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

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



Case Details

This is page 34 out of 43

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VAERS ID: 1765535 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-02
Onset:2021-03-02
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute kidney injury, COVID-19, Chemotherapy, Dyspnoea, Endotracheal intubation, Mechanical ventilation, Odynophagia, Radiotherapy, Vaccine breakthrough infection
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), 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), Malignancy related therapeutic and diagnostic procedures (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-12
   Days after onset: 193
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Breakthrough COVID-19 infection. Admitted for painful swallowing. Progressed to shortness of breath and difficulty breathing. History of esophageal cancer with recent start of chemo and radiation. Required intubation and ventilator support. Developed acute kidney injury, and goal changed to comfort measures.


VAERS ID: 1766330 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-05-14
Onset:2021-09-09
   Days after vaccination:118
Submitted: 0000-00-00
Entered: 2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-20
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol, aspirin, bisacodyl, brimonidine, budesonide/formoterol, cetirizine, diphenhydramine, dorzolamide, ferrous sulfate, folic acid, Magnesium ocide, pantoprazole, KCl, tizanidine, trazodone
Current Illness:
Preexisting Conditions: BMI of 44, COPD, CHF, depression, arthritis, GERD, OSA, pulmonary HTN
Allergies: lisinopril, vicodin, potassium iodide, cephalexin, ciprofloxacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: 9/9/21 pos for covid 9/15/21: admitted to hospital and put on steroids and had 1 dose of tocilizumab pt intubated and put on ventilator pt expired on 9/20/21 of COVID


VAERS ID: 1766944 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Three (3) people drying after receiving the second dose of the Moderna vaccine; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Three (3) people drying after receiving the second dose of the Moderna vaccine) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Concomitant product use was not provided by the reporter. Treatment information was not provided. Company Comment - This case concerns a female patient of an unknown age with no relevant medical history reported, who experienced serious unexpected event of death. The patient died on an unknown date after the second dose of mRNA-1273 (vaccination date was not reported). The cause of death was not reported. It is unknown if an autopsy was performed. The rechallenge was not applicable as no additional dosing is expected. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Sender''s Comments: This case concerns a female patient of an unknown age with no relevant medical history reported, who experienced serious unexpected event of death. The patient died on an unknown date after the second dose of mRNA-1273 (vaccination date was not reported). The cause of death was not reported. It is unknown if an autopsy was performed. The rechallenge was not applicable as no additional dosing is expected. The benefit-risk relationship of mRNA-1273 is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1767972 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-10
Onset:2021-08-23
   Days after vaccination:166
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cough, Death, Respiratory arrest, Respiratory tract congestion, Rhinorrhoea, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-29
   Days after onset: 6
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: 08/23/2021 Antigen+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with symptom onset 8/23/2021: Runny Nose/Congestion, Cough. Hospitalized on unknown date for unknown duration. Death 8/29/2021. From Vital Records COD = ACUTE RESPIRATORY ARREST, COVID 19 PNEUMONITIS. per vital records (09/08/2021) other significant conditions: (none listed). place of death: HOSPITAL-INPATIENT PRONOUNCING AND CERTIFYING PHYSICIAN;


VAERS ID: 1768064 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-04-13
Onset:2021-08-23
   Days after vaccination:132
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-26
   Days after onset: 3
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: comorbidities are hypertension and diabetes
Allergies:
Diagnostic Lab Data: 08/23/2021 PCR+ COVID-19 test at Hospital; 08/23/2021 PCR+ COVID-19 test at Hospital
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Hospitalized 8/23/2021. Death 8/26/2021.


VAERS ID: 1768151 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-09-03
Onset:2021-10-05
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cardiac arrest, Chest pain, Dyspnoea, Electrocardiogram abnormal, Resuscitation, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: end-stage renal disease, Hypertension, CAD with pacemaker
Allergies: Codeine, Penecillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diagnosed with COVID on 9/22 and treated OP with antibiotics and monoclonal antibody infusion. Admitted to hospital on 10/5 with increasing chest pain and shortness of breath. Abnormal EKG. Cardiology and Nephrology followed patient. COVID + on admission. Had cardiac arrest with 5 rounds of chest compressions and multiple meds. Family contacted and requested DNR so ACLS was terminated.


VAERS ID: 1768160 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-10
Onset:2021-08-06
   Days after vaccination:177
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 UN / SYR

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Pain, Respiratory tract congestion, Rhinorrhoea
SMQs:, Anaphylactic reaction (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-10
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Chronic lung disease, Diabetes, Cardiovascular disease, Renal disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Aches, Runny Nose/Congestion, Cough Death due to COVID-19 complications


VAERS ID: 1768179 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-13
Onset:2021-08-17
   Days after vaccination:185
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 26L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-19
   Days after onset: 33
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: Diabetes, Renal disease
Allergies:
Diagnostic Lab Data: 08/17/2021 PCR+ COVID-19 test; 08/24/2021 PCR+ COVID-19 test; 09/14/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with symptom onset 8/24/2021: Shortness of breath/difficulty breathing. Hospitalized 8/27/2021 for unknown duration. Death 9/19/2021. From Vital Records = COVID-19. Per vital records, Not yet coded ; Other Significant Conditions include: None listed. lace of death: HOSPITAL-INPATIENT, certified by: PRONOUNCING AND CERTIFYING PHYSICIAN; occ/ind: MECHANIC, SALES


VAERS ID: 1768207 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-19
Onset:2021-10-05
   Days after vaccination:200
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, COVID-19 pneumonia, Cardioversion, Ejection fraction decreased, Electrocardiogram ST segment elevation, Endotracheal intubation, Haemofiltration, Hepatic failure, Hypoxia, Mechanical ventilation, Oxygen saturation decreased, Pneumothorax, Pulse absent, Respiratory failure, Resuscitation, Seizure like phenomena, Shock, Ventricular tachycardia, Vomiting
SMQs:, Torsade de pointes/QT prolongation (narrow), Acute renal failure (narrow), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Myocardial infarction (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Convulsions (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: COPD, hypertension, leukemia
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Transfer from clinic where patient was attempting to receive monoclonal antibody infusion when found to be hypoxic with SPO2 in low 80s. Upon arrival to our hospital vomited and underwent seizure like activity and lost pulse. CPR initiated with v tach. Defibrillated, intubated, started on amiodarone drip. Developed shock and started on levophed and propofol drips. STAT EKG showed ST elevation, code STEMI was called. Ejection fraction 15%. Started on remdesevir for covid pneumonia but stopped due to liver failure. Given dexamethasone. Developed right sided pneumothorax and developed renal failure requiring CRRT. Increasing respiratory failure with max vent settings and flolan. Family decided to transition to comfort care.


VAERS ID: 1768219 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-08-01
Onset:2021-08-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD 040C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Death, Endotracheal intubation, Feeling abnormal, Pulseless electrical activity, Resuscitation, Syncope, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-02
   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: LOSARTAN, AMLODIPINE, MONTELUKAST
Current Illness: NONE
Preexisting Conditions: ESSENTIAL (PRIMARY) HYPERTENSION
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dose #2 on Sunday 8/1/2021, decedent expressed no medical complaints at that time. However, on 8/2/2021, decedent told his wife that he "wasn''t feeling good" but went to work as a landscaper anyway. On 8/2/2021 at the end of the work day, the decedent had a witnessed collapse and CPR was initiated by bystanders. Paramedics found decedent to be in vfib and defibrillated and subsequently intubated. Epi given every four minutes, Amiodarone between epi. Decedent was found to be in asystole and back to vfib and shocked again. Second dose of Amiodarone was given and Narcan and decedent went into PEA. When bicarbonate was given, decedent back into vfib, shocked and back into PEA until pronounced at 1805 hours.


VAERS ID: 1768225 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-06-12
Onset:2021-08-08
   Days after vaccination:57
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022C21A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026D21A / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19 pneumonia, Cough, Death, Dyspnoea, Pain, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-30
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, Aches, Shortness of breath/difficulty breathing, Cough Cause of death: ACUTE HYPOXIC RESPIRATORY FAILURE, COVID PNEUMONIA


VAERS ID: 1768259 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-12
Onset:2021-08-24
   Days after vaccination:193
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Endotracheal intubation, Intensive care, Mental status changes, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Angioedema (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-25
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 08/24/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom onset date: altered mental status. Hospitalized 8/24/2021-8/25/2021. Death 8/25/2021. Per medical records, patient presented to ER with altered mental status. Patient was emergently intubated and was admitted to ICU. Patient''s previous medical history and symptoms were unable to be obtained due to patient''s clinical condition. Per patient''s husband, she was recently released from hospital and had recently had COVID-19. Patient expired on 08/25/2021. Vital records data not available yet.


VAERS ID: 1768415 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-08-17
Onset:2021-08-20
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Death, Extra dose administered, Laboratory test, Multiple organ dysfunction syndrome, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-09-10
   Days after onset: 21
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: Allopurinol 300 mg; Lipitor 20mg; Protonix 40mg; Hydroxyurea
Current Illness: CMML (Chronic myelomonocytic) Leukemia
Preexisting Conditions: CMML (Chronic myelomonocytic) Leukemia
Allergies: He had an allergy to sulfur
Diagnostic Lab Data: See above
CDC Split Type: vsafe

Write-up: He had due to chemo hospital stay had 9 months of extremely low white blood cell count that didn''t move at all. 1/07/21 on a Thursday he had his first COVID vaccine, his has labs drawn done every Friday and when he went to the Doc. On 1/8 the white blood cell count had moved up just a little. And it was still moving up just a little and had his 2nd dose on Friday 2/4/21. And from then on every week when he went in for bloodwork it would go up just a little more. It continued to go up slowly and when he had his 3rd vaccine Aug 7th after the shot while in the hospital his white blood cell count went up 40k (he hit 340K) in a 12 hour period. We got to the emergency room they took lab work and by 8pm the next day it went up by 40K. They were pulling white blood cells out and he was making more that they could pull out. On 9/10 we lost him, the white blood cells attached his organs and made them all start shutting down. On Aug 12th before his vaccine his white blood cell count was 104K. By 9/6 he was over 300K. So his wbc tripled from his 2nd shot to his 3rd shot.


VAERS ID: 1768471 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-01-07
Onset:2021-01-15
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Blood test, Death, Extra dose administered, White blood cell count increased, White blood cell disorder
SMQs:, Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-10
   Days after onset: 237
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: He was taking Allopurinol 300 mg, Lipitor 20mg, Protonix 40mg, Hydroxyurea
Current Illness: CMML (Chronic myelomonocytic) Leukemia
Preexisting Conditions: CMML (Chronic myelomonocytic) Leukemia
Allergies: He had an allergy to sulfur
Diagnostic Lab Data: weekly blood work draws on fridays
CDC Split Type: vsafe

Write-up: after shot on thursday, on friday his white blood cell count moved up just a little when he did his routine weekly blood work on fridays. the wbc count went up dispite the fact that he had been doing weekly xarixo shots (white blood cell boosting shots) from may 2020 - jan 2021 and the wbc did not move even after this time. and for the first time it went up after his 1st covid shot. WBC count slowly started going up and never stopped and continued to go up and when he got his 3rd shot in august it went up an accelerated rate in the 3 weeks and then he died. I noticed before his aug shot, he was at 700 at his wbc count and was at 100k on his august shot and 3 wks later at nearly 400K after that shot.


VAERS ID: 1768518 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-09-13
   Days after vaccination:202
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Acute respiratory failure, COVID-19, COVID-19 pneumonia, Death
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-02
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death U07.1 - COVID-19 J96.01 - Acute respiratory failure with hypoxia J12.82 - Pneumonia due to coronavirus disease 2019 N17.9 - Acute kidney failure, unspecified


VAERS ID: 1768522 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-25
Onset:2021-08-17
   Days after vaccination:173
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 UN / SYR

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Respiratory failure, Sepsis
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-24
   Days after onset: 7
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: HYPOXIC RESPIRATORY FAILURE COVID-19, SEPSIS COVID-19, PNEUMONIA COVID-19


VAERS ID: 1768531 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-05-15
Onset:2021-09-08
   Days after vaccination:116
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 035C21A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-02
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Acute respiratory failure with hypoxia Pneumonia due to COVID-19 virus


VAERS ID: 1768554 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-18
Onset:2021-10-02
   Days after vaccination:226
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Hyponatraemia
SMQs:, Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-06
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death E87.1 - Hyponatremia


VAERS ID: 1768570 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-27
Onset:2021-09-24
   Days after vaccination:209
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 24M20A / UNK - / -

Administered by: Unknown       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: 2021-10-04
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death I63.9 - Acute CVA (cerebrovascular accident)


VAERS ID: 1768580 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-04
Onset:2021-09-25
   Days after vaccination:174
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Death
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (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), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-04
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death N17.9 - AKI (acute kidney injury)


VAERS ID: 1768591 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-16
Onset:2021-09-28
   Days after vaccination:224
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O-012L20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O-031M20A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Transient ischaemic attack
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-03
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death G45.9 - TIA (transient ischemic attack)


VAERS ID: 1768599 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-28
Onset:2021-09-18
   Days after vaccination:143
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003C21A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-02
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death J18.9 - Pneumonia, unspecified organism J96.01 - Acute respiratory failure with hypoxia


VAERS ID: 1768611 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-18
Onset:2021-09-07
   Days after vaccination:201
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-01
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death J96.01 - Acute respiratory failure with hypoxia


VAERS ID: 1768620 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-20
Onset:2021-09-30
   Days after vaccination:222
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Death
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (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), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-01
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Acute kidney injury


VAERS ID: 1768718 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-25
Onset:2021-08-23
   Days after vaccination:151
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-24
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalization and Death


VAERS ID: 1768827 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Washington  
Vaccinated:2021-04-01
Onset:2021-06-16
   Days after vaccination:76
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Mechanical ventilation, Myocardial infarction, Pulmonary oedema, Stent placement, Thrombosis
SMQs:, Cardiac failure (narrow), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-15
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Heart problems
Allergies: None
Diagnostic Lab Data: Hospital
CDC Split Type:

Write-up: He had a heart attack two months after receiving the shot. They had to put a stent in. He had blood clots they didn''t know where they were coming from. One month later, July 12, he had another heart attack that killed him. They put him on a ventilator and after they removed that he was doing fine. Then they put him on rendezevere. It filled his lungs with fluid and he was gone in 12 hours. They murdered him.


VAERS ID: 1768835 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-16
Onset:2021-08-23
   Days after vaccination:188
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Multiple organ dysfunction syndrome, Subdural haematoma
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Accidents and injuries (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-06
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Unknown
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: MULTI SYSTEMS FAILURE, TRAUMATIC SUBDURAL HEMATOMA Death on 9/6/2021


VAERS ID: 1768856 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-03-04
Onset:2021-07-22
   Days after vaccination:140
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 2 - / -

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: 2021-09-08
   Days after onset: 48
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 35 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: NON HODGKINS LYMPHOMA; LAST TREATMENT 7/2021
Allergies: UNKNOWN
Diagnostic Lab Data: POSITIVE FOR COVID 19 ON 8/1/2021
CDC Split Type:

Write-up: PATIENT DIED FROM COVID 19 AFTER BEING FULLY VACCINATED


VAERS ID: 1768972 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-04-27
Onset:2021-09-10
   Days after vaccination:136
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017C21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest X-ray normal, Chills, Computerised tomogram abdomen abnormal, Confusional state, Death, Depressed level of consciousness, Disturbance in attention, Dyspnoea, General physical health deterioration, Pneumonia, Pneumonitis, Pyrexia, SARS-CoV-2 test positive, Urine analysis, Urine analysis normal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg QD, Buspirone 5 mg BID, Calcium Citrate +Vit D; BID, Cholecalciferol 50 mcg QD, Duloxetine 60 mg QD, Esomeprazole 40 mg QD, Furosemide 20 mg QD, Lasmiditan 50 mcg QD, Mycophenolate 500 mg BID, Nitrofurantoin 50 mg QD, Prednis
Current Illness:
Preexisting Conditions: Renal transplant, Liver transplant, Degenerative joint disease, Depression, Anxiety, GERD, Chronic Immunosuppression, Chronic pain syndrome, Benign neoplasm of colon, S/P insertion of spinal cord stimulator, Osteoporosis, S/P kyphoplasty, panlobular emphysema, H/O myocardial infarction, Nicotine dependence, Combined systolic/diastolic CHF, CAD, Migraine, Essential hypertension, H/O cerebral infarction due to embolism of right cerebellar artery, Unintentional weight loss, polyneuropathy, hyperlipidemia, hypothyroidism.
Allergies: Topiramate, Nortriptyline, NSAID, Hydromorphone, Phenytoin
Diagnostic Lab Data: Positive COVID-19 test on 9/16/2021 using an unspecified platfrom using PCR or equivalent technology.
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Moderna Vaccines on 3/31/2021 and 4/27/2021. Presented to ED on 9/10/2021 with complaint of confusion, as per family this happens when patient has urinary tract infection. Patient stated that she took a home urinary tract infection test kit which resulted positive. She was evaluated for urinary tract infection, but urinalysis was unremarkable. Chest x-ray was normal, but she underwent CT of the abdomen and pelvis which did show findings in the lung bases consistent with pneumonia versus pneumonitis. She was prescribed doxycycline, but stopped taking it after 2 days due to nausea. Subsequently changed to levofloxacin on 9/14/2021 during follow-up clinic visit. On 9/16/2021 patient presented to ED with shortness of breath, labored breathing, fever and chills. Placed on 6L O2 NC. Despite aggressive treatment, she has deteriorated and is no longer alert but is obtunded. Family has decided to transition to comfort care. Patient expired 9/25/2021.


VAERS ID: 1769681 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-12
Onset:2021-09-30
   Days after vaccination:202
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Condition aggravated, Death, Hyperglycaemia, Hyponatraemia, Hypoxia, Intensive care, Oxygen saturation decreased, Pneumonia bacterial, Superinfection, Type 2 diabetes mellitus
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: amLODIPine (NORVASC) 5 MG tablet ascorbic acid (VITAMIN C) 500 MG tablet aspirin 81 MG chewable tablet busPIRone (BUSPAR) 5 MG tablet Cholecalciferol (VITAMIN D3) 1000 UNITS TABS Cyanocobalamin (VITAMIN B 12) 500 MCG TABS escitalopram (LEXA
Current Illness: NA
Preexisting Conditions: Diabetes mellitus type 2, uncontrolled Depression Vitamin D deficiency Osteoporosis, unspecified OA (osteoarthritis) Hypothyroid Varicose veins of lower extremities Fatigue Anxiety OSA on CPAP Periodic limb movements of sleep Diabetic neuropathy Coronary artery disease of native artery of native heart with stable angina pectoris Anemia Essential hypertension Sleep disturbance Gout of left foot, unspecified cause, unspecified chronicity Asthma Thoracogenic scoliosis of thoracic region Chronic kidney disease, stage 4 (severe) Class 2 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 39.0 to 39.9 in adult Renal oncocytoma of left kidney Lower extremity edema Diabetic ulcer of toe of left foot associated with type 2 diabetes mellitus, with fat layer exposed PAD (peripheral artery disease) Rash COVID-19
Allergies: Brilinta [Ticagrelor] Statins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Deceased (10.4.21); Hospitalized (9.30.21); COVID-19 positive (9.30.21); fully vaccinated Discharge Provider: MD Primary Care Physician at Discharge: None Physician, MD None Admission Date: 9/30/2021 Date of Death: 10/4/21 Time of Death: 12:50 PM Preliminary Cause of Death: Acute respiratory failure due to COVID-19 PRESENTING PROBLEM: Hyponatremia [E87.1] Type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin [E11.65] COVID-19 [U07.1] Acute respiratory failure due to COVID-19 [U07.1, J96.00] Acute hypoxemic respiratory failure [J96.01] HOSPITAL COURSE: Patient admitted for acute hypoxic respiratory failure due to COVID-19 pneumonia. Patient was fully vaccinated, however she did not respond well to maximum medical therapy including iV decadron, IV remdesivir, and broad spectrum antibiotics to cover superimposed bacterial pneumonia. She was transferred to the ICU on maximum HFNC. She continued to have low oxygen levels. Patient decompensated and after long discussion with the family, resulted in transition to comfort care. She expired comfortably surrounded by family at 1250 on 10/4/21.


VAERS ID: 1771519 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-10
Onset:2021-09-05
   Days after vaccination:207
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / 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: 2021-09-05
   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: Ativan Levoxyl Norvasc Ecotrin Toprol Lexapro Aricept Privinil Lopressor
Current Illness:
Preexisting Conditions: dementia
Allergies: Codeine, erythromycin
Diagnostic Lab Data: Positive COVID-19 test
CDC Split Type:

Write-up: Patient expired due to COVID-19 after having been vaccinated.


VAERS ID: 1771542 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-12
Onset:2021-09-15
   Days after vaccination:215
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 - / 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: 2021-09-15
   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: Loratidine Azithromycin Atorvastatin Diltiazem ER Fenofibrate Valsartan Aspirin Celecoxib Escitalopram L. acidophilus Dapagliflozin Metformin Pioglitazone Multivitamin Exenatide Imbruvica
Current Illness:
Preexisting Conditions: CLL in relapse Hypertension Hyperlipidemia T2DM
Allergies: NKDA
Diagnostic Lab Data: Positive COVID-19 test
CDC Split Type:

Write-up: Patient expired due to COVID-19


VAERS ID: 1771603 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-09-30
Onset:2021-10-04
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048F21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute hepatic failure, Death
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-08
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Levemir subcutaneous insulin daily
Current Illness: Type 1 Diabetes mellitus, endometriosis, hypothyroidism
Preexisting Conditions: Type 1 Diabetes mellitus, endometriosis, hypothyroidism
Allergies: Clindamycin, Penicillin
Diagnostic Lab Data: In hospital medical record
CDC Split Type:

Write-up: Hospitalization, acute liver failure & death on 10/8/2021


VAERS ID: 1771748 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-03-01
Onset:2021-08-25
   Days after vaccination:177
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Death, Respiratory failure, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-29
   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: 08/25/2021 PCR+ COVID-19 test at Hospital.
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Hospitalized 8/25/2021-8/29/2021. Death 8/29/2021. From Vital Records COD = RESPIRATORY FAILURE, COVID-19. Per vital records, COD ICD Codes include: Not yet coded ; Other Significant Conditions include: None listed. place of death: HOSPITAL-INPATIENT; certified, PRONOUNCING AND CERTIFYING PHYSICIAN.


VAERS ID: 1771763 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-15
Onset:2021-08-20
   Days after vaccination:186
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cardio-respiratory arrest, Cough, Death, Pyrexia, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-27
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 08/24/2021 PCR+ COVID-19 test. 08/24/2021 Antigen+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with symptom onset 8/24/2021: Fever, Cough. Hospitalized 8/20/2021. Death 8/27/2021. From Records COD = CARDIORESPIRATORY ARREST, COVID-19 VIRAL PNEUMONIA. Per records, Other Significant Conditions include: None listed. lace of death: HOSPITAL-INPATIENT; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN, occ/ind: COOK, FOOD


VAERS ID: 1771765 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-19
Onset:2021-09-12
   Days after vaccination:236
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory failure, Atrial fibrillation, COVID-19, Cardiac failure congestive, Cardiomegaly, Chronic kidney disease, Death, Dialysis, Endotracheal intubation, Hyperlipidaemia, Hypertension, Hypervolaemia, Hypoxia, Pneumonia, Pulmonary oedema, SARS-CoV-2 test positive, Type 2 diabetes mellitus
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Lipodystrophy (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-25
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hypertension, Hyperlipidemia, Diabetes Mellitus type 2
Allergies:
Diagnostic Lab Data: Covid 19 RNA 09-12-2021
CDC Split Type:

Write-up: Patient tested positive for C19 on 09/12/2021. Pt was admitted to the hospital on 09/12/2021 and required intubation and immediate dialysis. Patient had an admitting diagnosis of acute hypoxemic respiratory failure: secondary to volume overload and C19 infection; C19 infection with Hypoxia, suspected pneumonia, acute on chronic kidney disease stage IV; pulmonary edema/volume overload due to congestive heart failure vs. worsening renal failure; acute on chronic congestive heart failure; cardiomegaly; hypertension; hyperlipidemia; diabetes type 2; atrial fibrillation in a controlled rate. Patient was intubated for 13 days before passing away.


VAERS ID: 1771861 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-08-17
Onset:2021-08-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA GIVEN ON 7/20/2 / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA GIVEN ON 8/17/2 / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Ascites, Blood culture negative, Blood fibrinogen decreased, Chronic hepatitis C, Computerised tomogram thorax abnormal, Culture urine negative, Death, Decreased appetite, Echocardiogram abnormal, Ejection fraction decreased, Fatigue, Hepatic cirrhosis, Hepatitis C virus test positive, Intensive care, International normalised ratio increased, Lung opacity, Platelet count decreased, Platelet transfusion, Pleural effusion, Prothrombin time prolonged, Thrombocytopenia, White blood cell count decreased
SMQs:, Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Liver-related coagulation and bleeding disturbances (narrow), Liver infections (narrow), Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-04
   Days after onset: 46
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Cardiac echo 9/29/21 showed EF 40-45%. Repeat on 10/3/21 showed EF 10-15%.
CDC Split Type:

Write-up: Chart review showed he received 2 Moderna COVID-19 mRNA vaccines on 7/20/21 and 8/17/21. Wife called PCP on 8/19/21 to report that he had developed loss of appetite and fatigue and appeared ill. PCP recommended ED eval, but pt did not go until 9/29. At that time he was found to have profound thrombocytopenia with platelets of 18000 and wbc 2700. Previous CBC on 7/21/21 showed wbc 6200 and platelets 150,000. INR initially 1.7 (9/29) then increased to 2.8 (10/3). PT 18 -- $g27, PTT 45-- $g62, Fibrinogen 110 then decreased to <80 mg/dl. Blood and urine cultures did not show any growth. CT C/A/P showed airspace opacities LLL/RUL/RLL and moderate right pleural effusion, hepatic cirrhosis, large ascites, NORMAL spleen. He was started on broad spectrum abx. ALso started on high dose dexamethasone per hem/onc for possible ITP. He received multiple platelet transfusions. He had chronic hep C, mRNA load 1209 mIU/mL. He developed hypotension refractory to IVF and had to be transferred to the ICU on 10/3/21 and subsequently passed on 10/4/21.


VAERS ID: 1771931 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-03-01
Onset:2021-08-26
   Days after vaccination:178
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-31
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 08/26/2021 PCR+ COVID-19 test
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Hospitalized 8/26/2021-8/31/2021. Death 8/31/2021. Vital Records data not available yet.


VAERS ID: 1772014 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-06-01
Onset:2021-09-17
   Days after vaccination:108
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009C21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Cardiac arrest, Death, Dyspnoea, Hypoxia, Intensive care, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (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), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-26
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient came to the emergency room on 09/17/2021 with complaints of shortness of breath after testing positive for COVID-19 on 09/11/2021. Patient was transferred to the ICU on 09/17/2021 later in the day due to acute hypoxemic respiratory failure. The patient was in the ICU for a total of 9 days before passing away due to acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Patient was hypoxic and eventually went to asystole and died at 5:30 PM on 9/26/2021.


VAERS ID: 1772016 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-03-23
Onset:2021-08-25
   Days after vaccination:155
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Dyspnoea, Fatigue, Pain, Pneumonia, Pyrexia, SARS-CoV-2 test positive, Urinary tract infection, Vaccine breakthrough infection
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-17
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Renal disease, Immunosuppressed (Leukemia)
Allergies:
Diagnostic Lab Data: 08/25/2021 Antigen+ COVID-19 test at INTERNAL MEDICINE GROUP; 09/03/2021 Antigen+ COVID-19 test at a Hospital; 09/09/2021 Antigen+ COVID-19 test at Hospital; 09/11/2021 Antigen+ COVID-19 test at Hospital; 09/15/2021 Antigen+ COVID-19 test at Hospital
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom onset: Fever, Aches, Shortness of breath/difficulty breathing, Fatigue or tiredness, Cough. Hospitalized 9/2/2021-9/17/2021. Death 9/17/2021. Vital Records data not available yet. Patient was hospitalized for UTI and was diagnosed with pneumonia. Patient was retired.


VAERS ID: 1772083 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-26
Onset:2021-09-21
   Days after vaccination:207
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / -

Administered by: Public       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: 2021-10-01
   Days after onset: 10
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: Case fully vaccinated with Moderna. Last dose on 2/26/2021. Tested positive for covid on 9/21/2021. Admitted to Medical Center on 9/27/2021. Expired on 10/01/2021 while still hospitalized.


VAERS ID: 1772156 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-04-01
Onset:2021-09-21
   Days after vaccination:173
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 2 - / -

Administered by: Public       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: 2021-09-30
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Case fully vaccinated with Moderna . Last dose on 4/1/2021. Tested positive for COVID on 9/21/2021. Admitted Medical Center on 09/21/2021. Expired on 9/30/2021 while still hospitalized.


VAERS ID: 1772180 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-04-22
Onset:2021-08-25
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-16
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 22 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: 08/27/2021 PCR+ COVID-19 test at local Medical Center
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Hospitalized 8/25/2021-9/16/2021. Death 9/16/2021. Vital records data not available yet.


VAERS ID: 1772352 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-24
Onset:2021-09-17
   Days after vaccination:177
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B211A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute kidney injury, Aortic stenosis, COVID-19, Cardiac murmur, Central venous catheterisation, Death, Echocardiogram, Hyperkalaemia, Hypoxia, Respiratory failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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

Write-up: Patient was admitted to hospital with hypoxic failure and COVID-19 . Poor baseline health prior to COVID. Hypoxemia worsed; was initially treated with remdesivir, decadron and baricitnib. Possible secondary bacterial pneumonia so baricitinib stopped and bacterial antibiotics started. Prior decubitus present upon admit. Murmur with severe aortic stenosis. Acute Kidney Injury with hyperkalemia; not a dialysis candidate. Patient made comfort care. Admitted to hospital 9/17/21. Died 9/30/2021. CEntral LIne placed 9/28/21


VAERS ID: 1774920 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-11
Onset:2021-10-02
   Days after vaccination:233
Submitted: 0000-00-00
Entered: 2021-10-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time prolonged, Blood fibrinogen increased, COVID-19 pneumonia, Cardiac arrest, Death, Epistaxis, International normalised ratio increased, Leukocytosis, Positive airway pressure therapy, Procalcitonin increased, Respiratory failure, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant 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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to the hospital under a medical service to the COVID-19 unit due to hypoxic respiratory failure secondary to COVID-19 pneumonia. He was started on remdesivir Decadron 6 mg b.i.d. Along with therapeutic dose Lovenox. He was admitted to another unit on BiPAP and pulmonology was consulted. Given his leukocytosis and elevated procalcitonin he was started on cefepime and azithromycin. The patient developed a nose bleed PTT and INR was extremely elevated thus he was given Kcentra and vitamin K. Fibrinogen was high not suggestive of DIC. Overnight the patient cardiac arrested code was called at despite ACLS measures the team was unable to obtain ROSC and resuscitation efforts were discontinued. The patient was pronounced deceased at 0249.


VAERS ID: 1774923 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-11
Onset:2021-10-04
   Days after vaccination:235
Submitted: 0000-00-00
Entered: 2021-10-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Acute respiratory failure, Angiogram pulmonary normal, Anticoagulant therapy, COVID-19 pneumonia, Death, Dialysis, Electrolyte imbalance, General physical health deterioration, Livedo reticularis, Peripheral coldness, Peripheral ischaemia, Platelet count decreased, Pneumonia bacterial, Renal failure, Thrombocytopenia, Thrombosis
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (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), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Chronic kidney disease (narrow), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted due to acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Additionally was found to have bacterial pneumonia started on cefepime and Zithromax. He was started on remsedivir along with Decadron. CTA was negative for pulmonary embolism. A few days into hospitalization the patient developed acute kidney injury nephrology was consulted felt it was likely secondary to thrombus. The patient also developed bilateral foot ischemia surgery is consulted and recommended continuation of anticoagulation. Surgery is consulted for line placement as the patient''s renal failure progressed to needing dialysis with electrolyte abnormality and the patient''s warfarin was reversed. The following day the patient developed severe thrombocytopenia with platelet count and in the 30s thus further anticoagulation was held and hematology was consulted. The patient''s lower extremity ischemia progressed and his extremities were cold mottled from the knee down. Multiple conversations were had with the patient and family and yesterday they decided given his overall poor prognosis and worsening condition the patient his family decided to cease aggressive care efforts and requested comfort measures. The patient passed away today with family at bedside.


VAERS ID: 1775206 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-09
Onset:2021-06-02
   Days after vaccination:85
Submitted: 0000-00-00
Entered: 2021-10-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 2 LA / SYR

Administered by: Public       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: 2021-06-02
   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: insulin, metoformin, lisinopril, esmeprasole
Current Illness: hypertension, hyperlipidemia, type II diabetes, morid obesity
Preexisting Conditions: same as above
Allergies: artificial sweetners
Diagnostic Lab Data:
CDC Split Type:

Write-up: myocardial infarction resulting in death


VAERS ID: 1775575 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-09-16
Onset:2021-09-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050E2114 / 3 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Blood test normal, Computerised tomogram normal, Death, Decreased appetite, Dysstasia, Eye movement disorder, Feeding disorder, Hypertension, Hypotension, Influenza like illness, Injected limb mobility decreased, Lethargy, Magnetic resonance imaging normal, Mobility decreased, Muscle spasticity, Pyrexia, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Ocular motility disorders (narrow), Tendinopathies and ligament disorders (broad), 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: 2021-09-25
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Calcium 600 Vitamin D3 Cholestoff B12 Preser Vision Amlodipine Tab 2.5 mg
Current Illness: no
Preexisting Conditions: no
Allergies: no
Diagnostic Lab Data: Cat scan MRI Normal Blood work normal
CDC Split Type:

Write-up: Day 1: lethery and weak Day 2: Flulike symtoms and no appetite Day 3: Vomiting, weaker, by evening could not stand up, lost ability to move left arm or leg up. Was taken to emergency room admitted to Hospital Day 4: Able to talk cat scan and MRI show no Neurological issue Legs is spastic and eyes open and close rapidly Day 3: Can mot sit upright ,Growing weaker Start antibiotics Day 4: Still cannot eat, Speaks last words, Low blood pressure and fever Day 5: High blood pressure and low blood pressure @nd Cat scan and MRI show nothing Start antibiotics Day 6 :start steriods, blood work normal Day 7: Eyes still track fighting for life Day 8: Dies


VAERS ID: 1775761 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-19
Onset:2021-02-01
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / -
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER 027L20A / 2 LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Balance disorder, Coordination abnormal, Disorientation, Dizziness, Fall, Impaired driving ability, Loss of personal independence in daily activities
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Vestibular disorders (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
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: see below
Current Illness: none
Preexisting Conditions: overweight, controlled blood pressure
Allergies: Demerol, Leboquin, Vytorin, pecans, walnuts
Diagnostic Lab Data:
CDC Split Type:

Write-up: Within 2 weeks he was having minor balance problems. We were told that these are not unusual symphoms and would go away. After second shot on 2/25/21, balance problems increased with dizziness and disorientation. His symphoms increased and he began falling 3-4 times a day. He was unable to finish weedeating the yard (we have 4-1/2 acres). That had never been a problem before. Through April he got much worse, dizziness, bodycoordination, and hand coordination. He had to stop driving, yard work, and building his4-place airplane. We saw Dr. in May. He was hoping it was weakness and started him with PT and Balance Training. No Change, particularly with balance. He began sleeping much more during the day with multiple naps and longer hours at night. He had always slept 6 hours at night and no daytime naps. He was so tired and the effort to get out of a chair was too much. By the middle of May he was having problems dressing, putting on his shoesand socks and buttoning his shirt. He was falling often and I insisted he use a cane for balance. IIn May and June I took him to all his doctors, internist, cardiac specialist, and even had his eyes tested in case they were part of the problem. He had a MRI of the brain that was negative, and heard imaging and cartatid artery sounding 6/8/2021. All were fine. He began falling more and tangling his feet, even using a came. sleeping mrre, and not able to do much at all. On June 26 we went t a special serive. He could not walk up the 8 steps to the Church. Two young men nearly carried him up the stairs. He was unable to dress himself for the occassion. The cane was no use, he fell three times that afternoon. He started having even more trouble with his feet tangling and was falling more. Often he did a slow roll forward. At 4:21 the morning of July 8, he was standing by the bed. I asked him what was the problem. He said that he needed to go to the bathroom. I ran around and grabbed him and half held him to the bathroom. He could not stand up on his own! I almost could not get him back into bed. He could not sit far enough back on the bed that he did not slide forward off the bed. The next morning, I took him to Hospital. After taking a chest xray, blood, and brain CAT scan, they brought him back to me and sat him in the love seat in the Emergency Room waiting room. After a few minutes he collapsed on me. He was not breathing and had a fixed stare. They got him into triage and got him breathing and his heart going. When stabilaized, they took him up fpr another CAT scan. He coded again! The first CAT was perfectly clear and this one, 40 minutes later, showed a massive bleed, not an anurism, deep in the Basal Ganglia/Thalmus area of the brain. He never regained consciousness and died 16 days lateer. Since his blood pressure had been carefully controlled all his adult life, he did not have uncontrolled blood pressure, ever! He was happy and occupied building his plane during the lockdown when we self-isolated for well over a year. He had so little pressure on him and commented several times what a perfect year we had had! We agreed it was one of our happiest. So pressure, unhappiness, or a bad family situation were not present to cause a stroke. In the nearly 58 years I was married to him he only had flu once and a light cold once. He took the shots for me bacause I had factors that indicated Covid would be particularly hard on me...Type 2 diabetic, 2 autoammune diseases, was 79, and had a double spinal fusion on the 8th of Decemver, 2020. Prescriptions: Mens Centrum Silver- Daily, Naproxin 500mg twice daily, Gabapentin 100mg 1 daily Omeprazole- Twice Daily, Allopurinol 300mg 1 daily, Mirtazapine 7.5mg 1 daily, Synthroid .175mg - 1 daily, vitimin D3 1 daily Zyrtec 1 daily, Oxybutynin 5mg twice daily Lisinopril 12.5mg - twice daily


VAERS ID: 1775828 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-05-27
Onset:2021-05-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026C21A / 2 AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest discomfort, Chills, Death, Dyspnoea, Hyperhidrosis, Pain
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-06
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: SWEATING, CHILLS, ACHES, SHORTNESS OF BREATH, TIGHTNESS IN CHEST FOLLOWED BY DEATH ON 06/06/2021


VAERS ID: 1776306 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-03-13
Onset:2021-08-23
   Days after vaccination:163
Submitted: 0000-00-00
Entered: 2021-10-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Apnoea, Areflexia, COVID-19, Cardio-respiratory arrest, Cellulitis, Chronic kidney disease, Condition aggravated, Cough, Dyspnoea, Echocardiogram normal, Electrocardiogram normal, Endotracheal intubation, Hypervolaemia, Hypoxia, Laboratory test normal, Liver disorder, Oxygen saturation decreased, Peripheral swelling, Pulmonary oedema, Pulseless electrical activity, Pupil fixed, SARS-CoV-2 test positive, Troponin normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Chronic kidney disease (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-16
   Days after onset: 24
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: carvedilol metolazone torsemide
Current Illness: On 8/23/21: 57-year-old male with PMHx of NASH cirrhosis, CKD, type 2 diabetes with peripheral neuropathy, and hypertension presented as a direct admission from outpatient cardiology appointment. He was admitted to medicine for management of volume overload suspected secondary to chronic kidney and liver disease. On initial admission he required up to 6 liters NC to maintain SPO2 greater than 88%. His resp decline was felt to be multifocal related to both his COVID infection as well as to pulmonary edema secondary to his known NASH cirrhosis, CKD, and HFpEF. He completed a five day course of remdesivir (stop date 8/29/21) and will continue dexamethasone for a total of ten days (stop date 9/3/21). Respiratory: Positive for cough and shortness of breath. Cardiovascular: Positive for leg swelling. Negative for chest pain. Discharge Disposition/Condition on 9/1/21 Disposition: Home with Home Health Condition: Stable (s/sx potential problems absent or manageable)
Preexisting Conditions: Past medical history: has a past medical history of Awaiting organ transplant status, Cellulitis (06/28/2021), Chronic diastolic congestive heart failure (CMS/HCC), Essential hypertension (04/02/2018), Extended spectrum beta lactamase (ESBL) resistance, History of urethral stricture (1/22/2018), Liver cirrhosis secondary to NASH (CMS/HCC), MRSA bacteremia (4/2/2018), Nephrolithiasis, Osteomyelitis of great toe of left foot (CMS/HCC) (7/15/2020), Paraspinal abscess (CMS/HCC) (4/4/2018), Portal hypertension (CMS/HCC), Stage 3b chronic kidney disease (CMS/HCC) (07/12/2021), and Type 2 diabetes mellitus with diabetic chronic kidney disease (CMS/HCC).
Allergies: pregabalin buspirone metformin NSAID prednisone
Diagnostic Lab Data: COVID PCR positive for covid on 8/23/21 and 9/10/21
CDC Split Type:

Write-up: On 09/10/21: Patient is a 57 y.o. male with recent COVID infection, HFpEF, NASH cirrhosis, CKD IIIb, and IDDM2 who presented to ED via EMS post-code after PEA arrest. According to patient''s wife, he developed acutely worsening shortness of breath early this morning. Wife called EMS after his shortness of breath did not improve upon resuming his home oxygen 3L NC which he had discontinued two days prior due to subjective improvement. Family estimates he stopped breathing less than 5 minutes prior to EMS arrival. EMS reports patient was apneic and in wide-complex PEA on arrival. He was coded for 20 minutes before ROSC. He arrived intubated and on levophed. Cardiogenic etiology considered due to transient hypoxia; however troponins without significant delta, EKG did not show ST abnormalities concerning for ischemia, or MI. Bedside echo without concerning findings. Infectious workup negative. Aggressively diuresed patient with minimal renal recovery. On exam patient was lacking gag reflex and pupils unreactive. Due to concern for severe anoxic encephalopathy and PVS, all sedation was stopped. Patient remained without any purposeful movement, without gag reflex, and without reactive pupils after $g48 hours of complete cessation of sedating agents. Poor prognosis discussed with wife (NOK) and daughter. They both stated he has previously said he would not want to continue with current measures in this type of situation. Wife (NOK) ultimately decided to withdrawal care and pursue comfort care. Patient was terminally extubated and discharged to inpatient hospice


VAERS ID: 1776391 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-30
Onset:2021-10-04
   Days after vaccination:157
Submitted: 0000-00-00
Entered: 2021-10-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Malaise, 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: 2021-10-10
   Days after onset: 6
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: CONGESTIVE HEART FAILURE, T2DM, HTN, MULTIPLE MYELOMA UNDERGOING CHEMOTHERAPY.
Allergies:
Diagnostic Lab Data: POSITIVE COVID TEST 10/4/21
CDC Split Type:

Write-up: DEVELOPED SYMPTOMS AND TESTING POSITVE FOR COVID19 10/4/21


VAERS ID: 1776504 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: New Mexico  
Vaccinated:2021-03-23
Onset:2021-03-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Fall, Injury, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: See attached list
Current Illness: See attached list
Preexisting Conditions: Asthma, diabetes, coronary disease, depression, APS
Allergies: See attached list
Diagnostic Lab Data: 03/24/2021
CDC Split Type:

Write-up: Loss of consciousness; fall; injury - over about 1 hour


VAERS ID: 1776925 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Unknown  
Location: Tennessee  
Vaccinated:2021-02-28
Onset:2021-08-25
   Days after vaccination:178
Submitted: 0000-00-00
Entered: 2021-10-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002V21A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Asthenia, Atrial fibrillation, Computerised tomogram abnormal, Death, Electrocardiogram abnormal, Fatigue, Heart rate increased, Oxygen saturation decreased, Palpitations, Pneumonia bacterial, Productive cough, Respiratory failure, Respiratory tract congestion, Sepsis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (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, arterial (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: CT revealed bacterial PNA
CDC Split Type:

Write-up: Patient has hx of hypertension and Stage 3 kidney disease, obstructive sleep apnea with c/o palpitations, productive cough, congestion, fatigue, and weakness. Patient''s HR was up and EKG revealed atrial fib with RVR. He was given antibiotics and steroids He was discharged on 8/22 and was readmitted on 8/25 with worsening of symptoms patient developed sepsis and returned with afib with RVR again. Patient''s oxygen demand increased and worsening resp. failure patient was intubated and placed on a ventilator. Patient also had a NSTEMI Patient was terminally extubated and expired on 8/28.


VAERS ID: 1776938 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-08-25
Onset:2021-09-23
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-10-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031B21A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031B21A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Dyspnoea, Positive airway pressure therapy, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-05
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: past medical history bilateral above-the-knee amputations, A. fib, prior left bundle branch block, prior DVT PE, prior chronic heart failure unclear if reduced ejection fraction
Allergies:
Diagnostic Lab Data: COVID PCR +9/23 and 9/26.
CDC Split Type:

Write-up: COVID PCR +9/23/21. Admitted for shortness of breath on Bi-pap.


VAERS ID: 1777335 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-04
Onset:2021-06-24
   Days after vaccination:140
Submitted: 0000-00-00
Entered: 2021-10-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 LA / IM

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-06-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lacertine 25mg, Simvastatin 20mg, and Aspirin 81mg
Current Illness: Hypertension and High Cholesterol
Preexisting Conditions: Hypertension and High Cholesterol
Allergies: No
Diagnostic Lab Data: Autopsy
CDC Split Type: vsafe

Write-up: My husband died of a massive pulmonary embolism four moths after receiving the vaccine on 06/24/2021 ( never had any symptoms or injuries prior to receiving the vaccine). I found my husband dead in our home upon arriving from work. An autopsy was performed and that''s how I learned that he died of a massive pulmonary embolism..


VAERS ID: 1778769 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-21
Onset:2021-10-09
   Days after vaccination:171
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 019B21A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-09
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Diabetes Hypertension Chronic Renal Disease COPD
Allergies: Unknown
Diagnostic Lab Data: PCR test administered by Hospital
CDC Split Type:

Write-up: Patient Contracted COVID-19 Patient Died from COVID-19 on 10/09/2021


VAERS ID: 1779007 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-08-31
Onset:2021-08-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Cold sweat, Death, Disorientation, Dyspnoea, Feeling abnormal, Gait disturbance, Influenza like illness, Pain, Pyrexia
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (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: Metformin, lisinopril and gabapentin
Current Illness:
Preexisting Conditions: Hypertension, prior MI status post stents, diabetes mellitus 2
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The decedent was feeling poorly prior to receiving his first Moderna vaccine on August 31, 2021. Approximately 2 hours after the vaccine, he developed a low-grade fever and body aches. He left for a trip the same day and his flu-like symptoms worsened. He later developed difficulty breathing. On September 7 or date of death, he developed cold sweats, low grade fever and labored breathing. He also became disoriented and had trouble walking. His date of death: 09/07/2021.


VAERS ID: 1779214 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-09-10
Onset:2021-10-08
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939906 / 3 RA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UJ694AA / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-08
   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: loratadine, fluticasone, omeprazole, lisinopril, tizanidine, carvedilol, hydrocortisone tablet, amlodipine, advair, magnesium oxide, potassium chloride liquid, imodium, prochlorperazine, gabapentin, ferrous sulfate, nortriptyline
Current Illness: anemia, ileostomy, type 2 Diabetes mellitus, Wolff-Parkinson-White, chronic pancreatitis, nicotine dependence, adrenal insufficiency, GERD, Crohns, hypertension, mild intermittent asthma, sleep apnea, hypokalemia
Preexisting Conditions: anemia, ileostomy, type 2 Diabetes mellitus, Wolff-Parkinson-White, chronic pancreatitis, nicotine dependence, adrenal insufficiency, GERD, Crohns, hypertension, mild intermittent asthma, sleep apnea, hypokalemia
Allergies: cephalexin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Notified by medical examiner that patient was found deceased at home 10/08/2021, no report of symptoms in interim


VAERS ID: 1779241 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-02-12
Onset:2021-10-09
   Days after vaccination:239
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anal incontinence, Anxiety, Bedridden, Breath sounds abnormal, Breath sounds absent, Death, Diarrhoea, Dyspnoea, Grimacing, Moaning, Oedema peripheral, Pain, Painful respiration, Pallor, Perineal pain, Peripheral coldness, Pulse absent, Somnolence, Vaginal discharge, Vaginal fistula
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Pseudomembranous colitis (broad), Dyskinesia (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Initial visit. Patient is sitting up in bed drinking some juice. She is somewhat drowsy, drifting off to sleep when not directly engaged. PPS 30%; bedbound. Patient denies pain when asked; states she feels much better than last night. Son reports that she had a good deal of pain and anxiety last night, but it is much better this AM after she received some Roxanol and Ativan before bed. When she does have pain, it is in the perineum. Having copious amounts of thin, malodorous brown drainage/stool coming from the vaginal fistula. She often groans and grimaces when peri-care is performed. from Skin is intact and pale/cool to touch. Fingers and legs very cool to touch. Unable to obtain sats as fingers were cold to touch and unable to warm them up. Respirations unlabored at rest; labored if repositioned and with pain. LS diminished throughout. Edema 2+ BLE. BS active; having constant stool leaking. Discussed timeline, prognosis, and reviewed patient?s routine medications and CCK. Written instructions provided. Discussed POC with son. No refills needed. Instructed to call hospice with any changes or concerns. Visit made to pronounce death. Patient had no pulse or respirations at time of visit


VAERS ID: 1779515 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-03
Onset:2021-10-07
   Days after vaccination:218
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, Diabetes mellitus inadequate control, Respiratory failure, Sepsis
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully vaccinated against Covid-19, died on 10/07/2021 from complications of Covid-19 pneumonia respiratory failure, sepsis, and uncontrolled diabetes. Second Moderna dose administered on 03/31/2021. Second Moderna dose Lot # 025B21A. Patient


VAERS ID: 1780477 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-08-18
Onset:2021-08-23
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cough, Death, Dyspnoea, Fatigue, Productive cough
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-03
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Exforge HCT, Metformin, Omega 3
Current Illness: none
Preexisting Conditions: Hypertension, Diabetes II both under control
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: cough, phlegm, shortness of breath, fatigue, for 12 days an then death.


VAERS ID: 1780517 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-09-10
Onset:2021-09-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Dyspnoea, Myocardial infarction
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-11
   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: uptravi, Sildenafil,Letairis
Current Illness: no
Preexisting Conditions: Long QT,Pulmonary Hypertension
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: Had a heart attack and was gasping for air


VAERS ID: 1782231 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-12
Onset:2021-09-01
   Days after vaccination:201
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-20
   Days after onset: 19
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: Chronic Lung Disease, Diabetes, Cardiovascular Disease, Chronic Renal Disease, Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized. Patient died due to COVID-19. Patient was fully vaccinated.


VAERS ID: 1782307 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-06
Onset:2021-10-10
   Days after vaccination:246
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Bradycardia, Brain compression, Brain oedema, COVID-19, COVID-19 pneumonia, Cerebellar stroke, Cerebral mass effect, Computerised tomogram head abnormal, Computerised tomogram thorax abnormal, Death, Dyspnoea, Endotracheal intubation, Fibrin D dimer increased, Influenza A virus test, Influenza B virus test, Intensive care, Ischaemic stroke, Lateral medullary syndrome, Neurological examination abnormal, Oxygen saturation decreased, Positive airway pressure therapy, SARS-CoV-2 test positive, Ultrasound Doppler normal, Unresponsive to stimuli, Vertebral artery occlusion
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-12
   Days after onset: 2
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:
Current Illness:
Preexisting Conditions: Nervous Stroke Compression Of Brain Hydrocephalus Respiratory Respiratory Failure Genitourinary Failure Renal Acute (Acute Kidney Injury) Infectious/Inflammatory COVID-19 Infection
Allergies: NKA
Diagnostic Lab Data: 10/11/2021 Influenza A/B, SARS CoV-2, PCR, Rapid, Varies- Sars CoV-2 PCR, Rapid DETECTED
CDC Split Type:

Write-up: transferred to hospital on 10/10/2021, Passed away on 10/12/2021 REASON FOR ADMISSION Stroke HOSPITAL COURSE Patient is a 79-year-old male admitted to the hospital on 10/10/2021 after he was found to have multiple focal ischemic strokes, mainly a left cerebellar stroke due to left vertebral artery and PICA occlusion. Past medical history if significant for atrial fibrillation on Xarelto, OSA on CPAP, and diabetes (on metformin). On 10/4/2021 he developed COVID-19 infection and presented to the ED for evaluation of shortness of breath and weakness. He was admitted to the medical floor and given supplemental oxygen, remdesivir, and dexamethasone. Around midnight on 10/10/2021 he became unresponsive and bradycardic with heart rates in the 30s with oxygen desaturation. He was initially placed on BiPAP but required intubation shortly thereafter. CT/CTA chest was obtained after intubation, negative for acute PE but did show findings consistent with Covid-19 pneumonia. Around 0200 a head CT was obtained which showed an acute left cerebellar infarct with effacement of the 4th ventricle and hydrocephalus with dilated 3rd ventricle and lateral ventricles. He was transferred to another hospital on 10/10/2021. Recommended starting barcitinib (JAK inhibitor) for COVID pneumonia. He was started on Lovenox 30 mg subcutaneous b.i.d. for D-dimer greater than 3000. Lower extremity ultrasound was negative for DVT. Neurology was consulted who recommended a repeat head CT with CTA 12 hours from the initial. CT/CTA at 1500 showed bilateral inferior cerebellar infarcts with an occluded left vertebral artery and left PICA. There is progressive edema with worse effacement of the 4th ventricle and the prepontine cistern. Given worsening mass effect and brain compression he was transferred to another hospital for management. His initial neurological exam was poor, although confounded by sedative medications. He was started on mannitol with improvement early in the day on 10/11/2021. Neurosurgery was consulted and evaluated. They discussed neurosurgical options with his family, who conveyed that surgical options would not reverse injury already sustained and therefore not be consistent with his wishes. His neurological exam worsened overnight on 10/11/2021 where he was not following commands in the left hemibody. Despite hydration and careful monitoring he developed acute kidney injury. Family including wife and three sons were updated via telephone regarding the severity of his strokes. After discussion they agreed that he would not want to live with neurological disability and losing any part of his independence would not be consistent with his wishes. He also had a living will stating that he would not want artifical means prolonging his life if recovery consistent with his wishes was not able to be achieved. Therefore, he was transitioned to comfort care measures after discussion with patients family on 10/12/2021. He passed away peacefully with family at the bedside at 4:44 pm.


VAERS ID: 1782372 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-02
Onset:2021-09-10
   Days after vaccination:192
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 2 UN / UN

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Death, Hypoxia, Lung infiltration, Respiratory depression, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-30
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: anastrozole 1 mg daily, candesartan 32 mg daily, gabapentin 300 mg daily and 600 mg nightly, calcium-vitamin D 500 mg-200 unit daily, levothyroxine 50 mcg daily, magnesium 30 mg daily, pantoprazole 40 mg daily, K-dur 20 mEq daily
Current Illness:
Preexisting Conditions: hypertension, history of breast cancer, peripheral neuropathy, hypothyroidism, osteoarthritis, fatty liver
Allergies: No known allergies
Diagnostic Lab Data: 9/11/2021: Chest x-ray: Multifocal infiltrates
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Moderna Vaccines on 2/3/2021 and 3/2/2021. Patient reportedly COVID positive on 9/8/2021. Patient presented to the emergency department for hypoxia on 9/10/2021 and admitted on 9/11/2021. Patient received: ascorbic acid, methylprednisolone, remdesivir, tocilizumab, and zinc. Patient''s respiratory status continued to decline throughout hospitalization. After discussion with family, patient was transitioned to comfort care. Patient expired 9/30/2021 at 1700.


VAERS ID: 1782423 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-04-07
Onset:2021-10-05
   Days after vaccination:181
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Ageusia, Anosmia, Chest pain, Cough, Death, Diarrhoea, Dyspnoea, Fatigue, Headache, Oropharyngeal pain, Pyrexia, Respiratory tract congestion, Rhinorrhoea, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-11
   Days after onset: 6
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: COPD, cardiovascular disease, and anxiety
Allergies:
Diagnostic Lab Data: Coronavirus RNA PCR specimen collected 9/30/2021
CDC Split Type:

Write-up: Hospitalized and death; symptoms include fever, rhinorrhea, sore throat, cough, shortness of breath, chest pain, headache, fatigue, diarrhea, congestion, and loss of taste/smell.


VAERS ID: 1782484 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-08-24
Onset:2021-09-29
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 052E21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Acute Systolic Heart Failure, Dilated Cardiomyopathy, History of Chest Pain, Hypertension.
Preexisting Conditions: Acute Systolic Heart Failure, Dilated Cardiomyopathy, History of Chest Pain, Hypertension.
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient Passed Away


VAERS ID: 1782614 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-17
Onset:2021-10-07
   Days after vaccination:232
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-07
   Days after onset: 0
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: diabetes, hypertension, TIA, OSA, dementia, glaucoma, pneumonia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dose 1 1/30/2021 Moderna lot # 029K20A patient dies of pneumonia, not a covid related death


VAERS ID: 1782634 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-29
Onset:2021-10-09
   Days after vaccination:194
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020B21A / 2 - / -

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: 2021-10-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hypertension, cardiac disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine #1 Moderna 3/1/2021 Lot # 011A21A patient died from cardiac arrest on 10/9/2021, not a covid related death


VAERS ID: 1782675 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-09-03
Onset:2021-09-09
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939906 / 3 - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal hernia, Computerised tomogram, Death, Decreased appetite, Dysstasia, Endoscopy, Laboratory test, Syncope, Unresponsive to stimuli, Vein collapse, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), 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: 2021-09-22
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations: I think several years ago she told me about pneumonia vaccine and she said she felt sick for about a week after that
Other Medications: She was taking Anastrozole, Tylenol, Claritin D, Eliquis, Metropole, Dorzolamide, Furosemide, Amiodarone, Lumigan, Losartan, Pravastatin, Pantoprazole, Nitroglycerine if needed
Current Illness: She had a sinus condition and that''s why she was taking Claritin d
Preexisting Conditions: Yea, she had heart condition and had stents put in maybe 10 years ago, back in the spring she was diagnosed with breast cancer and was on estrogen blocker
Allergies: She was allergic to sulfur drugs and also she couldn''t eat chicken
Diagnostic Lab Data: They did several tests. CT scans and other tests.
CDC Split Type: vsafe

Write-up: I had stayed with her Wed night and she seemed fine. Thurs morning I left about 2 in the afternoon. The next morning I found out she didn''t feel like eating that night and had been vomiting and the caregiver that came told me that also she was a little unresponsive and didn''t feel like eating anything. Caregiver thought to call the EMS and they evaluated her, at that time (9am) she was responsive and doing ok and advised not to take her to ER due to Covid situation. We decided not to take her. About 10 caregiver called back and she had fainted and couldn''t get up by herself. And she called EMS again and they came out and she was sitting up at that time and she was responsive again. They again advised that with the 2hr wait in the ambulance and advised that if it was their mother they wouldn''t take her. Since she was responsive she said she didn''t want to go to the ER. Another night caregiver came to stay with my Mom. The caregiver called and had called EMS and they were taking her to the ER because she became unresponsive again and was seen by Dr. and she was admitted to the hospital. Bunch of tests were run and she was there from Sept 10th until she passed away Sept 22. While there she couldn''t eat anything and she had a hernia where her stomach was coming up to her esophagus. And after a endoscopy she took a turn for the worse. They couldn''t draw blood because her veins started collapsing. they weren''t'' able to get her any medications or nutrients through her veins because I guess her body was shutting down. On the 20th she was admitted into hospice.


VAERS ID: 1782712 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-15
Onset:2021-10-05
   Days after vaccination:232
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Arthralgia, Asthenia, Back pain, COVID-19, Death, Dyspnoea, Dyspnoea exertional, Dysstasia, Fall, Head injury, Hypoxia, Positive airway pressure therapy, Rib fracture, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (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), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Arthritis (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-10
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID rapid test (10/5/2021) = positive
CDC Split Type:

Write-up: Patient is a 76 y.o. female patient injured as a result of a fall from standing height on 10/3/2021. Patient reports she slipped on water in her bathroom and hit her head, but denies LOC. Patient denies any difficulty breathing or chest pain at the time. She actually denies any pain from her fall. She was not able to get herself up from the bathroom floor and slept there that night. The following day she crawled into her bed room and was able to call for help. She again denies any pain or difficulty breathing, just general weakness preventing her from being able to get up from the floor. On the day of presentation she had developed pain of her back and right hip and this was her reason for presentation. She also reports that she had shortness of breath for the past 2 weeks especially on exertion. On evaluation in the ED she has been found to be COVID (+) and multiple rib fractures in various stages of healing. She was started on oxygen via nasal cannula on 10/5/2021. She was also started on dexamethasone at that time. She became more hypoxic and oxygen requirements increased, and she was requiring Bipap on 10/8/2021. She was started on remdesivir on 10/8/2021. Patient refused intubation and was made comfort measures on 10/9/2021. The patient expired on 10/10/2021.


VAERS ID: 1782792 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-16
Onset:2021-04-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B212A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cardiac failure congestive, Cholecystitis acute, Death, Gastrointestinal haemorrhage, SARS-CoV-2 test positive
SMQs:, Cardiac failure (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal haemorrhage (narrow), Infectious biliary disorders (narrow), Gallbladder related disorders (narrow), Ischaemic colitis (broad), Cardiomyopathy (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-01
   Days after onset: 8
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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: 04/23/21 tested + for COVID-19 via PCR
CDC Split Type:

Write-up: I am the epidemiologist reporting on behalf of 75-year-old male patient. The patient received two doses of the Moderna vaccine on 3/19/21 and 4/16/21. The patient tested positive for COVID-19 on 4/23/21 (5 days post second dose) via PCR. The patient died 5/1/21 (15 days post second dose) and the cause of death is listed as ?Pneumonia secondary to COVID 19?. Other significant conditions contributing to death but not resulting in underlying cause are listed as ?gastrointestinal hemorrhage, acute cholecystitis, and congestive heart failure.?


VAERS ID: 1782821 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-03-31
Onset:2021-09-30
   Days after vaccination:183
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cyanosis, Diarrhoea, Dyspnoea, Endotracheal intubation, Feeling hot, Hyperhidrosis, Nausea, Paranasal sinus discomfort, Posture abnormal, Respiratory symptom, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Pseudomembranous colitis (broad), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-01
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Loratadine, metformin, sitagliptin, simvastatin, losartan, metoprolol tartrate, calcium w/vitamin D, cinnamon bark, montelukast, fenofibrate, multivitamin w/minerals, multivitamin-iron-folic acid, fluticasone nasal spray, aspirin, tizanidin
Current Illness: none
Preexisting Conditions: Chronic low back pain Diabetes type 2 migraines hypertension mixed hyperlipidemia seasonal allergies
Allergies: meperidine - hives/swelling morphine - hives/swelling
Diagnostic Lab Data:
CDC Split Type:

Write-up: Presented to hospital after being unresponsive at home. Patient began having upper respiratory symptoms on the Sunday prior to admission with frontal sinus pressure. Began having diarrhea the day prior to admission. Day of admission patient was found to be nauseous, hot, profusely sweating and short of breath on the toilet. While on the toilet patient went unresponsive, slumped over, lips turned blue and EMS was called. Patient was intubated upon admission to the ER.


VAERS ID: 1782872 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-29
Onset:2021-09-14
   Days after vaccination:169
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047A21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-07
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HLD, HTN, DM, Peripheral neuropathy
Allergies:
Diagnostic Lab Data: COVID positive 9/14/21
CDC Split Type:

Write-up: Respiratory distress, Intubation, death


VAERS ID: 1782988 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: California  
Vaccinated:2021-09-10
Onset:2021-09-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: CefTRIAXone 2Gm once daily prescribed by Physician for heel wound.
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1 hour after vaccination patient felt dizzy and collapsed on kitchen floor. Paramedics were called and patient transported to Medical Center. Patient died several hours later.


VAERS ID: 1783008 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-04-15
Onset:2021-09-16
   Days after vaccination:154
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037B21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-17
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died due to COVID-19. Patient was fully vaccinated.


VAERS ID: 1783020 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-04-20
Onset:2021-04-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040B21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Fatigue, Feeling hot, Headache, Nausea, Peripheral swelling, Vomiting
SMQs:, Cardiac failure (broad), Acute pancreatitis (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-24
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: First vaccine, his arm was swollen but it went down, had flu-like symptoms, but said that it was nothing that he couldn''t deal w
Other Medications: None.
Current Illness: None.
Preexisting Conditions: Ebstein Barr.
Allergies: None.
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: He got his vaccination, his arm started swelling up and got hot. Then he started getting nauseated and he called over to where he got the vaccine, and they told him that it would be alright. He kept getting worse and he was tired. He was working on a project at home, and complained of a terrible headache. His mother kept asking him if he needed anything to eat or drink and he said no. He had been throwing up apparently, but did not know when possibly in the middle of the night. This continued for the several days, and he told her to leave him alone. Four days later his mother went to check on him, knocked on his door, there was no answer, and her son and daughter broke the door down and he was dead on the floor.


VAERS ID: 1783053 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-06-07
Onset:2021-09-12
   Days after vaccination:97
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN/NA / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, Atrial fibrillation, COVID-19, COVID-19 pneumonia, Cardiac arrest, Chest X-ray abnormal, Death, Dyspnoea, Endotracheal intubation, Intensive care, Lung infiltration, Positive airway pressure therapy, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Interstitial lung disease (narrow), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-12
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: 9/12/2021 CXR - perihilar infiltrates 9/12/2021 COVID 19 positive by PCR
CDC Split Type:

Write-up: Entered the ED 9/12/2021 with SOB and AFib (no history of AFib). Placed on bipap, admitted to ICU, intubated. Suffered multiple cardiac arrests, treated for probable PE. Client died 9/12/2021: Acute Hypoxic Respiratory Failure and Covid 19 Pneumonia. Submitter does not have access to further medical records. For further information, please contact.


VAERS ID: 1783124 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-19
Onset:2021-09-14
   Days after vaccination:207
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN/NA / 2 UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, Bronchial carcinoma, COVID-19 pneumonia, Computerised tomogram thorax abnormal, Cough, Death, Dyspnoea, Hypoxia, Lung opacity, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Non-haematological malignant tumours (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-18
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Hx prostate CA, anemia, CKD, HTN, PVD
Allergies: Unknown
Diagnostic Lab Data: 9/6/2021 Covid positive per antigen 9/14/2021 CT ground glass opacities, likely bronchogenic carcinoma, possible renal cell carcinoma
CDC Split Type:

Write-up: Admitted to hospital on 9/14/2021 with SOB, cough, hypoxia. Had been recommended monoclonal antibiotic therapy, but had not been initiated. DX: acute hypoxic respiratory failure, c-19 pneumonia. on 15 L O2, Decadron, declined intubation. 9/16/2021 awaiting transfer to hospice. Died 9/18/2021. Immunized with Moderna 1/22/2021 and 2/19/2021 - only 2/19 dose available. Copy of vaccination card received where client resided showing both doses.


VAERS ID: 1783607 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-08-22
Onset:2021-08-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-10-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 088D214 / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiomegaly, Death
SMQs:, Cardiac failure (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Autopsy was performed- 8/27/21- doctor said the heart muscle was enlarged and when I called her back to let her know that I was completing this VAERS report she said there was no inflammation but that the heart muscle was thicker than normal possibly due to drug use.
CDC Split Type:

Write-up: On August 27, 2021, was he found deceased in his bed. An autopsy was performed by the medical examiner''s office. Patients'' sister reported that the night before he went to bed and was behaving normally. On Saturday, August 28th, the medical examiner called and informed us that his heart was enlarged. No previous history of enlarged heart had ever been reported and no heart issues had ever been considered in his past.


VAERS ID: 1783814 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-03-25
Onset:2021-09-05
   Days after vaccination:164
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes, Cardiovascular disease, Renal disease, past kidney transplant making higher risk for autoimmune condition.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully vaccinated and hospitalized. Later died due to Covid related causes


VAERS ID: 1783819 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-04-06
Onset:2021-10-01
   Days after vaccination:178
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-01
   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: Diabetes, Renal disease, high blood pressure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully vaccinated and died due to Covid related causes


VAERS ID: 1784824 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-26
Onset:2021-09-17
   Days after vaccination:234
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-21
   Days after onset: 4
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 died due to COVID-19. Patient was fully vaccinated.


VAERS ID: 1784834 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-09
Onset:2021-09-16
   Days after vaccination:219
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Cardiopulmonary failure, Death, SARS-CoV-2 test positive, Vaccine breakthrough infection
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   Days after onset: 8
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: 09/16/2021 PCR+ COVID-19 test at Medical Center
CDC Split Type:

Write-up: Breakthrough COVID-19 case with unknown symptom status. Hospitalized unknown date for unknown duration. Death 9/24/2021. From Vital Records = ACUTE CARDIOPULMONARY FAILURE, ACUTE RESPIRATORY FAILURE, COVID 19. Per vital records, ICD Codes include: Not yet coded ; Other Significant Conditions include: None listed. place of death: HOSPITAL-INPATIENT, MEDICAL CENTER; certified by: PRONOUNCING AND CERTIFYING PHYSICIAN


VAERS ID: 1785001 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-04-17
Onset:2021-05-06
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 1 UN / SYR

Administered by: Private       Purchased by: ?
Symptoms: Arteriosclerosis, Autopsy, Condition aggravated, Diabetes mellitus, Hypertension
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Hypertension (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-09
   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: cervical spinal canal stenosis
Preexisting Conditions: atherosclerotic cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, and congestive heart failure
Allergies:
Diagnostic Lab Data: Autopsy report 05/ 12/ 2021 at 2:00 pm
CDC Split Type:

Write-up: Atherosclerotic Cardiovascular Disease, Hypertension and Diabetes Mellitus


VAERS ID: 1785015 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-06-15
Onset:2021-08-18
   Days after vaccination:64
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036B21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-24
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died due to COVID-19. Patient was fully vaccinated.


VAERS ID: 1785145 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-09-28
Onset:2021-10-09
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 020F21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory failure, Angiogram, COVID-19 pneumonia, Chest X-ray, Death, Dyspnoea, Echocardiogram, Endotracheal intubation, Hypoxia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-10-10
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Trelegy Ellipta 100/62.5 mg , Spironolactone 25 mg, sildenafil 20 mg, prevacid 15 mg, prednisone 20 mg, lasix 20 mg, Lexapro 20 mg, Eliquis 5 mg, Daliresp 500 mcg, cetirizine 10 mg, albuterol HFA
Current Illness: Pulmonary Hypertension, GERD, Pulmonary edema, diastolic heart failure, left ventricular hypertrophy, asthma, raynaulds syndrome, congestive heart failure
Preexisting Conditions: Pulmonary Hypertension, GERD, Pulmonary edema, diastolic heart failure, left ventricular hypertrophy, asthma, raynaulds syndrome, congestive heart failure
Allergies: tomato
Diagnostic Lab Data: cta scan, covid test, echocardiogram, cxr
CDC Split Type:

Write-up: Death diagnosed with covid pneumonia, hypoxia, acute respiratory failure, intubation, Death increased sob reported on 10/8/2021, recommended to go to ER. Patient admitted to Hospital. Death on 10/10/2021


VAERS ID: 1785167 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-04-14
Onset:2021-10-01
   Days after vaccination:170
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, General physical health deterioration, Intensive care
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-12
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes CAD Former smoker
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Was admitted 9/28/2021 to 10/1/2021 received 3 doses of Remdesivir. Pt was readmitted 10/6/2021 where he progressively worsened, pt was in ICU. Pt then put into hospice care and passed away 10/12/2021 at 1949


VAERS ID: 1785200 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-08
Onset:2021-08-29
   Days after vaccination:143
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-17
   Days after onset: 19
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: TYPE II DIABETES, END STAGE RENAL DISEASE, COPD, CORONARY ARTERY DISEASE
Allergies:
Diagnostic Lab Data: POSITIVE COVID19 PCR 8/29/2021
CDC Split Type:

Write-up: BECAME SYMPTOMATIC. EXPERIENCED RESPIRATORY FAILURE AND COVID19 PNEUMONIA. DIED 9/17


VAERS ID: 1785202 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-14
Onset:2021-08-30
   Days after vaccination:228
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Angiosarcoma, Biopsy, Death, Dizziness, Imaging procedure, Laboratory test, Photophobia, Vertigo, Vomiting
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Noninfectious meningitis (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Corneal disorders (broad), Retinal disorders (broad), Vestibular disorders (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-10-07
   Days after onset: 38
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 38 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: None
Preexisting Conditions: Low Back Pain (reported 2019)
Allergies: NKDA/NKA
Diagnostic Lab Data: Multiple laboratory tests, imaging and biopsies performed during the period between 31AUG to 07OCT.
CDC Split Type:

Write-up: Patient presented to medical clinic on 30AUG21 for evaluation of vertigo, photophobia, dizziness, vomiting. Patient was evaluated on 31AUG21 via Emergency Department, was later diagnosed with Angiosarcoma and passed away on 07OCT21.


VAERS ID: 1785212 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-12
Onset:2021-09-07
   Days after vaccination:207
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized. Patient died due to COVID-19. Patient was fully vaccinated.


VAERS ID: 1785275 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-17
Onset:2021-09-15
   Days after vaccination:210
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-27
   Days after onset: 12
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: clopidogrel, ferrous sulfate, furosemide, isosorbide mononitrate, losartan, meloxicam, metoprolol, nitroglycerin, pantoprazole, phenytoin, pramipexole, pravastatin, spironolactone, warfarin
Current Illness:
Preexisting Conditions: CAD, hypertension, A fib with RVR, HFrEF, hyperlipidemia
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: 9/15/21 - tested positive for COVID 9/20/21 present to ED with SOB 9/21/21 re-presents to ED with SOB and admitted. pt given remdesivir, dexamethasone, zinc and barcitinib during stay and expired 9/27/21


VAERS ID: 1785281 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-04-30
Onset:2021-10-02
   Days after vaccination:155
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Chest X-ray abnormal, Chronic obstructive pulmonary disease, Condition aggravated, Death, Endotracheal intubation, Lung opacity, Pneumonia, Positive airway pressure therapy, Pulmonary fibrosis, Septic shock
SMQs:, Angioedema (broad), Interstitial lung disease (narrow), Toxic-septic shock conditions (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-11
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: COPD, CAD, DM, HTN
Allergies: oxycodone
Diagnostic Lab Data: 10/2 Chest x ray showed new basilar opacity superimposed on bibasilar scarring and fibrosis, ,
CDC Split Type:

Write-up: Admitted with adult respiratory distress syndrome, septic shock, pneumonia, COPD . Family chose comfort care instead of aggressive treatments and patient died. Vapotherm, BiPap, intubated, pressors


VAERS ID: 1785380 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-11
Onset:2021-09-13
   Days after vaccination:186
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acidosis, COVID-19, Cough, Death, Dyspnoea, Endotracheal intubation, Feeding disorder, General physical health deterioration, Hyperkalaemia, Hypotension, Hypoxia, Mechanical ventilation, Positive airway pressure therapy, Renal failure, SARS-CoV-2 test positive, Urine output decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (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: 2021-10-06
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 17 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol MDI prn, Apixaban 5 mg BID, Aspirin 81 mg QD, Atorvastatin 20 mg QD, Azelastine Nasal BID, Carvedilol 12.5 mg BID, Lotrisone Lotion BID, Dorzolamide Ophth 1 drop both eyes BID, Doxycycline 100 mg BID, Dronedarone 400 mg BID, Flov
Current Illness:
Preexisting Conditions: Asthma, CAD, Diabetes, Hypertension, Hyperlipidemia, H/O basal cell carcinoma of nose, H/O heart artery stent, H/O MI, Obesity, Seasonal Allergies, Sleep Apnea.
Allergies: Amlodipine (Swelling), Sulfa (Nightmares)
Diagnostic Lab Data: Positive COVID-19 test on 9/19/2021 using the Abbott ID Now Platform using nucleic acid amplification technology.
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Pfizer Vaccines on 2/11/2021 and 3/11/2021. Presented to ED on 9/19/2021 with a 6 day history of cough and worsening shortness of breath. On admission was hypoxic on room air that improved with 5 L of oxygen via nasal cannula. Patient was treated with dexamethasone, remdesivir, and baricitinib. Ultimately had progressive hypoxemia requiring mask BiPAP making it difficult to eat or drink and on the evening of 9/30 was intubated. Over the next 7 days he continued to deteriorate with worsening hypoxemia requiring prone ventilation strategy. Despite maximization of ventilator efforts he never improved. Moreover, he developed persistent hypotension and renal failure with minimal urine output ultimately with acidosis and hyperkalemia. Palliative care was involved with family discussions. He was transitioned to DNR status and expired on 10/6/2021.


VAERS ID: 1785497 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-04-08
Onset:2021-09-19
   Days after vaccination:164
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039A21A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, COVID-19, Cardio-respiratory arrest, Chronic sinusitis, Cough, Death, Decreased appetite, Endotracheal intubation, Fatigue, Hypophagia, Hypoxia, Nucleic acid test, Pneumonia, Pneumonia bacterial, SARS-CoV-2 test positive, Sleep disorder
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (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), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-10
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Cetirizine 10 mg QD, Donepezil 10 mg QD, Gabapentin 100 mg BID Additional information for Item 9: Memantine 10 mg BID, Acetaminophen 650 mg Q6H PRN, Cal-Citrate QD, Carvedilol 6.25 mg BID, Dutasteride 0.5 mg QD, Furosemide 20 mg TID, Lisin
Current Illness:
Preexisting Conditions: Atrial fibrillation, Mild Alzheimer''s disease, BPH, CHF (Diastolic), Hypercholesterol, Cataracts, Hypertension
Allergies: NKDA
Diagnostic Lab Data: Positive COVID-19 test on 10/9/2021using the Luminex MAGPIX platform using PCR or equivalent Nucleic Acid Amplification(NAA)technology.
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Moderna Vaccines on 3/6/2021 and 4/8/2021. Presented to ED on 10/1/2021 for hypoxia. He was diagnosed with COVID in his PCP''s office on 9/21. His symptoms began on 9/19 with lack of energy and worsening of his chronic sinus issues. He received an infusion of monoclonal Abs on 9/30. He reports having decreased appetite (but no dysgeusia or anosmia) with poor PO intake, persistent cough that keeps him from being able to sleep, and fatigue with low energy. Today, he was noted to have saturations of 70''s at home. His sats here on RA measured on his ear lobe are 85%. He comes up to 95% on 2L. Patient was admitted and Additional information for Item 18: started on dexamethasone. He completed treatment for a secondary bacterial pneumonia and was started on abx again later for suspected hospital acquired pneumonia shortly before he passed. Patient''s O2 needs gradually increased, despite proning his O2 needs continued to worsen and he had to be intubated on 10/8. Patient coded on 10/10 and was pronounced at 15:01.


VAERS ID: 1785501 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-26
Onset:2021-09-10
   Days after vaccination:196
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Agitation, Body temperature increased, Bradycardia, COVID-19, Cardiac arrest, Condition aggravated, Cough, Death, Dyspnoea, Endotracheal intubation, Exposure to SARS-CoV-2, Fungal test positive, General physical health deterioration, Hypotension, Hypoxia, Idiopathic pulmonary fibrosis, Inappropriate schedule of product administration, Intensive care, Mechanical ventilation, Oropharyngeal pain, Oxygen saturation decreased, Positive airway pressure therapy, Productive cough, Pulse absent, Resuscitation, SARS-CoV-2 test positive, Sputum culture positive, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-10
   Days after onset: 30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 17 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Atorvastatin 20 mg QD, Levothyroxine 100 mcg QD, Nifedipine
Current Illness:
Preexisting Conditions: Iodopathic pulomonary fibrosis, pulmonary hypertension, CAD s/p CABG, Atrial FIbrillation, H/O Basal cell carcinoma of
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Moderna Vaccines on 1/19/2021 and 2/26/2021. Patient presented to a different facility on 9/10/2021 with complaints of worsening shortness of breath over the last month associated with cough and sore throat. Patient reported that he was recently exposed to Covid and tested positive on 9/9/2021 on a home test. He was admitted and completed a 5 day course of remdesivir, and completed a 10 day course of Decadron after being discharged on September 15. On September 23,


VAERS ID: 1785593 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-01-28
Onset:2021-10-12
   Days after vaccination:257
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Acute respiratory failure, Anaemia, COVID-19 pneumonia, Coagulopathy, Cyanosis, Embolism arterial, Encephalopathy, Endotracheal intubation, Epistaxis, Faeces discoloured, Heart rate decreased, Melaena, Mucosal haemorrhage, Pulmonary embolism, Rhabdomyolysis, Sepsis, Shock, Thrombocytopenia, Ultrasound scan abnormal, Upper airway obstruction
SMQs:, Rhabdomyolysis/myopathy (narrow), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (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 (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: aortic valve replacement
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital on 10/2 with covid pneumonia with acute hypoxia respiratory failure. Also stated history of having bright red bleeding per rectum. Treated with covid bundle medications. Intubated on 10/4 due to Upper airway obstruction due to large volume posterior aspect epistaxis. Internal maxillary artery embolization on 10/7 but continued to have anemia and thrombocytopenia with continued melanotic stool and suctioning of bleeding in the setting of severe sepsis. Received 9 units platelets and over 3 units PRBC. Diagnosed with bilateral sub segmental PEs but not candidate for anticoagulation due to bleeding risk. Evidence of rhabdomyolysis with AKI. Treated with cefepime and zyvox due to sepsis and shock. Coagulopathy continued with cyanosis of the upper and lower digits. Decreased pulsations in the dorsal pedis and upper extremities. Ultrasound showed no flow in right dorsalis pedis and dampened flow in right and left ulnar arteries. Given prophylactic anticoagulation due to bleeding risk. Mucosal bleeding increased. A=complicated course with encephalopathy and unable to be weend from vent. Family aware and transitioned to comfort care.


VAERS ID: 1785676 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-08-27
Onset:2021-09-13
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-10-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047B21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal pain upper, Chest pain, Hyperhidrosis
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-14
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to the hospital on 9/13 for both chest pain and abdominal discomfort. Called paramedics after a sharp pain was felt in her epigastric region and profuse sweating occurred.


VAERS ID: 1018310 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-01-16
Onset:2021-01-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 30042698 / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: SCIPPA; SEVENAL; QUAMATEL; MEFORAL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrioventricular block first degree; Bladder cancer; Chronic gastritis; Coronary sclerosis; Depression; Emphysema pulmonary; Strangulation ileus; Type 2 diabetes mellitus; Urinary bladder excision
Allergies:
Diagnostic Lab Data:
CDC Split Type: HUMODERNATX, INC.MOD20210

Write-up: Death; A regulatory authority report was received from a physician, concerning a 78 year-old male patient, who received Moderna''s COVID-19 Vaccine and patient died. The patient''s medical history included strangulation ileus, depression, atrioventricular block first degree, coronary sclerosis, emphysema pulmonary, type 2 diabetes mellitus, urinary bladder excision, chronic gastritis, and bladder cancer. Products known to have been used by the patient, within two weeks prior to the event, included escitalopram oxalate, phenobarbital, famotidine, and metformin hydrochloride. On 16 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 (batch number 30042698) for COVID-19 infection prophylaxis. The patient died on the day of vaccination. The reporter stated that the patient had several chronic concurrent diseases at the time of the vaccination, however, the patient was in a fair general condition for the vaccination. It was reported that the patient was well-oriented and after the vaccination, no abnormalities were detected during the observation period. Treatment information was not provided. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on 16 Jan 2021. The autopsy was performed and the causes of death were reported as bronchitis, cardiac failure and arteriosclerosis. The reporter assessed the causality as unlikely related between the event and mRNA-1273. Follow-up received on 01 Feb 2021 included NNI.; Reporter''s Comments: An 78 year old vaccinated patient died on the day of vaccination. He had several chronic concurrent diseases at the time of the vaccination. However, The patient was in a fair general condition for the vaccination, he was well-oriented. After the vaccination, no abnormalities were detected during the observation period. The autopsy was performed and the causes of death were reported as bronchitis, cardiac failure and arteriosclerosis. Based on above there is an unlikely the causal relationship between the suspect vaccine and the death of the patient. The case is serious due to the patient''s death as reported. Further information is expected. The autopsy was performed and the causes of death were reported as bronchitis, cardiac failure and arteriosclerosis.; Reported Cause(s) of Death: bronchitis; cardiac failure; arteriosclerosis


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