted with massive portal vein thrombosis and low plt in setting of infection. Symptoms started one week prior


VAERS ID: 1213551 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-02-06
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Intensive care, Pneumonia aspiration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Too numerous to list
CDC Split Type:

Write-up: DEATH, ABDOMINAL DISTENTION, CHF EXACERBATION. Narrative: Pt died after completion of COVID vaccine series. Pt in CLC at time of both vaccinations. Hospitalized for CHF exacerbation 01/05 COVID vaccine dose #1 01/01 c/o abdominal distention, diarrhea 01/08 c/o increased SOB and continued diarrhea/abdominal distention, sent to ED, low potassium, borderline elevation troponin, gaseous distention on CT, admitted to hospital, states SOB and leg swelling for a few weeks now (likely unrelated to vaccine) 01/21 discharged from hospital to CLC; during course, found to have severe hypokalemia and renal failure, abd ileus, treated for electrolyte imbalance 01/26 admitted to hospital with c/o coffee ground emesis & abdominal distention 01/27 COVID vaccine dose #2 moved to critical care mid hospitalization with like aspiration PNA and numerous complications 02/06 patient passed away after withdraw of care Unlikely that vaccine contributed to death but death likely due to comorbidities and advanced age. Patient did not have acute specific ADR at time of vaccine or between vaccinations and date of death that could be attributed to vaccine. Hospitalized prior to and after vaccinations. Numerous comorbidities including acute on chronic HF and kidney failure pre-disposed patient to death.


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

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

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

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


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

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

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

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


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

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

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

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


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

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

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

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


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

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

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

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


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

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

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

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


VAERS ID: 1213955 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-09
Onset:2021-04-03
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: My brother is now dead, less than one month after his second shot


VAERS ID: 1213958 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-04-12
Onset:2021-04-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 201A21A / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Blood calcium normal, Blood chloride normal, Blood creatinine normal, Blood magnesium normal, Blood thyroid stimulating hormone normal, Chest X-ray normal, Chest discomfort, Death, Discomfort, Electrocardiogram normal, Full blood count normal, Gastrointestinal pathogen panel, Glycosylated haemoglobin, Lipids normal, Troponin normal
SMQs:, Anaphylactic reaction (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: HYDROCHLOROTHIAZIDE 25MG CALCIUM CARBONATE 1500MG
Current Illness: NONE
Preexisting Conditions: NICOTINE DEPENDENCE OSTEOARTHRITIS
Allergies: NO KNOWN ALLERGIES
Diagnostic Lab Data: 4/12/21 - Hgb A1c 5.4% 4/12/21 - Chem7/Ca++, Gi Panel, Magnesium, Tsh, Lipid Profile (non-fasting) - all results within normal/acceptable range 4/14/21 - CBC, Chemistry Panel, CR/CL, Trop - all results within normal/acceptable range 4/14/21 - Portable upright AP chest x-ray - normal 4:14/21 - EKG - no abnormal findings or changes
CDC Split Type:

Write-up: PATIENT PRESENTED TO CLINIC FOR ANNUAL WELLNESS VISIT ON 4/12/2021 AND RECEIVED THE JANSSEN COVID-19 VACCINE FOLLOWING HIS VISIT. ON 4/14/2021 PATIENT CALLED EMS FOR C/O CHEST TIGHTNESS. DISCOMFORT HAD RESOLVED BY THE TIME EMS ARRIVED. PATIENT WAS TAKEN TO ER FOR FURTHER EVALUATION. PATIENT REMIANED FREE OF CHEST TIGHTNESS/DISCOMFORT THROUGHOUT THE VISIT AND CARDIAC WORK-UP AT THE ER WAS ESSENTIALLY NORMAL. PATIENT WAS DISCHARGED HOME WITH F/U INSTRUCTIONS. ON 4/15/21 RN RECEIVED A CALL FROM THE COUNTY MEDICAL EXAMINER STATING THAT PATIENT WAS FOUND DECEASED IN HIS DRIVEWAY THIS MORNING AT AROUND 09:41 AM. THERE WERE NO SIGNS OF FOUL PLAY AT THE SCENE. PATIENT''S RECENT PHYSICAL AND LAB WORK WITH HIS PROVIDER ON 4/12/2021 SHOWED NO FINDINGS OF CONCERN. PATIENT HAD NO CHRONIC ILLNESSES, WAS ACTIVE, AND OFFERED NO MEDICAL CONCERNS AT HIS VISIT ON 4/12/2021.


VAERS ID: 1213993 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-05
Onset:2021-03-21
   Days after vaccination:44
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN9581 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Death, Urinary system X-ray
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: atorvastatin, beneprotein, acetaminophen, bisacodyl, cetirazine, clotrimazole, esomeprazole, lasix, hydrocortisone, lisinopril, maalox, mylanta, oxybutynin, miralax, senna
Current Illness: Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing
Preexisting Conditions: unspecified intellectual disability, congenital stenosis and stricture of esophagus, HTN, GERD, Hx ileus
Allergies: cefazolin, celery
Diagnostic Lab Data: KUB 2/24/21
CDC Split Type:

Write-up: Abdominal pain, transferred to ER 2/24/21, admitted to hospital, Expired at hospital 3/21/21


VAERS ID: 1214056 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-04-08
Onset:2021-04-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Face injury, Fall, Skin laceration
SMQs:, Accidents and injuries (narrow), Hostility/aggression (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: denied blood thinners during screening/unknown if taking other meds
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: denied any allergies
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: got up out of his chair to leave from his 15 minute wait and fell face down on the floor. He did not put his hands out and received a cut on his left cheek below eye from glasses. He was assisted onto his feet and back onto his chair. Vital signs were BP-117/64, Pulse 85, RR 18, O2 sat 98% (WNL). Water provided to patient. Had him take several deep breaths. Band Aid applied to cut on cheek. Patient did not complain of any symptoms. Denies dizziness. Refused to seek further medical attention or go to ER. He was then assisted back to his car by staff after the incident.


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Chronic Kidney disease, coranary disease, mulitple medical , full list can be gotten from primary
Preexisting Conditions: stage 4 renal failure,
Allergies: none listed
Diagnostic Lab Data: none
CDC Split Type:

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknow
Diagnostic Lab Data: Glucose 143
CDC Split Type:

Write-up: Cardiac Event


VAERS ID: 1214325 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Unknown  
Location: Illinois  
Vaccinated:2021-02-05
Onset:2021-04-07
   Days after vaccination:61
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anxiety, Death, General physical health deterioration, Glycosylated haemoglobin, Hypoglycaemia, Metabolic function test, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acidophilus, allopurinol, aspirin, Breo Ellipta, candesartan, vitamin D3, clopidopgrel, ferrous sulfate, insulin lispro, lactulose, lyrica, metformin, metoprolol tartrate, pantoprazole, senna plus, simvastatin, tradjenta, tramadol, vitamin
Current Illness: UTI, hypoglycemia, smoking cessation
Preexisting Conditions: Obesity, functional quadriplegia, COPD, Severe DJD, Osteoarthritis, Severe neuropathy, Smoking, R heel III ulcer, diabetes
Allergies: no known allergies, latex
Diagnostic Lab Data: CMP, A1C 4/5/21
CDC Split Type:

Write-up: Severe anxiety, Kidney Failure, Hypoglycemia, ER visits, Overall decline, Hospice care, Expired


VAERS ID: 1214416 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-15
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK AR / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xeljanz, Metformin, Glimepiride, Aturuastatin, Carvedilol
Current Illness: None
Preexisting Conditions: Rheumatiod Arthritis, Diabetic
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away suddenly (heart failure) on Feb 15th, 11 days after receiving the 1st Pfizer shot. I know he had other health issues, but he had a good bill of health from his doctors prior to this. I thought this should be reported.


VAERS ID: 1214482 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-11
Onset:2021-03-01
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   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: Not feeling well according to mother the night before he passed away. 11 days after vaccination.


VAERS ID: 1214500 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-04-02
Onset:2021-04-14
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP7533 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood test normal, Caesarean section, Death, Dyspnoea, Exposure during pregnancy, Pulmonary embolism, Seizure
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (narrow), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None reported.
Current Illness: None reported.
Preexisting Conditions: None reported.
Allergies: None reported.
Diagnostic Lab Data: Yes, 4/14 bloodwork at clinic 4/15 labs at hospital
CDC Split Type:

Write-up: Patient at 27 weeks of pregnancy, reported to midwife at regular visit on 4/14/21 that she was experiencing SOB but all blood work normal - assumed normal SOB with pregnancy. Night/morning of 4/15 started seizures, transported to ED. Diagnosed with massive pulmonary embolism. Emergency C-section prerformed by Dr. Pt. did not survive.


VAERS ID: 1214501 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-23
Onset:2021-04-04
   Days after vaccination:71
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9808 / 2 RA / IM

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

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

Write-up: DEATH


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

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

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

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


VAERS ID: 1214544 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-03-08
Onset:2021-04-11
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Brain stem haemorrhage, Computerised tomogram head abnormal, Death, Hydrocephalus, International normalised ratio normal, Intraventricular haemorrhage, Prothrombin time prolonged
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Nifedipine 30 mg daily Prednisone 10 mg daily Oxycodone 10 mg po Q 6hrs prn Serataline 50 mg po daily Cilostazol 100 mg po bid Albuterol inhaler Metoprolol Succinate 50 mg po daily
Current Illness: ED visit for chest pain on 4/9/21
Preexisting Conditions: Chronic pain, depression, chronic headaches, Buerger disease, clotting disorder (reported by family), COPD
Allergies: NKDA
Diagnostic Lab Data: 4/11/21 PT- 12.6 INR- 1.0 Potassium-2.7 CT head- lmpression: large brain stem hemorrhage with small intraventricular hemorrhage and moderate hydrocephalus
CDC Split Type:

Write-up: Patient died of a brain stem bleed on 4/11/21. It is unknown if the vaccine received on 3/8/21 is in any way related to his passing.


VAERS ID: 1214640 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-04-11
Onset:2021-04-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Life support, Loss of consciousness, Unresponsive to stimuli
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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: Emergency Room
CDC Split Type:

Write-up: After receiving the J&J vaccine on Sunday afternoon, when my husband got up on Monday morning he passed out in the bathroom and was unresponsive. The EMTs arrived and were able to revive him in the ambulance. When they reached the hospital he was put on life support. After he coded again in the Emergency room they told me he was without oxygen for too long and was taken off the respirator. He passed away at 4:10 PM.


VAERS ID: 1214705 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-27
Onset:2021-04-04
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8727 / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension, Diabetes, plasma cell neoplasm, malignant neoplasm, thrombocytopenia
Preexisting Conditions: pulmonary hypertension, malignant neoplasm
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on April 4 2021


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

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

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

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


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

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

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

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: nkma
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown


VAERS ID: 1214997 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-03-26
Onset:2021-04-14
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / -

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

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

Write-up: Patient was terminal when he received the vaccine


VAERS ID: 1215033 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-03-31
Onset:2021-04-01
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8734 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Toxicologic test
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown, potentially alprazolam according to the sister. Sister was researching medication use.
Current Illness: None known by sister, except indication of alcoholism and generally "not a healthy person". Sister is researching medical history.
Preexisting Conditions: Potentially alcoholism.
Allergies: None indicated on vaccination consent form.
Diagnostic Lab Data: Toxicology labs are pending at the state toxicology lab.
CDC Split Type:

Write-up: Patient sister contacted Pharmacy on 4/09/2021 about 4:30pm to report that her sister had passed away on 4/1/2021 approximately 7 hours after receiving her first Covid-19 vaccine at our clinic. The sister reports that she spoke with her the evening of 3/31/2021approximately at 7:45pm. The sister, indicated that her sister had been drinking and drank frequently. Stated her sister was an unhealthy person, drank everyday and could have been taking Alprazolam but wasn''t sure. The sister stated that the patient''s son had spoke/seen mom in the house around 8:30 pm. Patient was found in the household bathtub at around 1:00am, 911 was called and she was reported to be deceased upon arrival.


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

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

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

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Proair, EQ Allergy Relief, Albuterol, HCTZ, Prednisone, Singulair, Symbicort, Bumetanide, Carvedilol, Azithromycin
Current Illness:
Preexisting Conditions: Chronic systolic congestive heart failure, Pulmonary fibrosis
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1215380 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-02-05
Onset:2021-03-31
   Days after vaccination:54
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 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: peripheral vascular disease
Preexisting Conditions: cerebrovascular disease wernickes encephalopathy chronic obstructive pulmonary disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: no symptoms


VAERS ID: 1215401 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-04-05
Onset:2021-04-14
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / -
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: PER PROFILE AND PATIENT''S SISTER, HE WAS NOT TAKING ANY MEDICATIONS AT THE TIME OF VACCINE.
Current Illness: NO KNOWN ILLNESSES AT TIME.
Preexisting Conditions: PER PATIENT''S SISTER, HE HAD DIABETES.
Allergies: NKDA
Diagnostic Lab Data: NONE SO FAR
CDC Split Type:

Write-up: PATIENT''S SISTER CALLED THIS AFTERNOON STATING HE HAD RECEIVED THE JANSSEN COVID VACCINE 4/05 AND THEY FOUND HIM DEAD THIS MORNING. THEY ARE NOT CERTAIN IF IT WAS FROM VACCINE. THEY CLAIM HE HAS NO OTHER HEALTH ISSUES AND IS NOT ON ANY OTHER MEDICATIONS. THEY HAVE NOT PERFORMED AUTOPSY. SHE WAS MORE RELAYING INFORMATION RATHER THAN BLAMING THE DEATH ON THE VACCINE. SHE REQUESTED WE SUBMIT REPORT TO VAERS; SHE HAS NO WAY TO AND DOES NOT KNOW HOW.


VAERS ID: 1215403 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-04-07
Onset:2021-04-14
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805018 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Oxycodone, Amlodipine/atorvastatin, metformin, losartan, atorvastatin, gabapentin, metoprolol tartrate, clonidine, duloxetine, spiriva resp, advair diskus, fluticasone, bupropion xl, lamotrigine, albuterol hfa, monteleukast, furosemide, pot
Current Illness: None
Preexisting Conditions: HTN, low back pain, T2DM, bilat primary osteoarthritis of hip, anxiety, severe persistent asthma, depression, CVA Hx.
Allergies: Lisinopril
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 1 week post vaccination - patient, not responding to albuterol HFA, called 911, he passed out, was unresponsive, pronounced dead.


VAERS ID: 1215435 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-03-07
Onset:2021-03-18
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805031 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Back pain, Death, Epistaxis, Haemoptysis, Increased viscosity of upper respiratory secretion, Secretion discharge, Thrombosis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: High Blood Pressure, Kidney disease
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient began experiencing back pain on March 14 and on or around March 18 he started coughing up blood clots according to a coworker. Patient lived alone and was unable to be reached on Sunday March 21. I went over to his house and found him deceased in his bed. Patient had a trashcan beside his bed and it appeared to have some blood in it. Patient had thick mucus coming out of his mouth and blood coming out of his nose. According to paramedics he had passed a few hours before finding him. Unfortunately Patient has been cremated so there is no way to say that this was related to the Covid 19 shot from Johnson and Johnson, however there are new reports that blood clots have been a side effect. I would like to speak with someone from the Department of Health to discuss this further. I feel this could be related to the vaccination and I would to know how long the Health Department knew about this possible side effect. If patient would have known sooner that the blood clots were a side effect I feel he would have gone to the Emergency Room. Patient had no health insurance and he was trying to prevent getting Covid. This has caused our family so much heartache and we are all very apprehensive about getting the Covid Vaccine ourselves. Please contact me as soon as possible, I am also patient''s executor so I am able to speak to you on behalf of patient and our family. Thank you.


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

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

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

Write-up: fatal pulmonary embolism from RLE DVT


VAERS ID: 1216091 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-03-23
Onset:2021-04-13
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Unknown
Preexisting Conditions: Unkown
Allergies: NKA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient at gym working out and had a seizure, when 9-1-1 crews arrived patient was post-ictal, while treating the patient he had another seizure, during transport patient went into cardiac arrest, crews provided ACLS care and transported patient to hospital for treatment. Resuscitation efforts were terminated by physician in emergency room.


VAERS ID: 1216134 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-03-19
Onset:2021-04-04
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 AR / SYR

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

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

Write-up: Cardiac arrest...death


VAERS ID: 1216189 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: California  
Vaccinated:2021-04-01
Onset:2021-04-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805025 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Brain natriuretic peptide increased, Echocardiogram abnormal, Emphysema, Gait inability, Haemoglobin decreased, Heart rate increased, Hypoxia, Intracardiac thrombus, Leukocytosis, Lumbar vertebral fracture, Peripheral artery thrombosis, Platelet count decreased, Procalcitonin normal, Pulmonary hypertension, Thrombosis prophylaxis, Tricuspid valve incompetence, Troponin increased, White blood cell count increased
SMQs:, Cardiac failure (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prednisone, Metoprolol, amlodipine, furosemide
Current Illness: To ED with acute back pain, constipation, recent root canal, had received tramadol and Medrol dosepak at Urgent Care
Preexisting Conditions: Hypertension, congestive heart failure, obesity, back pain, chronic kidney disease not requiring dialysis
Allergies: Penicillin, Sulfa
Diagnostic Lab Data: Hg dropped from 9.3 on admission to 6.8 and subsequently 6.4 with no apparent bleeding source. Platelets dropped from 130K to 61K to 59K. WBC on admission was 22.9; troponin rose on day 2 from 0.067 to 0.174. Procalcitonin 0.95 on admission increased to 1.40 on day 2. BNP on day 2 was 157.
CDC Split Type:

Write-up: 78 year old woman admitted with severe back pain, inability to ambulate and leukocytosis on 3/31/21. History of hypertension, CHF, obesity, chronic kidney disease, and back pain. Work up included multiple consults. The patient was placed on SQ heparin for VTE prophylaxis. Acute L5 fracture was found along with emphysematous changes. Neurosurgical evaluation- no surgery was necessary. During the first 24 hours (before receiving the vaccine), the patient''s Hg dropped 9.3 to 6.8 and platelets dropped 130K to 61 K with no apparent bleeding source. PRBC transfusion was given. GI consult was obtained the patient was scheduled to have EGD the following morning (day 3). Cardiology was obtained for elevated troponin and hypoxia. An echo obtained on day 2 showed moderate elevated pulmonary artery pressure, mild to moderate tricuspid regurgitation, and normal sized right atrium and ventricle. The patient received the Janssen vaccine upon request the morning of hospital day 2 (4.1.21 at 11:02). At 11:37PM on 4/1/21 the patient received 5mg IV metoprolol for elevated HR of 132 (BP 129/67). At 0128 on 4/2/21 the patient''s heart rate dropped into the 60''s and then declined further requiring cardiac resuscitation. The attempt was unsuccessful and the patient expired at 01:43 on 4/2/21. An autopsy was conducted (results available on 4/13/21) showed a 4 cm clot in the patient''s right atrium and a mural thrombus in her femoral artery.


VAERS ID: 1216240 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-03-16
Onset:2021-04-08
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-12
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Iron Multi vitamin
Current Illness: Na/unknown
Preexisting Conditions: NA- cancer 30 years ago
Allergies: Na/unknown
Diagnostic Lab Data: See hospital
CDC Split Type:

Write-up: Massive stroke Death 4 Days later


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

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Acute respiratory failure, COVID-19 pneumonia, Death, Endotracheal intubation
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Haematological malignant tumours (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-07
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: depression, hyperlipidemia
Preexisting Conditions:
Allergies: penicillin, shellfish,
Diagnostic Lab Data:
CDC Split Type:

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


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

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

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

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


VAERS ID: 1216626 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 RA / IM

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

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

Write-up: None stated.


VAERS ID: 1217480 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: New Jersey  
Vaccinated:0000-00-00
Onset:2021-04-01
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: Unknown
Allergies:
Diagnostic Lab Data:
CDC Split Type: USJNJFOC20210416142

Write-up: DEATH; This spontaneous report received from a consumer concerned a 60 year old African American, Not Hispanic or Latino male. The patient''s weight, height, and medical history were not reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported) dose was not reported, 1 total administered as approximately on 26-Mar-2021 for prophylactic vaccination. The batch number was not reported and has been requested. No concomitant medications were reported. On 01-APR-2021, the patient died from unknown cause of death. It was reported that, the patient death occurred about 6-7 days after receiving the vaccine. It was unknown, if an autopsy was performed. The patient death occurred about 6-7 days after receiving the vaccine. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. This report was serious (Death).; Sender''s Comments: 20210416142-covid-19 vaccine ad26.cov2.s -Death. This event(s) is considered unassessable. The event(s) has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event(s).; Reported Cause(s) of Death: UNKNOWN CAUSE OF DEATH


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

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

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

Write-up: deceased on 4/13/21


VAERS ID: 1218288 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-13
Onset:2021-04-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8731 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypophagia, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: Acetaminophen Tablet 325mg, 2 tabs by mouth
Current Illness: 1/20/2021 Admitted to Hospice for Myelodysplastic Anemia
Preexisting Conditions: Dementia, CVA, Hemiplegia,HTN,B12 Deficiency, Anemia, GI Refux, BPH and Dysphagia
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: 4/14/2021 at ~8am, Patient was out of bed and in his wheelchair and consumed 100% of his breakfast. During lunch time, he only consumed 25% of his meal. At ~2pm, patient was noted to be unresponsive. Oxygen saturation was 88% and B/P was low and oxygen was administered and Oxygen Saturation increased to 92%. The patient was placed in bed and Dr and the family were notified. The resident was continuously monitored by the Hospice nurse, who happened to be on-site and the primary nurse. At ~6:30pm it was noted that patient was having labored breathing so 0.25 ml of Morphine Sulfate Solution 20mg/ml was administered with releif. At 8:30pm, patient expired.


VAERS ID: 1218410 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-29
Onset:2021-02-05
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, Asthenia, Atrial fibrillation, Back pain, Body temperature decreased, COVID-19 pneumonia, Chest X-ray abnormal, Computerised tomogram head normal, Computerised tomogram normal, Diarrhoea, Fall, Heart rate increased, Hypoxia, Lung infiltration, Magnetic resonance imaging spinal abnormal, Metabolic encephalopathy, Procalcitonin increased, Respiratory rate increased, SARS-CoV-2 test positive, Sepsis, Skin laceration, Spinal compression fracture, Troponin increased, X-ray of pelvis and hip normal
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), 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 (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (narrow), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented after falling on February 5 with injury to her scalp. She apparently also fell on 2/4/21. Family was uncertain as to whether patient loss consciousness. According to family, patient has been weak over the last day or 2 with no other complaints aside from some diarrhea. EMS was notified PM Feb 5, and the patient was found to have atrial fibrillation with elevated heart rate to the 160s and hypoxic to the low 80% range on room air. She had a low-grade temperature and elevated respiratory rate according to EMS. Evaluation in the ED demonstrated bilateral chest infiltrates on chest x-ray (right greater than left), elevated heart rate with atrial fibrillation, and back pain. Imaging demonstrated a T11 compression fracture (possibly new), elevated pro-calcitonin (2.80 ng/mL) and elevated troponin (1.45 ng/mL). Her venous blood gas showed mild hypoxemia (7.39/25/41/33/57), and head CT did not show acute changes and her cervical CT was negative for fracture. Pelvic x-ray did not show fracture. She was covid positive. Admitted for acute hypoxemic respiratory failure and severe sepsis secondary to COVID-19 pneumonia and acute metabolic encephalopathy. Received 3 days of remdesivir and 4 days of IV dexamethasone. Also ceftriaxone was given 4 days for possible UTI. Goal of care switched to inpatient hospice on 2/8/21.


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s sister, spoke to Public Health staff to say that he passed away suddenly on 4/3/21 from a cardiac arrest, he had no underlying health conditions she states but did take some medications, she believes for blood pressure.


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

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

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

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


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

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

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

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


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

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

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

Write-up: Patient''s daughter called and reported he was hospitalized for a heart attack and passed away on 4/5/2021.


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: Patient passed away on April 13, 2021 at home at 1810 He was 72 years old had severe aortic stenosis and hypertension and had an aortic valve replacement (TAVR) at hospital on Jan 20, 2021. He was readmitted to hospital for shortness of breath which was evaluated from Feb 19 - Feb 21, 2021 I spoke with his daughter today. She was with him at home when he went to the bathroom and since he had not come out for some time, she knocked on the door and found him collapsed in the bathroom. She called 911, who did CPR, however he had passed away. He was referred to the coroner. He had his first Moderna vaccine on March 15, 2021 after which he had not had any side effects. He received his second dose on April 12, 2021 and had not mentioned any side effects other than mild abdominal discomfort. Daughter said his shortness of breath had been improving after his discharge from the hospital. He had not complained of chest pain, cough, fever, diarrhea, in the last few days. I paid condolences to daughter and told here we would be reviewing the case to see if there was any relationship to him receiving the Covid19 vaccine and that the case had already been referred to the coroners office.


VAERS ID: 1218602 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-03-01
Onset:2021-04-12
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Abdominal X-ray, COVID-19, Cerebral atrophy, Chest X-ray abnormal, Computerised tomogram abdomen abnormal, Computerised tomogram head abnormal, Computerised tomogram pelvis abnormal, Encephalomalacia, Endotracheal intubation, Gastrointestinal necrosis, Hypotension, Lung infiltration, Magnetic resonance imaging, Mechanical ventilation, Mental status changes, Metabolic acidosis, Platelet count normal, Pneumatosis intestinalis, Pneumobilia, Portal venous gas, Pyrexia, Renal failure, SARS-CoV-2 test positive, Shock
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (broad), Anaphylactic reaction (narrow), Angioedema (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Tumour lysis syndrome (narrow), Respiratory failure (broad), 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: 2021-04-13
   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: acetaminophen(acetaminophen 325 mg oral tablet), 650 mg= 2 TAB, PO, Every 4 Hours, PRN atorvastatin(atorvastatin 20 mg oral tablet), 40 mg= 2 TAB, PO, Daily azelastine nasal(azelastine 137 mcg/inh (0.1%) nasal spray), 2 Sprays, NASAL, Twi
Current Illness: COVID+
Preexisting Conditions: Acute kidney injury Bipolar affective Chronic pain Depression Elevated LFTs Encephalopathy Hematuria History of DVT in adulthood Mitral valve stenosis Panic attack Sepsis Stroke Urinary anomaly
Allergies: NSAIDs
Diagnostic Lab Data: see above
CDC Split Type:

Write-up: colonic necrosis 62 yo woman history of prior L occipital CVA and DVT on Xarelto presented to Hospital on April 6 with mental status changes. Patient was noted to be in severe metabolic acidosis, renal failure and shock. Chest x-ray showed interstitial infiltrates and she tested positive for SARS-CoV2. She required intubation and mechanical ventilation. CT brain showed encephalomalacia and atrophy, no new changes. She was transferred on April 8. She was given IV bicarb for persistent metabolic acidosis. Initially she was only treated with steroids, then antibiotics were added for fever and persistent hypotension. She started to spike fevers up to 40. Abdominal CXR ordered prior to MRI, showed possible pneumatosis. A follow up CT April 13 abdomen/pelvis was done which shows colonic pneumatosis, with air in the SMV, portal vein, air in the liver. No thrombocytopenia; platelets on April 13 were 310k, as low as 260 on April 8.


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

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

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

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


VAERS ID: 1218764 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-10
Onset:2021-04-06
   Days after vaccination:55
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9089 / UNK - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9089 / UNK - / IM

Administered by: Other       Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Brain herniation, Cerebral haemorrhage, Cerebral mass effect, Chest X-ray abnormal, Computerised tomogram head abnormal, Condition aggravated, Deep vein thrombosis, Haemoglobin decreased, International normalised ratio increased, Leukaemia recurrent, Leukapheresis, Leukocytosis, Lung infiltration, Lung opacity, Oedema peripheral, Platelet count decreased, Prothrombin time prolonged, Respiratory viral panel, Subdural haemorrhage, Thrombocytopenia, Viral test negative, White blood cell count increased
SMQs:, Cardiac failure (broad), Liver-related coagulation and bleeding disturbances (narrow), Angioedema (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Accidents and injuries (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Haematological malignant tumours (narrow), Infective pneumonia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-04-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol (Coreg), acyclovir, Lipitor, HCTZ, lisinopril, metformin, Ivosidenib (Tibsovo), Allopurinol (Zyloprim), Acetaminophen (Tylenol)
Current Illness: AML, CKD, T2DM, HTN, HLD
Preexisting Conditions: AML
Allergies: Sulfa drug, citrus, latex
Diagnostic Lab Data: INR 1.8. PT 20.1, PTT 24.7, WBC 102K, Hgb 6.7, platelet 57, respiratory viral panel negative. CXR: Patchy ground-glass opacities in the right upper lobe and right lower lobe. Mild interstitial infiltrates in the upper lobes bilaterally. Extensive DVT from the right common femoral vein through the distal popliteal vein. CT brain: Left occipital intraparenchymal hemorrhage measuring 5.8 x 2.8 x 3.1 cm as well as diffuse left hemispheric subdural hemorrhage measuring 11 mm, resulting in 16 mm rightward midline shift, subfalcine, and left uncal herniation.
CDC Split Type:

Write-up: Patient with Hx of AML received 1st dose COVID vaccine 2/10/2021, 2nd dose 3/4/2021. She developed DVT of the right leg, AML relapse. The patient has been diagnosed with AML back in 2016 and underwent several lines of therapy including chemotherapy with 7 and 3 and the last treatment was decitabine with maintenance treatment with ivosidenib. Having severe leukocytosis and right-sided leg edema with DVT raised concern about blast crisis and leukostasis. Patient was admitted to hospital and received. ceftriaxone and azithromycin for possible pneumonia. She underwent leukophoresis on the 4/6/2021, 4/7/2021. Patient received IV heparin gtt for DVT but later on was on hold given worsening thrombocytopenia. She was transferred from one hospital to another hospital. I do not think the development of DVT was due to COVID vaccine. But prior to COVID vaccine, patient was in AML remission.


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Basaglar, Trulicity, Metformin, Plavix, Crestor, Lasix, Enalapril, Synthroid, Arimidex, Xanax
Current Illness: No acute illness at the time of the vaccine. Was having problems with uncontrolled DM2.
Preexisting Conditions: DM2, HPL, HTN, Breast CA in remission, Lung CA in remission, CVA, hypothyroidism, asthma
Allergies: Codeine, Invokana, Glyburide, Aleve, Aromacin
Diagnostic Lab Data: None. Found dead outside of home by EMS.
CDC Split Type:

Write-up: Death


VAERS ID: 1218848 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-04-01
Onset:2021-04-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Angioedema, Death
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lexapro, Actos, Lopressor, Lasix, Risperdal, Prilosec, Metformin, Lipitor, Lisinopril, Tresiba, Glipizide, Vit D
Current Illness: Doing okay otherwise. Lisinopril was increased 2 days before death due to elevated blood pressure.
Preexisting Conditions: DM2, HTN, HPL h/o traumatic head injury years ago, depression, GERD, HPL
Allergies: None
Diagnostic Lab Data: Was evaluated in hospital ER. Died after presentation. Not sure if any tests were done as he was distressed on arrival per report.
CDC Split Type:

Write-up: Angioedema on 4/2/21 leading to death


VAERS ID: 1218987 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 51
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amentadine cardadopa dokuspat ometprazole razagiline spirolactone
Current Illness:
Preexisting Conditions: parkinsons
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Date and time of vaccination: (list both if they received both shots): 02/02/21 1100, 02/23/21 1200 Date and time adverse event started: 02/05/21 1100 SOB AFTER FIRST SHOT ,FATIGUE , WAS ADMITTED TO HOSPITAL FOR 7 DAYS , RELEASED AND THEN RETURNED TO THE HOSPITAL , SENT BACK TO , SAW THE DOCTOR 24TH OF MARCH , DOCTOR ADVISED WATER REDUCTION AND THE PATIENT HAD DEVELOPED CHF , PATIENT PAST ON THE 29TH


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

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

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

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


VAERS ID: 1219067 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-20
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805029 / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyslipidaemia, Infarction, Surgery, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Dyslipidaemia (narrow), Myocardial infarction (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Cardiomyopathy (broad), Lipodystrophy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient had been off of his statin medication of 2 weeks according to the daughter
Current Illness:
Preexisting Conditions: hyperlipidemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 03/24/21, patient hotel , patient fainted , tried to revive by family , ems was called , patient underwent surgery , patient did not survive surgery , death certificate was for acute infarction and dyslipidemia , patient passed


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

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

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

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


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Garlic, Preservision AREDs Softgel, Multivitamins with minerals. Aspirin, Levothyroxine, Amlodipine, Losartan
Current Illness: Denied any illness at time of receiving vaccine, uncertain as to how pt. felt one month prior to vaccine.
Preexisting Conditions: Current everyday smoker, Hypothyroidism, HTN, Hyperlipidemia, Osteoarthritis, Osteoporosis
Allergies: NKA
Diagnostic Lab Data: Lab and CXR done in ER. Troponin level was 117; HR 40''s, BP 93/44. CXR indicated mild cardiomegaly and no acute infiltrates.
CDC Split Type:

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


VAERS ID: 1219334 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-03-17
Onset:2021-03-22
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6207 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, amlodipine, aspirin, atorvastatin, cholecalciferol, diphenhydramine, glipizide, melatonin
Current Illness: hypertension, uncontrolled type 2 diabetes, hyperlipidemia, COPD, sleep apnea, tobacco use, alcohol abuse, cocaine abuse
Preexisting Conditions: hypertension, uncontrolled type 2 diabetes, hyperlipidemia, COPD, sleep apnea, tobacco use, alcohol abuse, cocaine abuse
Allergies: tramadol, lisinopril
Diagnostic Lab Data: no autopsy performed
CDC Split Type:

Write-up: Death on 3/22. Unknown cause. Family found him unresponsive. Did not pursue autopsy.


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

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen 500mg q 4hr prn, alendronate 70mg q 7 days, aspirin 81mg daily, atrovastin 40mg daily, baclofen 20mg 4 x day, buspirone 30mg bid, calcium carbonate 1000mg bid, carvedilol 6.25 bid, vitamin D3 1000 units daily, diclofenac sodiu
Current Illness: Decubitus sacral ulcer, stage 3, iron deficiency anemia, urinary tract infection associated with cystostomy catheter, class 1 obesity, wound infection, dysautonomia orthostatic hypotension syndrome, hypersomnia with sleep apnea, obstructive sleep apnea, autonomic dysreflexia, t4 spinal cord injury (chronic), major depressive disorder, pain medication agreement, chronic suprapubic catheter, hypothyroidism, hyperlipidemia, generalized anxiety disorder, neurogenic bladder, chronic pain, osteoarthrosis involving lower legs, DM type 2.
Preexisting Conditions: See item 11
Allergies: metoprolol, mirtazapine, olanzapine, sulfamethoxazole, cephalexin, erythromycin base, pioglitazone
Diagnostic Lab Data: none
CDC Split Type:

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


VAERS ID: 1219505 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-03-03
Onset:2021-03-07
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Angiopathy, Atrophy, Blindness unilateral, Computerised tomogram abnormal, Death, Headache, Laboratory test abnormal, Neck pain, Platelet count normal, Spinal osteoarthritis, Troponin increased, X-ray abnormal
SMQs:, Myocardial infarction (narrow), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad), Arthritis (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: HYPERTENSION, A-FIB
Allergies: UNKNOWN
Diagnostic Lab Data: 3/15/21 CT, LABS, XRAYS= ARTHRITIC CHANGES C-3. TROPONIN CRITICAL HIGH PLATELETS WNLS 3/19/21 CT, LABS=SHOWS POSSIBLE VERTEBRAL ARTERIAL OCCLUSION WITH POSSIBLE DISECTION
CDC Split Type:

Write-up: STARTING HAVE SEVERE PAIN IN LOWER NECK UP INTO LEFT SIDE OF HEAD SEVERAL DAYS AFTER VACCINE. ER ON 3/15/21 SHOWED ARTHRITIS IN C-3. SENT TO DR FOR FOLLOW UP. 3/17/21 PUT ON ORAL PREDNISONE, PAIN SHOTS X4 IN AREA. 3/19/21 RETURN TO ER, INCREASED PAIN AGAIN, LOSE OF SIGHT IN LEFT EYE, CT SHOWED POSSIBLE VERTEBRAL ARTERIAL OCCLUSION WITH POSSIBLE DISECTION. ADMITTED. ALSO SAW MICRO VASCULAR CHANGES AND ATROPHY. NEURO CONSULT FOR THROMBECTOMY VS MEDICATION MANAGEMENT. PER FAMILY, PAIN MEDS, NO FURTHER MRI OF BRAIN, COMFORT CARES. PT DIED 3/22/21.


VAERS ID: 1219577 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood potassium increased, Blood urea increased, Condition aggravated, Dyspnoea, Full blood count, General physical health deterioration, Hypotension, International normalised ratio increased, Laboratory test abnormal, Metabolic function test, Unresponsive to stimuli, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Atorvastatin 40, Cholecalciferol, MVI, Omeprazole, Polytehylene Glycol powder, Potassium Chloride ER 20 MEQ, Senna, Setraline, Spironoloctone, Torsemide, Warfarin 4mg, Colace.
Current Illness: 3/15 Adm with deconditioning, acute/chronic CHF, severe mitral valve stenosis, left atrial thrombus, A-fib. 3/25 Adm - ADL dysfunction, deconditioning, CHF, severe mitral valve stenosis.
Preexisting Conditions: Mitral valve disease, mitral valvuloplasty-1998. Tachycardia and Bradycardia, Pacemaker-2002. Pulmonary hypertension, Tircuspid valve regurgitation. GERD, Dyslipidemia, HTN, Insomia, Depression.
Allergies: Codeine, Hydrocodone, Morphine
Diagnostic Lab Data: 3/27/2021- CBC/BMP, INR. WBC- 15.93, BUN- 61, Crea- 1.95, K+ 5.2, INR 5.3. Sent to ER with hypotension and abnormal labs. 82/50mmHg, Pulse of 61.
CDC Split Type:

Write-up: 3/27/2021- @3 AM resident with increase in SOB with unresponsive episodes. Pt states she has history of unresponsive episodes related to cardiac issues, declined hospitalization.


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

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

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

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


VAERS ID: 1219772 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-08
Onset:2021-04-16
   Days after vaccination:39
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Failure to thrive
SMQs:, Neonatal disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hypertension, hyperlipidemia, stroke, diabetes Mellitus type 2
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died 1 month after vaccination, cause of death is failure to thrive


VAERS ID: 1219816 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-02-25
Onset:2021-03-23
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Barium swallow abnormal, Blood creatinine normal, Blood urea increased, Cardiomegaly, Chest X-ray abnormal, Condition aggravated, Death, Decubitus ulcer, Dyskinesia, Dysphagia, General physical health deterioration, Hyperhidrosis, Lung infiltration, Osteoarthritis, Prealbumin, Rib deformity, Scoliosis, Spinal osteoarthritis, Weight decreased, White blood cell count normal
SMQs:, Acute renal failure (broad), Cardiac failure (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dyskinesia (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Arthritis (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Proscar, Keppra, Synthroid, Magnesium Oxide, Tamsulosin, Prosource powder, Vitamin C
Current Illness: Worsening bilateral hip pressure wounds, primary care giver at home unable to and is having difficulty providing care at home due to resident overall decline.
Preexisting Conditions: Dysphagia, Epilepsy, Alzeimer''s disease, Trisomy 21, Hx of UTI, Benign Prostatic Hyperplasia, Hypothyroidism, abnormal posture, Hx of pneumonia and at risk of aspiration.
Allergies: Ciprofloxacin
Diagnostic Lab Data: 2/25 Diet texture downgraded to puree. 2/28 T-100.0 diaphoretic, intermittent jerking of BUE. 3/2 Significant weight loss, he has total of 30 lbs weight loss in the past year. 03/01 WBC- 7.31, BUN- 17, CREA- 0.79. 3/01 CXR- The cardiac silhouette is mildly enlarged. Mild S-shaped scoliosis. Moderate diffuse spondylosis. Chronic deformities of the left ribs. There are changes of degenerative joint disease. Bilateral basilar air space infiltration of the lower lobes. 3/10 CXR- Bilateral lower lobe infiltrates. Started on IM Rocephin x 7 days. Increasing difficulty swallowing. 3/10: wbc- 6.87, bun-17, Crea- 0.74, Pre-albumin- 21.2. 3/11 WBC- 5.57, BUN-16, CREA- 0.80. MBS done showed sever dysphagia and aspiration with all consistency. Hospice eval. 3/20- WBC-10.28, BUN- 22, CREA- 0.79. 3/22 Admitted to Hospice. 3/21 O2 at of 70% AP- 120, R-50, suipplemental O2 initiated. 3/23-Resident passed.
CDC Split Type:

Write-up: Resident passed on 3/23/2021. Resident continues to decline medically. 2/22 He was admitted to nursing home with worsening pressure injury.


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

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

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

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


VAERS ID: 1220012 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-08
Onset:2021-03-22
   Days after vaccination:73
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine normal, Blood thyroid stimulating hormone decreased, Blood urea normal, Death, Diet refusal, General physical health deterioration, Haemoglobin decreased, Herpes zoster, Hypophagia, Lethargy, Red blood cell count decreased, Refusal of treatment by patient, Weight decreased, White blood cell count normal
SMQs:, Haematopoietic erythropenia (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypothyroidism (broad), Hyperthyroidism (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aliskiren Fumarate, Citalopram Hydrobromide, Donezepil, HCL, Isosorbide Mononitrate ER, Miralax, Protonix, Remeron, Synthroid, Eliquis 2.5, Ferrous Sulfate, Keppra, Lamictal, Mighty Shake, Senokot S.
Current Illness: Hx of Covid-19- 05/09/2020. Receiving palliative care
Preexisting Conditions: Dementia, Cerebral infarct, PVD, Atherosclerotic heart disease, supraventricular tachycardia, Dyshphagia, Hypothyroidism, Essential HTN, Anxiety, Zoster, Postviral fatigue syndrome, Vitamin D deficiency, Hx of Pulmonary Embolism, long term use of anticoagulant, SIADH, TIA, Unspecified convulsion, Hyperlipidemia, MDD, Abnormal EEG.
Allergies: Lisinopril, Statins, Sulfa Antibiotics.
Diagnostic Lab Data: She has history of elevated D-Dimer. 3/10 WBC- 6.85, RBC- 3.63, HBG- 11.1, BUN-18, CREA- 0.89, TSH- 1.030.
CDC Split Type:

Write-up: 02/21/21- Resident has been refusing meds and meal with continued poor PO nutritional intake, and lethargic. She continue to have periods of medication refusal and continued poor PO intake. 3/8 She developed shingles to her R buttock and was started on Acyclovir cream x7 days. She continues to decline medically. Admitted to Hospice on 3/12, poor PO intake and weight loss. 3/23 Resident passed.


VAERS ID: 1220155 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-04
Onset:2021-02-08
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Internal haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Norvasc, Xarelto, Lipitor, hydrocortisone, metformin, supplemental iron pills.
Current Illness: none
Preexisting Conditions: stroke survivor
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Internal bleeding resulting in death.


VAERS ID: 1220223 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-22
Onset:2021-04-06
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: OFEV, Metformin, Remeron, Prilosec, Prednisone, Xopenex, jardiance, Gabapentin
Current Illness: Interstitial Lung Disease, Bronchiectasis, Coronary Artery Disease, Diabetes
Preexisting Conditions: Interstitial Lung Disease, Bronchiectasis, Diabetes, Coronary Artery Disease
Allergies: Heparin, Furosemide, lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: None stated.


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

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

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

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


VAERS ID: 1220532 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-03-14
Onset:2021-03-31
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 4/16/2021 I received a phone call from public health informing us that the patient died on 3/31/2021.


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