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From the 11/19/2021 release of VAERS data:

Found 4,746 cases where Vaccine is COVID19 and Manufacturer is MODERNA and Patient Died

Government Disclaimer on use of this data



Case Details

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VAERS ID: 1848307 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-03-22
Onset:2021-04-27
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-11-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA D06B7 OR 21A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Immobile, Limb injury
SMQs:, Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-01
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: WARFARIN; METOPROLOL; LEVOTHYROXINE SODIUM; MEMANTINE HCL; DONEPEZIL HCL
Current Illness:
Preexisting Conditions: Comments: No medical history was provided by the reporter.
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Foot wound; passed away about a week after becoming immobile; This spontaneous case was reported by a consumer and describes the occurrence of IMMOBILE (passed away about a week after becoming immobile) and LIMB INJURY (Foot wound) in a 91-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 059B21A and D06B7 or 21A) for COVID-19 vaccination. No medical history was provided by the reporter. Concomitant products included WARFARIN, METOPROLOL, LEVOTHYROXINE SODIUM, MEMANTINE HYDROCHLORIDE (MEMANTINE HCL) and DONEPEZIL HYDROCHLORIDE (DONEPEZIL HCL) for an unknown indication. On 22-Mar-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 19-Apr-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 27-Apr-2021, after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced IMMOBILE (passed away about a week after becoming immobile) (seriousness criteria death and medically significant). On an unknown date, the patient experienced LIMB INJURY (Foot wound) (seriousness criterion medically significant). The patient died in May 2021. The reported cause of death was Immobile. It is unknown if an autopsy was performed. At the time of death, LIMB INJURY (Foot wound) outcome was unknown. Treatment information was not provided. Concomitant medication include blood thinner medication. This case concerns a 91-year-old female patient with no relevant medical history, who experienced the unexpected events of Immobile and Limb Injury. The events occurred approximately 9 days after the second dose of mRNA-1273 (Moderna COVID-19 Vaccine) and had a fatal outcome, with death occurring in the following week. The benefit-risk relationship of mRNA-1273 (Moderna COVID-19 Vaccine) is not affected by this report.; Sender''s Comments: This case concerns a 91-year-old female patient with no relevant medical history, who experienced the unexpected events of Immobile and Limb Injury. The events occurred approximately 9 days after the second dose of mRNA-1273 (Moderna COVID-19 Vaccine) and had a fatal outcome, with death occurring in the following week. The benefit-risk relationship of mRNA-1273 (Moderna COVID-19 Vaccine) is not affected by this report.; Reported Cause(s) of Death: Immobile


VAERS ID: 1849492 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cerebrovascular accident, Chest X-ray abnormal, Computerised tomogram abnormal, Death, Dysgraphia, Dysstasia, Electrocardiogram normal, Fatigue, Gait disturbance, Hemiparesis, Insomnia, Laboratory test, Loss of personal independence in daily activities, Mobility decreased, Nervous system disorder, Pain, Peripheral swelling, Pneumonia, Pulmonary thrombosis, Speech disorder, Unresponsive to stimuli
SMQs:, Cardiac failure (broad), Angioedema (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-16
   Days after onset: 64
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 45 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lorazepam Enalapril Desvenlafaxine Suc E12 Tramadol HCL Mirtazapine Trazadone Melantonin as needed Fiber laxative
Current Illness:
Preexisting Conditions: Mild high blood pressure Chronic depression and anxiety
Allergies: Codine
Diagnostic Lab Data: EKG - normal. CAT Scan - identified a mild stroke on left side of brain. Lung x-rays - pneumonia early in the first hospital. Lung x-rays - blood clot found in right lung. Many other tests. Nothing could be identified as to why she was having continued neurological issues.
CDC Split Type:

Write-up: Within 12 hours, could not sleep, had body aches, and loss of strength. Could not stand up from a seated position by herself. Condition continued to worsen. Saw personal physician on Feb. 26 and at that point was very weak and fatigued from continued inability to sleep. Was taken to the ER on March 2 and admitted into the hospital. At that point she could not communicate / talk, she could not sign her name, and could barely walk with a great deal of help. EKG was normal. Found signs of a mild stroke on the left side of her brain and had neurological issues on the left side of her body to the point that she could not use her left arm or leg. Had swelling in her legs that would not dissipate. Was released from the hospital on March 28 and transferred to a rehab facility with continued plans of strengthening and return to home. She still could not stand or walk on her own and barely with two people helping her at maximum assistance. On April 2, she was transferred from the rehab facility to the ER by ambulance due to worsening condition and not responsive but heart was fine. Was transferred back to the rehab facility that night after being treated. On April 6 was transferred to Hospital due to her condition worsening again. Found a large blood clot in her right lung. At this point she could no longer move herself due to weakness and continued neurological issues of her left side. Heart continued to be strong. She passed away on April 16, 2021. Cause of death is unknown.


VAERS ID: 1849596 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-03-29
Onset:2021-07-25
   Days after vaccination:118
Submitted: 0000-00-00
Entered: 2021-11-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNAVAILABLE / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Aortic valve incompetence, Atrial fibrillation, Blood corticotrophin normal, Cardiac pacemaker insertion, Catheter placement, Central venous catheterisation, Death, Echocardiogram, Echocardiogram abnormal, Encephalopathy, Endocarditis, Feeling abnormal, General physical health deterioration, Haemodialysis, Hepatorenal syndrome, Hypoperfusion, Hypotension, Illness, Intensive care, Malaise, Mental status changes, Pulmonary oedema, Pyrexia, Sepsis, Somnolence, Streptococcal bacteraemia, Torsade de pointes
SMQs:, Torsade de pointes/QT prolongation (narrow), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Embolic and thrombotic events, venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-26
   Days after onset: 32
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: T2DM, ulcerative ileocolitis, primary sclerosing cholangitis, cirrhosis, and portal hypertension. Previously underwent liver transplant eval last year at ICVA with neg LHC and TTE. Wasn''t sick enough to be listed
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient did state he had his 2nd dose of Moderna, but it is not documented where this reporter can find the date (would have been sometime in April). He told this reporter he started to not feel well about 3 weeks after his 2nd dose. He eventually felt so bad he sought treatment in July. He was admitted 8/6/2021 with group B streptococcus agalactiae bacteremia, sepsis resulting in fever, encephalopathy and AKI (likely due to SBP). TTE 8/17 showed severe AR and possible vegetation. TEE 8/18 confirmed infective endocarditis c/b AoV insufficiency. Patient is not an IV drug user. Hospital course also complicated by Afib w RVR and was started on dilt drip, now off as patient''s HR improved and he has had low BP in setting of likely worsening AoV insufficiency. Patient also with pulmonary edema periodically requiring 1-2L O2 . Furthermore, 8/22 patient had short run of torsades treated with Mag Over the past several days, patient has developed hepatocardiorenal syndrome with worsening AKI. Transfer to ICU for consideration of CRRT initiation. Structural and CT surgery following due to severe AI. Tentative plan for TAVR. Patient with slowly worsening AMS as well, acute-subacutely worsening today. Thought to be due to hypoperfusion v acute illness. Cosyntropin stim test for hypothermia negative. Patient arrived to ICU somnolent but arousable. HD catheter, PICC and A-line were placed for CRRT initiation, pressor initiation and hemodynamic monitoring respectively. Patient''s hemodynamics continued to worsen evening after ICU transfer and temporary pacemaker was inserted and patient was paced with HR 90-110. Despite pressor support and temporary pacemaker, patient continued to worsen and was persistent in stating he no longer wished for current cares to continue. It was felt patient would not tolerate TAVR or liver transplant at this state as patient was not improving with pressor, CRRT, temporary pacemaker and hemodynamic support and as a result decision was made with family to transition patient to comfort cares. He ultimately succumbed into death on 8/26/2021


VAERS ID: 1849728 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-09
Onset:2021-04-16
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-11-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood test, Computerised tomogram, Death, Hypoxia, Interstitial lung disease, X-ray
SMQs:, Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-08-07
   Days after onset: 113
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 90 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lantus 100mg. 27 units daily Metformin 1000 mg daily Elequis 5mg daily Amlodapine 5mg
Current Illness: None known
Preexisting Conditions: Diabetics Bladder surgery 28 years lost op
Allergies: None known
Diagnostic Lab Data: X-ray Cat scans Blood tests Multiple
CDC Split Type:

Write-up: Acute and pervasive interstitial lung disease causing hypoxia requiring hospitalization to assist with oxygen needs of 5?10L per min Three month hospital followed by death on 08/07/21


VAERS ID: 1849869 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-05-06
Onset:2021-09-29
   Days after vaccination:146
Submitted: 0000-00-00
Entered: 2021-11-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018B21A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Acinetobacter bacteraemia, Acute respiratory failure, Anticoagulant therapy, Axillary vein thrombosis, Blood culture negative, COVID-19, COVID-19 pneumonia, Circulatory collapse, Cognitive disorder, Computerised tomogram thorax abnormal, Death, Deep vein thrombosis, Electroencephalogram abnormal, Encephalopathy, Endotracheal intubation, Goitre, Jugular vein thrombosis, Magnetic resonance imaging head normal, Mechanical ventilation, Neurological examination, Pulmonary artery dilatation, Scan with contrast abnormal, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Thrombophlebitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypothyroidism (broad), Hyperthyroidism (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

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? Yes
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 76 y.o female with h/o COPD on 2 L home oxygen, type 2 diabetes, hypertension, having been found unresponsive at HCF. With GCS 3 patient intubated, and mechanically ventilated at a local HCF. Diagnosed with COVID-19 and acinetobacter bacteremia. Right upper extremity with occlusive DVT in right brachial and basilic vein with nonocclusive thrombus in right axillary vein, initiated anticoagulation. Previous CT revealed no PE, However, did show dilated pulmonary arteries. Repeat CT chest with contrast 09/14 revealed small amount of thrombus in left jugular and extensive chronic findings including goiter and marked enlargement of left pulmonary artery prior to previous. Pt was transferred to another HCF for vascular surgery evaluation, advised nonsurgical, continuing anticoagulation. Pt persistently, off sedation, demonstrated no significant improvement with cognition/neurologic status. MRI brain 9/13 revealed no acute intracranial abnormally. EEG resulted abnormal with severe generalized slowing, consistent with severe encephalopathy, concern for possible epileptiform discharge prompted Neurology evaluation, provided Keppra. Pt was provided broad-spectrum antibiotics with cefepime and doxycycline, negative repeat blood cultures prompted discontinuation of antibiotics after 5 days of therapy. HCF provided counsel with family members regarding goals of care, ultimately, decision made to transition to comfort measure on the afternoon on 09/18/2021. Pt succumbed to illness, suffered cardiopulmonary collapse as result of acute respiratory failure with hypoxemia secondary COVID-19 viral pneumonia at 1;45am on 09/29/2021


VAERS ID: 1850162 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: California  
Vaccinated:2021-11-02
Onset:2021-11-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 035C21A / 3 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-05
   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: Metformin, lisinopril, arorvastatin, vitamin c, turmeric
Current Illness: Controlled High cholesterol, controlled hypertension, controlled diabetes
Preexisting Conditions: Controlled High cholesterol, controlled hypertension, controlled diabetes
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Massive Heart attack. Patient is deceased


VAERS ID: 1850335 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-06-01
Onset:2021-10-23
   Days after vaccination:144
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048B21A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003C21A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 15
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 Nontraumatic intracranial hemorrhage, unspecified Hemorrhagic cerebrovascular accident (CVA)


VAERS ID: 1850339 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-07
Onset:2021-11-03
   Days after vaccination:210
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Death, Systemic inflammatory response syndrome
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), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   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 SIRS (systemic inflammatory response syndrome) Acute kidney injury


VAERS ID: 1850358 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-10-28
Onset:2021-10-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray abnormal, Dyspnoea, Pneumonia
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Finasteride Senokot Oxybutynin Lactulose Lisinopril
Current Illness: none
Preexisting Conditions: HTN
Allergies: None
Diagnostic Lab Data: CXR
CDC Split Type:

Write-up: Began with sob soon after vaccination. DX pneumonia and put on oxygen.


VAERS ID: 1850464 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-11-05
Onset:2021-11-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 071F21A / 3 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol Succ ER 50 MG Tab Take 1 by mouth at bedtime Vitamin D2 1.25mg Take 1 by mouth weekly Meloxicam 15mg Tablet Take 1 by mouth daily Pravastatin Sodium 20 MG Tab Take 1 by mouth daily Tramadol HCL 50 MG Tablet 1-2 by mouth twice to
Current Illness: None
Preexisting Conditions: Hyperlipidemia Hypertension Varicose Veins
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was found deceased at home on 11/06/2021.


VAERS ID: 1850465 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-02
Onset:2021-11-06
   Days after vaccination:277
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 12M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   Days after onset: 0
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: CVA, Lung disease, hypertension, CKD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dose 1 1/7/2021 Moderna Lot # 026L20A Pt die d in the hospital


VAERS ID: 1850490 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-04-23
Onset:2021-11-04
   Days after vaccination:195
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007C21A / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Breast cancer female, Death, Neoplasm malignant
SMQs:, Breast malignant tumours (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-05
   Days after onset: 1
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: Breast cancer with mets, liver failure, anemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dose 1 3/22/2021 007B21A Moderna Pt died of end stage breast cancer


VAERS ID: 1850695 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-11-02
Onset:2021-11-07
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011F21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Cirrhosis, hypertension, COPD, Hypothyroidism, Osteoporosis, h/o basal cell cancer
Preexisting Conditions: as above
Allergies: no known allergies documented
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Death 11/7/2021 with no related event upon vaccine administration


VAERS ID: 1850803 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-11-02
Onset:2021-11-06
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939906 / 3 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Condition aggravated, Death, Dementia, Dysphagia, General physical condition abnormal, Pallor
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: cloNIDine Patch Weekly 0.2 MG/24HR, Dextrose-NaCl Solution 5-0.45 % 50 ml/hour, Morphine Sulfate (Concentrate) Solution 100 MG/5ML Give 0.25 ml.
Current Illness: The patient was re-admitted to the nursing home on 9/28/21 after a lengthy hospitalization. Th The patient had advanced end-stage dementia, failure to thrive and dysphagia. The resident was on comfort measures with supportive care.
Preexisting Conditions: The resident had a history of osteomyelitis to foot/ankle wound and hypertension.
Allergies: Atenolol
Diagnostic Lab Data: The patient was a DNR receiving comfort care. No tests were completed.
CDC Split Type:

Write-up: Reporting to VAERS d/t death less than a week following vaccination. The resident was comfort measures and receiving supportive care in a nursing home. The resident was no longer able to swallow food d/t end-stage dementia and dysphagia. The resident did not exhibit side effects of the vaccination. On 11/6/21 at 2:07PM the patient was ill looking, respirations were non-labored and regular. At 3:30PM the patient was pale, and without respirations or a heart beat.


VAERS ID: 1850904 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-05
Onset:2021-05-07
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031B21A / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown pt possibly passed from covid complications.


VAERS ID: 1850927 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-08
Onset:2021-10-15
   Days after vaccination:221
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029A21A / 2 - / IM

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: 2021-10-30
   Days after onset: 15
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. Second dose given on 3/8/2021. Tested positive for covid on 10/15/2021. Admitted to Medical Center on 10/21/2021. Expired on 10/30/2021 while still hospitalized.


VAERS ID: 1850960 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-11-03
Onset:2021-11-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Cardiac index decreased, Cardiogenic shock, Catheterisation cardiac abnormal, Chronic obstructive pulmonary disease, Condition aggravated, Coronary artery occlusion, Death, Essential hypertension, Lactic acidosis, Multiple organ dysfunction syndrome, Pneumonia, Respiratory failure
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol HFA, clonidine, lamictal, pravastatin, gabapentin, erenumab, ubrogepant, cyclobenzaprine, vitamin d3, fluoxetine, omeprazole, lisinopril, aspirin daily, anoro Ellipta, eletriptan, hydroxyzine, topiramate, zomitriptan nasal spray
Current Illness: cough, body aches, SOB with exertion
Preexisting Conditions: COPD, tobacco use, anxiety/depression, bipolar, chronic back pain, hypertension, dyslipidemia, migraines, carotid stenosis
Allergies: amoxicillin, codeine, erythromycin, solu-medrol, sulfa, tramadol
Diagnostic Lab Data: cardiac index less than 1.5 on epi 8 and levo 70, hypoxemic respiratory failure, lactic acidosis. Cardiac catheterization showed occluded left dominant circumflex. Patient was evaluated for ECMO but felt to be a poor candidate due to her advanced multiorgan dysfunction and proceeding medical comorbidities.
CDC Split Type:

Write-up: Admitted to hospital on 11/5/2021 with community acquired pneumonia, COPD exacerbation, benign essential htn, on 11/5/2021. On 11/7 developed acute STEMI, likely RV infarct at ~8am. Code STEMI, transferred to hospital for emergent cardiac cath, possible PCI. Noted to have cardiogenic shock, respiratory failure, Acute mycodardial infarct, lactic acidosis, which was deemed non-survivable. Expired at 1:25 pm on 11/7/2021


VAERS ID: 1850995 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-13
Onset:2021-10-08
   Days after vaccination:209
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029A21A / 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: 2021-11-04
   Days after onset: 27
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 3/13/2021. Tested positive for covid on 10/8/2021. Admitted to Hospital on 10/29/2021. Expired on 11/04/2021 while still hospitalized.


VAERS ID: 1851033 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-05-25
Onset:2021-10-18
   Days after vaccination:146
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 UN / IM

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: 2021-10-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC Split Type:

Write-up: PT PASSED FROM COMPLICATIONS RELATED TO COVID


VAERS ID: 1851055 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-10-25
Onset:2021-11-02
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0746C21A / 3 - / -

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: 2021-11-08
   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:
CDC Split Type:

Write-up: case fully vaccinated with moderna. Second dose administered on 2/12/2021. Also had booster dose of moderna on 10/25/2021. Tested positive for COVID on 11/2/2021. Admitted to Hospital 11/02/2021. Expired on 11/08/2021 while still hospitalized.


VAERS ID: 1851121 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-09-22
   Days after vaccination:203
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Bradycardia, COVID-19, Cough, Dyspnoea, Endotracheal intubation, Haematemesis, Haematochezia, Intensive care, Nausea, Pulse absent, Respiratory arrest, Respiratory failure, Resuscitation, SARS-CoV-2 test positive, Unresponsive to stimuli, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt in ED with a positive COVID test; dx''d with respiratory failure; pt c/o N/V, SOB, cough; experienced 3 episodes of hematochezia; transferred to ICU; pt became unresponsive and vomited up blood; was intubated; bradycardia and no pulse; CPR started; pt never regained pulse or respirations


VAERS ID: 1851149 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-05-15
Onset:2021-11-02
   Days after vaccination:171
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017C21A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Back pain, COVID-19, COVID-19 pneumonia, Cardiomegaly, Chest X-ray abnormal, Chest discomfort, Chest pain, Cough, Death, Dyspnoea, Dyspnoea exertional, Eye movement disorder, Pain, Peripheral swelling, Positive airway pressure therapy, Pulmonary artery wall hypertrophy, Pulse absent, Pyrexia, Respiratory failure, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   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: Tylenol 1000mg nightly, Norvasc 5mg, Aspirin 81mg, Vitamin D3, Aricept 5mg, Gabapentin 600mg, Cozaar 50mg, Melatonin, Namenda 5mg, Centrum vitamin, Zoloft 25mg, Zyloprim 300mg, Indocin 25mg
Current Illness: OSA, HLD, HTN, Cerbral aneurysm.
Preexisting Conditions: OSA, HLD, HTN, Cerbral aneurysm.
Allergies: Bee venom
Diagnostic Lab Data: COVID-19 PCR positive 11/1/21 Chest Xray 11/2/21: Slightly enlarged right main pulmonary artery. Adenopathy not region not excluded. Cardiac silhouette slightly enlarged. Some of this may be projectional. Lungs show no consolidation. Minimal blunting of both costophrenic angles is seen.
CDC Split Type:

Write-up: Patient was admitted to reporting hospital on 11/2/21 and died on 11/6/21. Patient arrived with approx 5-6 days of chest tightness, dyspnea on exertion, and perhaps some radiation of this feeling to the left side of sternum and back. Patient had fever, cough, shortness of breath, chest pain and leg swelling. Patient was transferred to our hospital as a known COVID positive patient. COVID-19 pneumonia with hypoxic respiratory failure and possible CHF. On the morning of 11/6/21, patient was awake and alert and was talking to the nurse after he had taken his Bipap mask off to transition to Vapotherm, when he suddenly became unresponsive and his eyes rolled back. He subsequently lost his pulse as well. Patient was noted to be DNR and thus aggressive resuscitative measures were not carried out.


VAERS ID: 1851846 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-10-27
Onset:2021-11-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-11-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / 3 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, Blood bicarbonate decreased, Blood electrolytes, Blood glucose decreased, Blood glucose increased, Blood lactic acid, Blood magnesium increased, Blood pH decreased, Blood phosphorus increased, COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Condition aggravated, Death, Diarrhoea, Hypoacusis, Hypoglycaemia, Lactic acidosis, Mental status changes, Respiratory arrest, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Lactic acidosis (narrow), 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), Dementia (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hearing impairment (narrow), Chronic kidney disease (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Hypoglycaemia (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol HFA (PROVENTIL HFA, VENTOLIN HFA, PROAIR HFA) 108 (90 Base) MCG/ACT inhaler alendronate (FOSAMAX) 70 MG tablet atorvastatin (LIPITOR) 40 MG tablet benzonatate (TESSALON) 100 MG capsule bisoprolol (ZEBETA) 5 MG tablet Blood Glucose
Current Illness: 10.4.21: Patient reported to PCP having diarrhea after every meal for past 3 months 10.27.21: Seen at PCP for complaint of diarrhea 11.1.21: Urgent Care - diarrhea, altered mental status 11.1.21 - 11.3.21: Hospital admission - hypoglycemia, diarrhea, acute hypoxemic respiratory failure, pneumonia due to COVID-19 11.7.21: Emergency department - patient EXPIRED.
Preexisting Conditions: Hyperglycemia Dyslipidemia Coronary artery disease OSA (obstructive sleep apnea) Hypothyroid Osteoarthritis Encounter for monitoring of systemic steroid therapy Osteopenia Insomnia w/ sleep apnea COPD, moderate (HCC) Cardiomyopathy, ischemic DOE (dyspnea on exertion) Hypertension, benign Hyperlipidemia Myocardial infarction (HCC) Type 2 diabetes mellitus with diabetic polyneuropathy, with long-term current use of insulin (HCC) Rheumatoid arthritis with negative rheumatoid factor, involving unspecified site (HCC) Bilateral hearing loss, unspecified hearing loss type Coronary artery chronic total occlusion Osteoarthritis of right knee, unspecified osteoarthritis type Bradycardia, drug induced Iatrogenic hypotension Knee osteoarthritis Leukocytosis Acute pain of right knee Encounter for other orthopedic aftercare Knee stiffness, right Difficulty in walking involving lower leg joint Status post total knee replacement, unspecified laterality Exudative age-related macular degeneration of left eye with active choroidal neovascularization (HCC) Chronic disease anemia Prostatism LADA (latent autoimmune diabetes in adults), managed as type 1 (HCC) PAD (peripheral artery disease) (HCC) Diabetic polyneuropathy associated with type 1 diabetes mellitus (HCC) Paroxysmal atrial fibrillation (HCC) PAF (paroxysmal atrial fibrillation) (HCC) Pneumonia due to COVID-19 virus
Allergies: DuloxetineUnknown KeflexOther
Diagnostic Lab Data: Lactic Acid 10.8 High Panic pH Venous 7.06 Low Panic Phosphorus Level 9.6 High Magnesium Level 3.0 HCO3 9 Low Panic Glucose Level 562 pH Arterial 6.95 Low Panic
CDC Split Type:

Write-up: PATIENT NOW DECEASED (11.7.21) - presented to ED (altered mental status - coded; expired) ED - DX: acute respiratory failure with hypoxia; COVID-19; respiratory arrest; lactic acidosis Hospitalized (11.1.21 - 11.3.21); COVID-19 positive (11.1.21); Fully vaccinated PLUS booster Date of Admission: 11/1/2021, Hospital Day: 3 Discharge Date: 11/3/2021 PRESENTING PROBLEM: Hypoglycemia [E16.2] Diarrhea, unspecified type [R19.7] Acute hypoxemic respiratory failure due to COVID-19 (HCC) [U07.1, J96.01] Pneumonia due to COVID-19 virus [U07.1, J12.82] HOSPITAL COURSE: Patient is a 87 y.o. male who presents today with diarrhea . History obtained from medical record and patient. Patient is extremely hard of hearing and severely limiting obtaining history , does not have hearing aids with him . Niece and nephew now on floor however are not informed as to current medical issues. In ed on arrival found to be hypoxic to 87% placed on 3 lnc , cxr findings consistent with covid infection . Tested positive for covind 19 . Blood glucose on arrival found to be 34 , subsequent testin with rather rapid rise with a meal only . He was given decadron in ed . Hospitalist service consulted for admission further evaluation. Patient was continued on supplemental oxygen and administered dexamethasone and Remdesivir. He was weaned to room air with adequate oxygenation. Patient diarrhea improved likely related to COVID-19. PT/OT evaluated advised home with assist home health PT/OT. Case manager was consulted to arrange for outpatient services. Electrolytes were monitored and repleted throughout the admission. Patient was symptomatic lead treated with antitussives, antiemetics, analgesics p.r.n. patient clinically improved and hemodynamically stable for discharge. Discussed plan of care discharge with patient including outpatient follow-up PCP in 7 days. He will continue 3 additional days of dexamethasone and antitussives. Patient was advised to follow-up outpatient ENT for evaluation of cochlear implant. Patient was advised given difficulties with hearing to stop driving until cochlear implant issues addressed. Patient voiced understanding and was agreeable with the plan of care and discharge. CM arranged for patients niece to pick patient up.


VAERS ID: 1853219 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Georgia  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: 5 days after my friends brother took the vaccine he died; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (5 days after my friends brother took the vaccine he died) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received 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. Company Comment: This case concerns a male patient (age not provided) with no relevant medical history, who experienced the unexpected event of Death. The event occurred approximately 5 days after a dose of mRNA-1273 (Moderna Covid-19 vaccine); It''s unknow if it was the first or second dose. The rechallenge was not applicable. Limited information provided precludes a complete medical or causal assessment of this case. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report. This case was linked to US-MODERNATX, INC.-MOD-2021-369784 (E2B Linked Report).; Sender''s Comments: This case concerns a male patient (age not provided) with no relevant medical history, who experienced the unexpected event of Death. The event occurred approximately 5 days after a dose of mRNA-1273 (Moderna Covid-19 vaccine); It''s unknow if it was the first or second dose. The rechallenge was not applicable. Limited information provided precludes a complete medical or causal assessment of this case. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report. US-MODERNATX, INC.-MOD-2021-369784:MOD21-158695/Same reporter; Reported Cause(s) of Death: brother took the vaccine he died


VAERS ID: 1853227 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / OT

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

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

Write-up: Both my father and my mother took your Moderna Covid vaccine and both died a few weeks later; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Both my father and my mother took your Moderna Covid vaccine and both died a few weeks later) in a male patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 039K20A) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided No concomitant products were reported. No treatment drugs were reported. Company Comment: This case concerns a male patient (age not provided) with no relevant medical history, who experienced the unexpected event of Death (Nos). The event occurred approximately few weeks (unspecified) after a dose of mRNA-1273 (Moderna Covid-19 vaccine), It''s unknwon if it was the first or second dose. The rechallenge was not applicable. Limited information provided precludes a completed medical or causal assessment of this case. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report. This case was linked to MOD-2021-370921 (Patient Link).; Sender''s Comments: This case concerns a male patient (age not provided) with no relevant medical history, who experienced the unexpected event of Death (Nos). The event occurred approximately few weeks (unspecified) after a dose of mRNA-1273 (Moderna Covid-19 vaccine), It''s unknwon if it was the first or second dose. The rechallenge was not applicable. Limited information provided precludes a completed medical or causal assessment of this case. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1853228 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / UNK - / OT

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

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

Write-up: Both my father and my mother took your Moderna Covid vaccine and both died a few weeks later; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Both my father and my mother took your Moderna Covid vaccine and both died a few weeks later) in a female patient of an unknown age who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch no. 039K20A) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. Not Provided No Concomitant medication was provided. No treatment medication was provided. Company Comment: This case concerns a female patient with no relevant medical history, who experienced the unexpected event of Death (Nos). The event occurred approximately few weeks (unspecified) after a dose of mRNA-1273 (Moderna Covid-19 vaccine); It''s unknown if it was first or second dose. The rechallenge was not applicable. Limited information provided precludes a complete medical or causal assessment of this case. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report. This case was linked to MOD-2021-370905 (Patient Link).; Sender''s Comments: This case concerns a female patient with no relevant medical history, who experienced the unexpected event of Death (Nos). The event occurred approximately few weeks (unspecified) after a dose of mRNA-1273 (Moderna Covid-19 vaccine); It''s unknown if it was first or second dose. The rechallenge was not applicable. Limited information provided precludes a complete medical or causal assessment of this case. The benefit-risk relationship of mRNA-1273 (Moderna Covid-19 vaccine) is not affected by this report.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1853611 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-06-19
Onset:2021-10-27
   Days after vaccination:130
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / 1 AR / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009D21A / 2 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Acute respiratory distress syndrome, Atrial fibrillation, COVID-19, COVID-19 pneumonia, Condition aggravated, Death, Debridement, Diabetic ketoacidosis, Endotracheal intubation, Extubation, General physical health deterioration, Hypercapnia, Hypervolaemia, Hypoxia, Infection, Intensive care, Mechanical ventilation, Necrotising fasciitis, Paralysis, Rash, Resuscitation, SARS-CoV-2 test positive, Septic shock, Supraventricular tachycardia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), 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: 2021-10-31
   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: ascorbic acid (VITAMIN C) 1000 MG tablet atorvastatin (LIPITOR) 20 MG tablet hydrochlorothiazide (HYDRODIURIL) 50 MG tablet metFORMIN (GLUCOPHAGE) 500 MG tablet metoprolol succinate-XL (TOPROL-XL) 100 MG 24 hr tablet Omega-3 Fatty Acids (FI
Current Illness:
Preexisting Conditions: Sleep apnea Acute respiratory failure with hypoxia Primary hypertension Venous stasis ulcer of left calf limited to breakdown of skin with varicose veins Peripheral venous insufficiency PAF (paroxysmal atrial fibrillation) Morbidly obese Necrotizing fasciitis Septic shock Tobacco dependence Type 2 diabetes mellitus without complication, without long-term current use of insulin Hyperlipidemia, unspecified hyperlipidemia type DKA, type 2, Diabetic ulcer of toe of left foot associated with type 2 diabetes mellitus
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospitalized 10/26/2021; COVID-19 positive 10/27/2021, fully vaccinated BRIEF OVERVIEW: Discharge Provider: DOCTOR Primary Care Physician at Discharge: DOCTOR Admission Date: 10/26/2021 DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Septic shock HOSPITAL COURSE: Patient is a 60 year old male with PMH of HTN, HLD, DMII, super morbid obesity who initially presented to outside hospital with a 2-3 day history of right groin rash and found to have necrotizing fascitis. Patient underwent his initial debridement at outside hospital prior to transferring to Butterworth SICU. Of note, patient was hypoxic prior to intubation and found to have COVID-19 pneumonia which was treated with steroids and Remdesivir. Patient was intubated and sedated upon transfer and had pressor requirements due to septic shock from the necrotizing fascitis. Patient underwent IV abx therapy, resuscitation with fluids and pressors, and ventilator support. Patient underwent a second debridement for source control the following day. Patient''s ICU course was also complicated by Diabetic ketoacidosis for which he was on endotool with DGMS following, AKI, and SVT with RVR. During his ICU course, source control was obtained from his infection, however patient''s respiratory status continued to decline with ARDS. Patient on high ventilator requirements of 90-100% Fi02 with hypercarbia due to large body habitus with chest wall restrction, COVID-19, and volume overload due to resuscitation for septic shock. Patient was paralyzed during his course to assist with ventilation however this did not improve his respiratory status. Pulmonary critical care was consulted however patient not a candidate for ECMO given his BMI. Discussion was held with family (sister) on 10/31/21 given poor prognosis even with aggressive therapy. Comfort care was ultimately decided upon per family. Paralyzation was stopped and patient was subsequently extubated and expired on 10/31/2021 at 1354


VAERS ID: 1853848 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-17
Onset:2021-10-16
   Days after vaccination:241
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 LA / IM

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-10-24
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was tested for COVID 19 for preprocedural colonoscopy. Patient was positive and initially had no symptoms. Patient became symptomatic and presented to the hospital where he was hospitalized. Patient passed away from complications on 10/24/2021.


VAERS ID: 1854245 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-09-01
Onset:2021-09-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 052E21A / 1 - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute respiratory failure, Ascites, Blood potassium decreased, Cardiac arrest, Death, Dyspnoea, Hypokalaemia, Pneumonia, Respiratory failure, Septic shock
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-26
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: overweight
Allergies:
Diagnostic Lab Data: Death Certificate states cause of death: Acute Hypercapnic Hypoxic Respiratory Failure, Cardia Arrest, Critical Hypokalemia, Septic Shock
CDC Split Type:

Write-up: Shortness of breath, Ascitis, low potassium, cardiac arrest, pneumonia


VAERS ID: 1854316 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-01
Onset:2021-09-28
   Days after vaccination:239
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Endotracheal intubation, General physical health deterioration, Hypoxia, Mechanical ventilation, Positive airway pressure therapy, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-08
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt to ED with worsening SOB, hypoxic, placed on HF O2 with intermittent BiPAP; hx of squamous cell carcinoma of right upper lobe, post chemo radiation, COPD, CKD; pt''s condition worsened, he went into respiratory distress requiring intubation and mechanical ventilation; condition continued to deteriorate; was placed on comfort care and extubated; pt died in the hosp


VAERS ID: 1854317 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-10-20
Onset:2021-11-07
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 035C21A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Blood creatinine increased, Cardiac arrest, Cardiac failure congestive, Cardiomegaly, Chest pain, Condition aggravated, Fall, Respiration abnormal, Respiratory arrest, Urinary tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amLODIPine Besylate Tablet 10 MG, Aspirin 81 mg Tablet Delayed Release, Atorvastatin Calcium Tablet 40 MG, Lantus Solution (Insulin Glargine) 10 units, Losartan Potassium Tablet 100 MG, Multi-Vitamin/Minerals Tablet, Potassium Chloride ER T
Current Illness: Patient was admitted to the nursing home on 10/27/21 following a hospitalization. The resident was hospitalized for chest pain, a fall at home and generalized weakness. The patient was planning to admit to hospice prior to the ER visit. While admitted at the hospital the patient was noted to have severe cardiomegaly, CHF, UTI and elevated serum creatinine. He required supplemental oxygen at 2L/min at all times. The resident received the seasonal influenza vaccine prior to admission on 10/21/2021-unknown manufacturer or lot number.
Preexisting Conditions: Diabetes, CHF, pacemaker placement, COPD, atrial fibrillation, chronic back pain, hypertensive heart and chronic kidney disease, hyperlipidemia, edema, history of myocardial infarction
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: On 11/7/2021 the patient was observed to be in bed with absence of respirations and heartbeat. The patient was a DNR upon admission.


VAERS ID: 1854367 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-15
Onset:2021-09-19
   Days after vaccination:188
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Cardiac arrest, Cardio-respiratory arrest, Death, Life support, Pulse abnormal, SARS-CoV-2 test positive, Troponin increased, Urinary tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), 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: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt transferred from hospital for evaluation of elevated troponin; pt found to have a positive COVID test and UTI; while pt was being assessed he went into cardio respiratory arrest; ACLS protocol was performed and a pulse was regained; spoke with pt''s wife and she requested no future CPR; pt arrested again and died in the hospital


VAERS ID: 1854402 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-22
Onset:2021-08-28
   Days after vaccination:187
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Death, Dyspnoea, General physical health deterioration, Hypotension, Positive airway pressure therapy, Renal impairment, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), 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 (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-08
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
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: pt transferred to Hospital from PCP; pt was to receive IV infusion of Regeneron (for positive COVID test) but was dyspneic and O2 sats in the 70s on RA; was transferred from Hospital to another Hospital and found to have COVID pneumonia; placed on NRB mask and eventually BiPAP; given steroids and inhalers; no remdisivir due to renal function; pt''s condition deteriorated in spite of treatments; was placed on comfort care measures when pt experienced hypotension and she passed away in the hospital


VAERS ID: 1854431 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-11-03
Onset:2021-11-07
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 27C21A / 3 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypopnoea, Tachypnoea, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: UTI, MRSA left eye, n/v, multiple wounds, esophageal biopsies, tachypnea, and gas.
Preexisting Conditions: emiplegia and hemiparesis following cerebral infa... 5/14/2021 Obstructive and reflux uropathy, unspecified 5/14/2021 Urinary tract infection, site not specified 8/27/2021 Encounter for surgical aftercare following surgery... 5/14/2021 Acquired absence of other specified parts of diges... 8/17/2021 Cholecystitis, unspecified 5/14/2021 Weakness 5/17/2021 Unspecified abnormalities of gait and mobility 8/18/2021 Dysphagia, oropharyngeal phase 8/18/2021 Adult failure to thrive 5/14/2021 Chronic diastolic (congestive) heart failure 5/14/2021 Unspecified dementia without behavioral disturbanc... Essential (primary) hypertension 5/14/2021 Hyperlipidemia, unspecified 5/14/2021 Benign prostatic hyperplasia with lower urinary tr.. Retention of urine, unspecified 5/14/2021 Major depressive disorder, single episode, unspeci... 5/14/2021 Major depressive disorder, recurrent, unspecified 5/14/2021 Gastro-esophageal reflux disease without esophagit... 5/14/2021 Old myocardial infarction 5/14/2021 Cataract extraction status, unspecified eye 5/14/2021 Vitamin D deficiency, unspecified 5/14/2021 Muscle weakness (generalized) 5/16/2021 Cognitive communication deficit 5/18/2021
Allergies:
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: RESIDENT BECAME TACHYPNEA, SHALLOW BREATHING AND NON-RESPONSIVE PROUNCED DECEASED PER RN AS ORDERED PER MD


VAERS ID: 1854443 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-09-19
   Days after vaccination:226
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Cerebrovascular accident, Cough, Death, Dyspnoea, Malaise, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-03
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt with positive COVID test x 1 wk; presents to ED with increase in SOB, cough, fever, malaise; treated with corticosteroids, antiviral, bronchodilators; hx of non-Hodgkins lymphoma, treated with immune therapy; O2 supplementation of BiPAP and Vapotherm NRB; suffered left MCA CVA while in hospital; DNI and no PEG tube placement; comfort measures; pt died in the hospital with daughter at her side


VAERS ID: 1854473 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-24
Onset:2021-11-05
   Days after vaccination:254
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ELP264 / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EN6200 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-05
   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: CLL; DM2; CAD; a-fib; HTN; HLD; Hx of CVA
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: fully vaccinated-covid releated death


VAERS ID: 1854488 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-31
Onset:2021-10-18
   Days after vaccination:201
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, COVID-19, Death, Hypoxia, Intensive care, Oxygen saturation decreased
SMQs:, Asthma/bronchospasm (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-03
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 17 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Carvedilol 12.5 mg BID, Insulin glargine 38 units QD, Tylenol Additional information for Item 9: PRN, Aspirin 81 mg QD, Clonidine 0.2 mg BID, Famotidine 20 mg QD, Furosemide 40 mg QD, Losartan 25 mg QD, Mycophenolate 360 mg BID, Prednisone
Current Illness:
Preexisting Conditions: Aortic valve prosthesis, Atrial fibrillation, CHF, CAD, DM type 2, Hyperlipidemia, Renal transplant, Hypertension
Allergies: Adhesive (Rash)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death."Patient received "Patient received Moderna Vaccines on 3/3/2021 and 3/31/2021. Admitted 10/18 as transfer from an outside hospital. Transferred to ICU 10/19 due to worsening hypoxia. Placed on high-flow nasal cannula in ICU and had stable O2 saturations followed by worsening hypoxemia. Per patient and family request transitioned to DNR/DNI. Patient required non-rebreather mask on top of his high-flow nasal cannula in order to maintain O2 saturations. Remained on the settings for several days without significant improvement. On 11/01/2021 Epoprostenol with some improvement for 48 hours, O2 saturations up to 100%. Attempts were made to Additional information for Item 18: wean off of non-rebreather mask, however, patient immediately desaturated to less than 80%. Patient had sudden decrease in oxygenation the morning of 11/03/2021 and was never able to achieve O2 saturations greater than 89%. Patient continue with significant hypoxemia in the afternoon followed by bradycardic episode, expired at 2:15 p.m.


VAERS ID: 1854556 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-04-29
Onset:2021-11-08
   Days after vaccination:193
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008C21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes type 1, thyroid cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: vaccine Dose 1 given 3/30/2021 Moderna Lot # 020B21A Pt died in the ER following a motor vehicle accident


VAERS ID: 1854576 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-02
Onset:2021-11-08
   Days after vaccination:251
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA N/A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Heart failure, COPD, hypertension, diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine dose 1 given 2/2/2021, Lot # N/A Moderna Patient died of Covid 19, heart failure on 11/8/2021


VAERS ID: 1854606 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Decreased appetite, Diarrhoea, Dyspnoea, Loss of consciousness, Mechanical ventilation, Nausea, Type 1 diabetes mellitus
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-19
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: anti rejection medication, insulin, hydroxychloroquine
Current Illness:
Preexisting Conditions: Kidney transplant patient, diabetic, rheumatoid arthritis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: loss of appetite, nausea, diarrhea, within 1st day. passed out on day 6 - cardio Dr said was an effect of low insulin levels. By day 9 she was having difficulty breathing. Was admitted to hospital that day for oxygen. 5 days after entering hospital was placed on ventilator. Died 14 days later.


VAERS ID: 1854762 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Blood disorder, Blood iron decreased, Death, Immediate post-injection reaction, Intensive care
SMQs:, Haematopoietic cytopenias affecting more than one type of blood cell (broad), Hypersensitivity (narrow), Haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-04
   Days after onset: 96
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: None
Preexisting Conditions: Heart, High BP - all controlled by medications
Allergies: None
Diagnostic Lab Data: Full Blood Test Completed PRIOR TO Vaccine in Feb, prior to Vaccine, with no symptoms or signs of Leukemia
CDC Split Type:

Write-up: Immediate blood disorder; low iron, etc., which resulted in hospital critical care, then died 04Jun2021 of Acute Myeloid Leukemia


VAERS ID: 1854838 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-06-12
Onset:2021-10-02
   Days after vaccination:112
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043B21A / 1 LA / IM

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

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

Write-up: Death


VAERS ID: 1854890 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-10-27
Onset:2021-11-08
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-11-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017F21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Completed suicide
SMQs:, Suicide/self-injury (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-08
   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: Victoza, lisinopril, metformin, repaglinide, atorvastatin, nicoderm
Current Illness: Migraines
Preexisting Conditions: Diabetes mellitus Type 2, Obesity, essential hypertension, hyperlipidemia, migraine
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Suicide on 11/8/21


VAERS ID: 1857039 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: New York  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: 3 patient died; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of DEATH (3 patient died) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. Death occurred on an unknown date The cause of death was not reported. It is unknown if an autopsy was performed. It was reported that an oncologist informed to the reporter that few of her patient died out of 100-200 fully vaccinated probably caught COVID. And 3 patient died. They ran unspecified test on them had no protection from vaccine. No antibody found. No concomitant medications were reported. No treatment medications were reported. Company comment: This spontaneous case report concerns a subject of unknown age and gender that experienced the serious unexpected AESI event of Death after an unknown period of Moderna COVID-19 vaccine administration. The rechallenge is not applicable. The benefit-risk relationship of Moderna COVID-19 vaccine is not affected by this report; Sender''s Comments: This spontaneous case report concerns a subject of unknown age and gender that experienced the serious unexpected AESI event of Death after an unknown period of Moderna COVID-19 vaccine administration. The rechallenge is not applicable. The benefit-risk relationship of Moderna COVID-19 vaccine is not affected by this report; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1857591 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-06-12
Onset:2021-06-01
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 005C21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Ammonia, Coma, Cytogenetic analysis, Death, Fatigue, Haemodialysis, Haemofiltration, Intensive care, Ornithine transcarbamoylase deficiency, Tremor
SMQs:, Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Congenital, familial and genetic disorders (narrow), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-01
   Days after onset: 92
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: Simvastatin 40 MG PO QD Ezetimibe 10 MG PO QD Fenofibric Acid 135 MG PO QD Lisinopril 5mg PO QD Metoprolol Tartrate 100 MG PO QD
Current Illness:
Preexisting Conditions: Hx of early onset cardiovascular disease Dyslipidemia Hypertension
Allergies: NKDA
Diagnostic Lab Data: Genome sequencing showed the c.?106C$gA OTC and ABCA1 gene variants. 9/16/2021.
CDC Split Type:

Write-up: Pt started complaining to family of progressive fatigue, n/v, and tremor that started within days to 1 week after 2nd dose of Moderna. Saw PCP several times for progressive symptoms over the next 2-3 months. Presented to ICU after found down for up to 24 hours. Serum ammonia levels were found to be 436 on presentation. Despite CRRT/HD, ammonia scavengers, low protein diet, pt never woke from coma and expired after being placed on comfort care. Later found to have partial OTC deficiency with no prior episodes of hyperammonemia. Also, no known family hx of any urea cycle disorders.


VAERS ID: 1857715 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-02-08
Onset:2021-08-28
   Days after vaccination:201
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Sudden Cardiac Death


VAERS ID: 1857749 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-10-26
Onset:2021-11-01
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017F21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Altered state of consciousness, Death, Lethargy, Myocardial infarction
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-04
   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: prilosec, flagyl, doxycycline, xarelto, diltiazem, furosemide
Current Illness: h pylori
Preexisting Conditions: unknown
Allergies: beta blockers
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s husband stated she became lethargic on 11/01/2021 and was not aware of her surroundings, they called an ambulance and she was hospitalized, the patient passed away on 11/04/2021 with the cause of death stated as a heart attack per her husband.


VAERS ID: 1857772 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-24
Onset:2021-10-19
   Days after vaccination:237
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M02A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-02
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen prn, Alendronate 70 mg QWeek, Ascorbic Acid 1000 mg QD, Calcium Carbonate / Magnesium Carbonate QD, Cholecalciferol 8000 mg QD, Folic Acid 1 mg QD, Glucosamine/Chondroitin QD, Hydrochlorothiazide 12.5 mg QD, Losartan 50 mg QD,
Current Illness:
Preexisting Conditions: Osteoporosis, Hypertension, DM type 2, Rheumatoid Arthritis,
Allergies: Penicillin (Rash)
Diagnostic Lab Data: Positive COVID-19 on 10/19/2021using the Roche LIAT SARS assay 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 1/21/2021 and 2/24/2021. Patient was admitted for hypoxic respiratory failure due to COVID-19, which was complicated by GI Bleed and ultimately superimposed bacterial pneumonia. Patient was transitioned to comfort care on 11/1/2021 and expired on 11/2/2021.


VAERS ID: 1857978 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-08
Onset:2021-10-01
   Days after vaccination:207
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19 pneumonia, Hypotension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-09
   Days after onset: 39
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 39 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 10/1/21 for COVID pneumonia after presenting with hypotension in the setting of increased ostomy output. increasing oxygen requirements and eventually required initiation of HFNC.


VAERS ID: 1857987 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-11-01
Onset:2021-11-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 071F21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Headache, Malaise, Myocardial infarction, Pain in extremity, Pulmonary embolism, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Heart Attack-Severe, Additional Details: 11/1/21 received moderna booster and first flu shot ever 11/2 headache, didn''t feel well 11/3 pain in right leg- collapsed at md and couldn''t be revived. Mother describes him as healthy and no underlying conditions thought clot earlier this year and pt using asa. We are told md ruled death heart attack as a result of pulmonary embolism.


VAERS ID: 1858071 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-02
Onset:2021-10-29
   Days after vaccination:241
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acidosis, Ageusia, Alanine aminotransferase normal, Anion gap, Anisocytosis, Anosmia, Aspartate aminotransferase increased, Band neutrophil percentage increased, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood chloride normal, Blood creatinine increased, Blood culture, Blood glucose normal, Blood potassium increased, Blood sodium decreased, Blood urea increased, Brain natriuretic peptide normal, Bronchoscopy abnormal, C-reactive protein increased, COVID-19, COVID-19 pneumonia, Carbon dioxide normal, Cardio-respiratory arrest, Cardioversion, Central venous catheterisation, Chest pain, Chest tube insertion, Condition aggravated, Cough, Death, Depressed level of consciousness, Differential white blood cell count, Dyspnoea, Dyspnoea exertional, Endotracheal intubation, Fibrin D dimer, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Headache, Hypotension, Intensive care, International normalised ratio increased, Lung opacity, Lymphocyte morphology abnormal, Lymphocyte percentage, Mean cell volume increased, Metamyelocyte percentage, Monocyte percentage increased, Nausea, Neutrophil percentage decreased, Oxygen saturation decreased, Platelet count decreased, Platelet morphology abnormal, Polychromasia, Productive cough, Protein total decreased, Prothrombin time prolonged, Pulseless electrical activity, Red blood cell count decreased, Red blood cell microcytes present, Red blood cell nucleated morphology present, Red cell distribution width increased, SARS-CoV-2 test positive, Skin discolouration, Troponin I normal, Ventricular fibrillation, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Agranulocytosis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (broad), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (broad), Malignant lymphomas (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), 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: 2021-11-04
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prior to Admission Medications Outpatient Home Medications Taking? ASPIR-LOW 81 mg Oral TBEC DR Tab Sig: Take 1 tablet by mouth daily Amiodarone (PACERONE) 200 mg Oral Tab Sig: Take 1 tablet by mouth daily Atorvastatin (LIPITOR) 10 mg O
Current Illness:
Preexisting Conditions: history of COPD, HTN, HFrEF (last Ef 36% on TTE 2019), and OSA (on CPAP)
Allergies: Spironolactone - Hyperkalemia
Diagnostic Lab Data: Results for Patient as of 11/10/2021 12:02 10/29/2021 12:45 NA: 129 (L) K: 5.7 (H) CL: 98 (L) CO2: 24 BUN: 35 (H) CREAT: 1.50 (H) ANION GAP4 SERPL: 7 GLUC: 112 TROPONIN I: <0.02 LDH: TND BNP: 61 ALT: 19 AST: 38 ALKP: 89 TBILI: 0.9 GFR-AFRAM: 52 (L) GFR NONAFR AMER: 45 (L) COMMENT, GLOMERULAR FILTRATION RATE: SEE NOTE ALB: 3.7 CRP, SER QL: 10.8 (H) TP: 6.3 WBC: 8.4 RBC''S: 3.59 (L) HGB: 12.9 (L) HCT: 39.8 MCV: 111 (H) RDW, RBC: 17.2 (H) PLT: 62 (L) PLT''S, BLD QL, MAN: CONFIRMD METAMYELOCYTES % MAN CNT: 5 (H) MYELOCYTES % MAN CNT: 13 (H) NEUTROPHILS % MAN CNT: 37 (L) BAND''S % MAN CNT: 11 (H) LYMPHS % MAN CNT: 20 LYMPHS ATYPICAL % MAN CNT: 3 MONOS % MAN CNT: 11 ANISOCYTOSIS: 2+ (A) MACROS: 2+ (A) MICROCYTES: 1+ (A) POLYCHROMASIA: 1+ (A) RBC''S NUCLEATED %, BLD QN, MAN: 2 PLT''S MORPH: LARGE (A) DIFF PANEL: MAN DIFF PT: 16.8 (H) INR: 1.4 D-DIMER: <0.27 BLD CULT RSLT: Final Report... LUNGS: Right greater than left mid and lower lung zone patchy parenchymal opacity. MEDIASTINUM/OTHER: Normal cardiomediastinal silhouette.
CDC Split Type:

Write-up: Date of Admission: 10/29/2021 Date of Death:11/4/2021 Reason for Hospital Admission (Admitting Diagnosis): Covid-19 pneumonia Hospital Course and Significant Findings: Patient is a 76 Y male with a past medical history of COPD, HTN, HFrEF (last EF 36% on TTE 2019) who presents with 1-week hx of worsening SOB in setting of recently diagnosed COVID-19. Patient reports that he has had shortness of breath in last few years. He has a hx of COPD and was being followed by pulmonologists. However, last week after returning from a trip patient started having increasing SOB and cough productive of sputum. He reports that it has been gradually getting worse. He uses inhalers at home which minimally helped. He also took Robitussin which seemed to have greatly helped his cough. However, the SOB is now to the point that he has difficulty breathing w/movement and sometimes w/talking. These were associated w/loss of taste / smell, headache, and nausea. Patient denies vomiting, abdominal pain, diarrhea, fevers, chills, or night sweats. Patient reports he may have been exposed to COVID + patient while on a trip where he was attending mother''s funeral. He and other attendees ended up being positive for COVID a few days after returning from trip. On admission, patient started on Remdesivir (10/29-11/2), Decadron 6 mg x1 (10/29), but due to escalation of oxygen requirements, steroids were changed to Solumedrol 125 mg BID (10/29 PM-11/1 AM), Solumedrol 60 mg BID (11/1 PM-11/2), and patient given dose of Tocilizumab 8 mg/kg x1 after discussion w/pulmonology (Dr.). Pt''s O2 requirements continued to increase, 11/1 requiring 10 L. 11/2 was on 7 L, but desaturated to high 80s with any movement or speech. On 11/4 AM, pt complained of significantly increased chest pain which limited his breathing, was placed on max oximizer. Status continued to decline and transitioned to max HFNC with NRB (60 L), and ICU was consulted. On examination, pt was obtunded, unable to clear secretions, appeared dusky, satting in high 80s on HFNC w/ NRB. Anesthesia was called for intubation. Pt was intubated, bagged, transferred to ICU. Upon arrival to ICU, pt went into PEA arrest, code blue was called. Converted to vfib, then shock administered and pt had ROSC. Central line, arterial line chest tube were placed and pressors, sedation, paralytics initiated. Pt continued to be hypotensive with worsening O2 saturations on max pressors. Bronchoscopy revealed significant blood. Pt was severely acidotic, hypotension worsening despite pressors. Discussed w/ family pt''s imminent passing and was made DNR/DNI, passed at 1500. Complications: none


VAERS ID: 1858818 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-11-09
Onset:2021-11-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 058F21A / 3 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Zinc, Vitamin D, warfarin, topiramate, lovastatin, terazosin, metformin, glipizide, escitalopram, finasteride, clonazepam,
Current Illness: none
Preexisting Conditions: diabetes, enlarged prostate, history of stroke, tremor
Allergies: penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Do not have exact adverse events -was told by facility that patient passed away in his sleep.


VAERS ID: 1860168 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-09-20
Onset:2021-10-27
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046C21A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-30
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Died; Inappropriate schedule of vaccine administered; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (Died) in a 58-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 076C21A and 046C21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On 20-Sep-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 27-Oct-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 27-Oct-2021, the patient experienced INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (Inappropriate schedule of vaccine administered). The patient died on 30-Oct-2021. The cause of death was not reported. It is unknown if an autopsy was performed. At the time of death, INAPPROPRIATE SCHEDULE OF PRODUCT ADMINISTRATION (Inappropriate schedule of vaccine administered) had resolved. No concomitant medication provided. 1st dose was given on 20Sep2021 with lot number 046C21A. Reporter states that she was fine with no illnesses prior to getting the vaccine. Company Comment: This case concerns a 58-year-old, female patient with no relevant medical history, who experienced the unexpected serious fatal adverse event of death. Inappropriate schedule of product administration was considered an additional event. The event death occurred approximately 1 month and 10 days after the second dose of Moderna COVID-19 vaccine with fatal outcome. Death occurred on 30-Oct-2021 and no autopsy results were available at the time of the report. Cause of death was reported as unknown. The rechallenge was not applicable due to the fatal outcome. The benefit-risk relationship of Moderna COVID-19 vaccine is not affected by this report.; Sender''s Comments: This case concerns a 58-year-old, female patient with no relevant medical history, who experienced the unexpected serious fatal adverse event of death. Inappropriate schedule of product administration was considered an additional event. The event death occurred approximately 1 month and 10 days after the second dose of Moderna COVID-19 vaccine with fatal outcome. Death occurred on 30-Oct-2021 and no autopsy results were available at the time of the report. Cause of death was reported as unknown. The rechallenge was not applicable due to the fatal outcome. The benefit-risk relationship of Moderna COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1860741 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-11-10
Onset:2021-11-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013F21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardioversion, Death, Endotracheal intubation, Full blood count, Intraosseous access placement, Metabolic function test, Resuscitation, Troponin, Unresponsive to stimuli
SMQs:, Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: abriaterone, aspirin, atorvastatin, chlorthalidone, vitamin d3, plavix, denosumab, docusate, flonase, eligard, lisinopril, metoprolol, multivitamin, naproxen, prednisone
Current Illness: Prostate cancer
Preexisting Conditions: prostate cancer, pacemaker, CAD, first degree heart block, essential hypertension, PVD, PAD
Allergies: no known allergies
Diagnostic Lab Data: CBC, CMP, troponin 11/10/2021
CDC Split Type:

Write-up: patient received covid booster shot, became unresponsive. Bystanders initiated CPR with AED. Shocks administered. EMS paged with paramedic intercept. Patient intubated, I/O placed. arrived to ED. Pronounced at 1754


VAERS ID: 1861051 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-31
Onset:2021-11-07
   Days after vaccination:221
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025B21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Hypoxia, Lethargy, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-08
   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: allopurinol (ZYLOPRIM) 100 MG tablet amLODIPine (NORVASC) 5 MG tablet aspirin EC (HALFPRIN) 81 MG tablet Cholecalciferol (VITAMIN D3) 2000 UNIT CAPS Cranberry 500 MG capsule diclofenac (VOLTAREN) 1 % GEL GEL ferrous sulfate (FEOSOL, 65 FE,)
Current Illness: None known
Preexisting Conditions: Hypokalemia CAD (coronary artery disease) HTN (hypertension), benign Goiter OA (osteoarthritis) Type II or unspecified type diabetes mellitus without mention of complication, not stated as uncontrolled Sciatica Pure hypercholesterolemia Elevated troponin Dyspnea CKD (chronic kidney disease) Decreased activities of daily living (ADL) UTI (urinary tract infection) Abnormal uterine bleeding Insomnia Dementia (HCC) Sepsis (HCC) HAP (hospital-acquired pneumonia) Facial droop Anemia Edema
Allergies: None known
Diagnostic Lab Data: COVID-19 test positive on 11/7/2021.
CDC Split Type:

Write-up: Patient presented to emergency department on 11/7/2021 for evaluation of hypoxia and fevers. Daughter reported patient has been increasingly lethargic for past week and developed a dry cough. Patient was found to be COVID-19 positive. She was evaluated by critical care for admission due to condition, but decision was made to make patient comfort care measures only due to severity of disease. Patient expired on 11/8/2021 from complications of COVID-19 infection.


VAERS ID: 1861248 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-11-09
Onset:2021-11-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 058F21A / 3 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Heart Failure, Chronic Kidney Disease Stage 4 (severe) Type 2 Diabetes, Heart dz
Allergies: Bactrim
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was end stage dialysis last dialysis was on Friday Nov 5th she refused to go to dialysis on Monday Nov 8th. Patient received vaccine on 11/09/2021 and on 11/10/2021 was unresponsive at 7am sent to ER and expired.


VAERS ID: 1861298 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-06-09
Onset:2021-11-03
   Days after vaccination:147
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient expired 11/3/2021


VAERS ID: 1861486 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-04-02
Onset:2021-09-08
   Days after vaccination:159
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 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: 2021-09-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 29 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol Xanax Brovana Dulcolax Pulmicort Dextrose Diclofenac sodium enoxaparin famotidin furosemide Apresoline Insulin Zofran Pericolace Metoprolol succinate Venlafaxine XR
Current Illness: Unknow
Preexisting Conditions: Acute renal failure Lactic acidosis diabetes pulmonary hypertension COPD Obstructive sleep apnea CAD
Allergies: Dilaudid Lisinopril
Diagnostic Lab Data: Positive COVID-19 PCR test on 7/27/2021
CDC Split Type:

Write-up: Patient had breakthrough infection and expired


VAERS ID: 1862380 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-11-10
Onset:2021-11-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039F21A / 3 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dizziness, Fatigue, 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: 2021-11-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: b.a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient felt dizzy and tired after the moderna booster. Afterwards, she fainted and passed away


VAERS ID: 1864497 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: My sister just dies from it; This spontaneous case was reported by a consumer and describes the occurrence of DEATH (My sister just dies from it) 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 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. No treatment information was provided. Most recent FOLLOW-UP information incorporated above includes: On 23-Feb-2021: Follow Up received include no new information; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1864914 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-03-30
Onset:2021-11-08
   Days after vaccination:223
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SC

Administered by: Private       Purchased by: ?
Symptoms: Acute pulmonary oedema, C-reactive protein increased, COVID-19, Death, Multiple organ dysfunction syndrome, Pneumonia
SMQs:, Cardiac 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), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-11
   Days after onset: 3
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: Unknown
Current Illness: Unknown
Preexisting Conditions: COPD, BPH, GERD, Dyslipidemia, hyperthyroidism, HTN, Anemia of chronic illness, iron deficiency and chronic kidney disease, cardiorenal syndrome, secondary hyperparathroidism, osteoarthritis
Allergies: None
Diagnostic Lab Data: CRP 6.50 MG/DL
CDC Split Type:

Write-up: Admitted into hospital on 11/8. Expired 11/11. Admitted with acute flash pulmonary edema, pneumonia and COVID. Experienced multisystem organ failure. Needed increase of oxygen.


VAERS ID: 1865279 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-10-29
Onset:2021-11-06
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNK / UNK UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Luvox, Lemectal
Current Illness: None
Preexisting Conditions: Elhers-Danlos, POTs
Allergies: None
Diagnostic Lab Data: Death
CDC Split Type:

Write-up: Death.


VAERS ID: 1865372 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-04-14
Onset:2021-08-08
   Days after vaccination:116
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042B21A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Agitation, COVID-19, Death, Endotracheal intubation, Oxygen saturation decreased, Respiratory failure, SARS-CoV-2 test positive, Shock
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-23
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PMH: CAD (CABG), DM, stage III CKD; in ED tests positive for COVID; dx''d with AHRF and AKI; no remdisivir given due to AKI; treated with IV steroids; intubated requiring up to 70 L O2 supplementation; agitation worsened; developed shock; given vasopressors, antibiotics; worsening O2 needs and increase of pressors; transitioned to comfort care and pt died in the hospital


VAERS ID: 1865446 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-05-26
Onset:2021-05-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002C21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: diabetes, hypertension, and heart disease (many years)
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: I am the epidemiologist reporting on behalf of 70 year-old male patient. Patient received two doses of the Moderna vaccine, according to immunization records. The first dose was on 4/23/21 and the second was on 5/26/2021. The patient was found dead at home on 5/28/2021 (2 days post second dose). The death certificate lists ?cardiopulmonary arrest? as the immediate cause of death secondary to ?diabetes, hypertension, and heart disease? (many years). No additional information is available.


VAERS ID: 1865447 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: North Dakota  
Vaccinated:2021-11-03
Onset:2021-11-06
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026D21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adverse event, Asthenia, Atrial fibrillation, Blood creatine phosphokinase MB, Blood creatine phosphokinase normal, Blood creatinine increased, Blood culture negative, Blood urea increased, C-reactive protein increased, Condition aggravated, General physical health deterioration, Hypotension, Klebsiella infection, Lethargy, Pneumonia klebsiella, Sepsis, Troponin I, Urinary tract infection, Urine analysis abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-09
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: propranolol 5 mg BID; torsemide 40 mg BID; pantoprazole 40 mg daily; gabapentin 200 mg TID; losartan 50 mg daily; simvastatin 20 mg; oxybutynin 5 mg ER daily; aspirin 81 mg daily; APAP 325 mg Q6H PRN; melatonin 5 mg nightly; loratadine 10 m
Current Illness: Patient had been experiencing some tremors and weakness.
Preexisting Conditions: Health failure; Hypertension; Hyperlipidemia; Atrial Fibrillation; Obstructive Sleep Apnea; Neuropathic Pain; Interstitial Lung Disease
Allergies: Sulfa antibiotics
Diagnostic Lab Data: Urine culture: $g100,000 colonies/mL Klebsiella pneumoniae (susceptibility showed now resistance). Blood cultures-neg. WBC-4.7; BUN-83; SCr-2.3; CRP-1.8; Troponin I, CKMB, CPK-neg;
CDC Split Type:

Write-up: Patient was brought to ER on 11/6/2021 due to severe weakness and lethargy. She was severly hypotensive with BP that could not be recorded, but she was also in Afib. She was given fluids and started on Zosyn for UTI/sepsis after urinalysis results were obtained. The patient continued to decline and the family decided to pursue comfort measures. The above adverse events may or may not be a result of the booster dose of vaccine, but per EUA provider is responsible to report serious adverse events irrespective of attribution to vaccination.


VAERS ID: 1865474 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-02-01
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Platelet count decreased, Radiotherapy
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Malignancy related therapeutic and diagnostic procedures (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: 248
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Event: Low Platelet count. Treatment: Received radiation therapy and blood infusions Outcome: Death


VAERS ID: 1865504 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-05-17
Onset:2021-05-19
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033C21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: CHF, Interstitial Lung Disease, OSA, AFIB (FEW weeks)
Preexisting Conditions: RHEUMATOID ARTHRITIS, HTN, DIABETES (MANY years).
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: I am the epidemiologist reporting on behalf of 75 year-old female patient. Patient received two doses of the Moderna vaccine, according to immunization records. The first dose was on 4/23/21 and the second was on 5/17/2021. The patient was found dead at home on 5/19/2021 (2 days post second dose). The death certificate lists ?cardiopulmonary arrest? as the immediate cause of death secondary to ?CHF, Interstitial Lung Disease, OSA, AFIB (FEW weeks) and RHEUMATOID ARTHRITIS, HTN, DIABETES (MANY years).? No additional information is available.


VAERS ID: 1865526 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-11-09
Onset:2021-11-11
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 058F21A / 3 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Alanine aminotransferase, Aspartate aminotransferase, Bladder catheterisation, Complication associated with device, Death, Epistaxis, Full blood count, Haemorrhage, International normalised ratio
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-11
   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: bisacodyl 10mg supp, prn; senna 8.6mg 1 tab BID PRN; Senna 8.6mg 1 tab BID; claritin 10mg 1 tab QD; Lasix 40mg 1 tab QD
Current Illness: Seborheic dermatitis, ASHD; constipation
Preexisting Conditions: history of DM2, ASHD; history of TBI, HTN
Allergies: PCNs, atorvastatin
Diagnostic Lab Data: 11/11/2021 INR, CBC, AST ALT.
CDC Split Type:

Write-up: Patient began with bloody nose, unable to stop bleeding, Pressure applied, ice applied, nasal clamp applied. Did also note some bleeding in foley. New foley placed, resident removed clamp and bleeding returned, resident was sitting at 90 degree angle in bed, and was swallowing blood. Suctioning and oxygen attempted. Family alerted and did come and request to have resident have comfort medications only in place of going to hospital. Resident expired 11/11/2021 1240.


VAERS ID: 1865638 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-05-14
Onset:2021-10-29
   Days after vaccination:168
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021B21A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 035C21A / 2 - / 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: 2021-10-29
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: COPD Hypertension Coronary artery disease Peripheral artery disease Hyperlipidemia
Allergies: Eggs Fish
Diagnostic Lab Data: Positive COVID-19 test on 10/27/2021
CDC Split Type:

Write-up: Patient had breakthrough infection and expired.


VAERS ID: 1865657 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-05
Onset:2021-10-15
   Days after vaccination:193
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 008B21-2A / 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: 2021-10-15
   Days after onset: 0
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: Apixaban Aspirin Atorvastatin Lisinopril Calcium carbonate-vitamin D3 Ibandronate
Current Illness: Unknown
Preexisting Conditions: COPD Chronic Cough CAD Hyperlipidemia Osteoporosis
Allergies: Penicillins
Diagnostic Lab Data: Positive COVID-19 test on 9/24/2021.
CDC Split Type:

Write-up: Patient had breakthrough infection and expired.


VAERS ID: 1865959 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-04-22
Onset:2021-07-20
   Days after vaccination:89
Submitted: 0000-00-00
Entered: 2021-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin, Aleve, multivitamin, vitamin B12
Current Illness: none
Preexisting Conditions: hyperlipidemia, anxiety/depression, thyroid nodule
Allergies: none known
Diagnostic Lab Data:
CDC Split Type:

Write-up: sudden death


VAERS ID: 1867115 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (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: Congestive heart failure; Hypertension
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; Chronic kidney disease
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: acute hypoxic respiratory failure; This literature-study case was reported in a literature article and describes the occurrence of ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) in a 90-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. LITERATURE REFERENCE: Characteristics and outcomes of adverse events after COVID-19 vaccination. J2021;2:e12565 The patient''s past medical history included Atrial fibrillation and Chronic kidney disease. Concurrent medical conditions included Hypertension and Congestive heart failure. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Acute hypoxic respiratory failure. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) to be possibly related. Concomitant medications were not reported Treatment medications were not reported This fatal literature-study case concerns a 90-year-old, female patient with medical history of Atrial fibrillation, Chronic kidney disease, Hypertension and Congestive heart failure who experienced the unexpected fatal event of ACUTE RESPIRATORY FAILURE. The event occurred unknown days after a dose of Moderna Covid 19 vaccine. The rechallenge is not applicable The benefit-risk relationship of Moderna Covid 19 vaccine is not affected by this report. This case was linked to MOD-2021-371537, MOD-2021-371538, MOD-2021-371539, MOD-2021-371540, MOD-2021-371541, MOD-2021-371542, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received 03-Nov-2021 included an Email with FTA received from the team and contains significant information.; Sender''s Comments: This fatal literature-study case concerns a 90-year-old, female patient with medical history of Atrial fibrillation, Chronic kidney disease, Hypertension and Congestive heart failure who experienced the unexpected fatal event of ACUTE RESPIRATORY FAILURE. The event occurred unknown days after a dose of Moderna Covid 19 vaccine. The rechallenge is not applicable The benefit-risk relationship of Moderna Covid 19 vaccine is not affected by this report.; Reported Cause(s) of Death: acute hypoxic respiratory failure


VAERS ID: 1867116 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiogenic shock, Septic shock
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Toxic-septic shock conditions (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Chronic obstructive lung disease; Congestive heart failure; Coronary artery disease; Hypertension; Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: septic shock; Cardiogenic Shock; This literature-study case was reported in a literature article and describes the occurrence of SEPTIC SHOCK (septic shock) and CARDIOGENIC SHOCK (Cardiogenic Shock) in a 75-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Hypertension, Congestive heart failure, Coronary artery disease, Chronic obstructive lung disease and Type 2 diabetes mellitus. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to at an unspecified dose. On an unknown date, the patient experienced SEPTIC SHOCK (septic shock) (seriousness criteria death, hospitalization and medically significant) and CARDIOGENIC SHOCK (Cardiogenic Shock) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Septic shock and Cardiogenic shock. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) and mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown Route) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered SEPTIC SHOCK (septic shock) and CARDIOGENIC SHOCK (Cardiogenic Shock) to be possibly related. Concomitant product and treatment medication use was not provided by the reporter. Company Comment: This case concerns a 75-year-old female patient, with medical history of Hypertension, Congestive heart failure, Coronary artery disease, Chronic obstructive lung disease and Type 2 diabetes mellitus, who experienced the unexpected, serious fatal events of SEPTIC SHOCK and CARDIOGENIC SHOCK. The events occurred during the 10 following days after the administration a dose of Moderna COVID-19 Vaccine. The reported cause of death was SEPTIC SHOCK and CARDIOGENIC SHOCK. The rechallenge was not applicable. Patient?s medical history of Hypertension, Congestive heart failure, Coronary artery disease, Chronic obstructive lung disease and Type 2 diabetes mellitus, remain as confounders. The benefit-risk relationship of Moderna COVID-19 Vaccine is not affected by this report. This case was linked to MOD-2021-371501, MOD-2021-371538, MOD-2021-371539, MOD-2021-371540, MOD-2021-371541, MOD-2021-371542, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email received from a regulatory authority and contains significant information. Added correspondence contact in general tab, medical relevant history in patient tab.; Sender''s Comments: This case concerns a 75-year-old female patient, with medical history of Hypertension, Congestive heart failure, Coronary artery disease, Chronic obstructive lung disease and Type 2 diabetes mellitus, who experienced the unexpected, serious fatal events of SEPTIC SHOCK and CARDIOGENIC SHOCK. The events occurred during the 10 following days after the administration a dose of Moderna COVID-19 Vaccine. The reported cause of death was SEPTIC SHOCK and CARDIOGENIC SHOCK. The rechallenge was not applicable. Patient?s medical history of Hypertension, Congestive heart failure, Coronary artery disease, Chronic obstructive lung disease and Type 2 diabetes mellitus, remain as confounders. The benefit-risk relationship of Moderna COVID-19 Vaccine is not affected by this report.; Reported Cause(s) of Death: Septic Shock; Cardiogenic Shock


VAERS ID: 1867117 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19
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 (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? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension; Waldenstrom''s macroglobulinaemia
Preexisting Conditions: Medical History/Concurrent Conditions: Chronic kidney disease; Lymphoma
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: acute hypoxic respiratory failure; COVID-19; This literature-study case was reported in a literature article and describes the occurrence of ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) and COVID-19 (COVID-19) in a 75-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included Chronic kidney disease and Lymphoma. Concurrent medical conditions included Hypertension and Waldenstrom''s macroglobulinaemia. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) (seriousness criteria death, hospitalization and medically significant) and COVID-19 (COVID-19) (seriousness criteria death and hospitalization). The reported cause of death was Acute hypoxic respiratory failure and covid-19. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) and COVID-19 (COVID-19) to be possibly related. Concomitant product and treatment medication use was not provided by the reporter. Company Comment: This literature-study case concerns a 75-year-old male patient with relevant medical history of chronic kidney disease and lymphoma, and concurrent medical conditions of hypertension and Waldenstrom macroglobulinemia, who experienced serious unexpected events of special interest (AESI) acute respiratory failure and COVID-19. The events occurred unspecified time after the unspecified dose of the Moderna COVID-19 vaccine . Rechallenge was not applicable due to nature of the event and as no information regarding number of doses administered, no rechallenge was done and thus, recurrence was not applicable . The patient passed away due to the events. It was not reported whether autopsy was performed. Patient''s medical history and concurrent condition may had contributed to development of the reported events and to the fatal outcome. The benefit-risk relationship of product is not affected by this report This case was linked to MOD-2021-371501, MOD-2021-371537, MOD-2021-371539, MOD-2021-371540, MOD-2021-371541, MOD-2021-371542, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email with a regulatory authority and contains significant information. Added correspondence contact in general tab; medical relevant history in patient tab; Sender''s Comments: This literature-study case concerns a 75-year-old male patient with relevant medical history of chronic kidney disease and lymphoma, and concurrent medical conditions of hypertension and Waldenstrom macroglobulinemia, who experienced serious unexpected events of special interest (AESI) acute respiratory failure and COVID-19. The events occurred unspecified time after the unspecified dose of the Moderna COVID-19 vaccine . Rechallenge was not applicable due to nature of the event and as no information regarding number of doses administered, no rechallenge was done and thus, recurrence was not applicable . The patient passed away due to the events. It was not reported whether autopsy was performed. Patient''s medical history and concurrent condition may had contributed to development of the reported events and to the fatal outcome. The benefit-risk relationship of product is not affected by this report; Reported Cause(s) of Death: acute hypoxic respiratory failure; COVID-19


VAERS ID: 1867118 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute 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), Hypersensitivity (broad), Respiratory failure (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Cerebrovascular accident; Obstructive sleep apnea syndrome; Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: acute hypoxic respiratory failure; Sepsis; This literature-study case was reported in a literature article and describes the occurrence of ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) and SEPSIS (Sepsis) in a 79-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. LITERATURE REFERENCE: Characteristics and outcomes of adverse events after COVID-19 vaccination. 2021;2:e12565 Concurrent medical conditions included Cerebrovascular accident, Type 2 diabetes mellitus and Obstructive sleep apnea syndrome. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) (seriousness criteria death, hospitalization and medically significant) and SEPSIS (Sepsis) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Acute hypoxic respiratory failure and Sepsis. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) and SEPSIS (Sepsis) to be possibly related. Concomitant medications were not provided Treatment medications were not reported Company Comment: This case concerns a 79-year-old, male patient with a history of Cerebrovascular accident, Type 2 diabetes mellitus and Obstructive sleep apnea syndrome, who experienced the fatal unexpected serious events of ACUTE RESPIRATORY FAILURE (AESI) and SEPSIS. The events occurred at within 10 days after a dose of Moderna COVID-19 vaccine. The rechallenge was not applicable due to the nature of the events. The medical history of Cerebrovascular accident, Type 2 diabetes mellitus and Obstructive sleep apnea syndrome remains a confounder. The benefit-risk relationship of Moderna COVID-19 vaccine is not affected by this report. This case was linked to MOD-2021-371501, MOD-2021-371537, MOD-2021-371538, MOD-2021-371540, MOD-2021-371541, MOD-2021-371542, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email with FTA received from the team and contains significant information.; Sender''s Comments: This case concerns a 79-year-old, male patient with a history of Cerebrovascular accident, Type 2 diabetes mellitus and Obstructive sleep apnea syndrome, who experienced the fatal unexpected serious events of ACUTE RESPIRATORY FAILURE (AESI) and SEPSIS. The events occurred at within 10 days after a dose of Moderna COVID-19 vaccine. The rechallenge was not applicable due to the nature of the events. The medical history of Cerebrovascular accident, Type 2 diabetes mellitus and Obstructive sleep apnea syndrome remains a confounder. The benefit-risk relationship of Moderna COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: acute hypoxic respiratory failure; Sepsis


VAERS ID: 1867119 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure, Septic shock
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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Chronic obstructive lung disease; Graves'' disease; Hypertension; Lung cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: acute hypoxic respiratory failure; septic shock; This literature-study case was reported in a literature article and describes the occurrence of ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) and SEPTIC SHOCK (septic shock) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Hypertension, Chronic obstructive lung disease, Graves'' disease and Lung cancer. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) (seriousness criteria death, hospitalization and medically significant) and SEPTIC SHOCK (septic shock) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Acute hypoxic respiratory failure and Septic shock. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) and SEPTIC SHOCK (septic shock) to be possibly related. Concomitant product and treatment medication use was not provided by the reporter. Company Comment: This case concerns a 76-year-old female patient, with medical history of hypertension, chronic obstructive pulmonary disease and lung cancer, who experienced the fatal events of ACUTE RESPIRATORY FAILURE and SEPTIC SHOCK. The events occurred on an unknown date after receiving an unknown dose number of the Moderna COVID 19 vaccine. The rechallenge is not applicable considering the outcome of the events. Patient''s medical history of hypertension, chronic obstructive pulmonary disease and lung cancer remains as a confounder. The benefit-risk relation of the Moderna COVID 19 vaccine is not affected by this report. This case was linked to MOD-2021-371501, MOD-2021-371537, MOD-2021-371538, MOD-2021-371539, MOD-2021-371541, MOD-2021-371542, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email with FTA received from SARA team and contains significant information. Added correspondence contact in general tab; medical relevant history in patient tab.; Sender''s Comments: This case concerns a 76-year-old female patient, with medical history of hypertension, chronic obstructive pulmonary disease and lung cancer, who experienced the fatal events of ACUTE RESPIRATORY FAILURE and SEPTIC SHOCK. The events occurred on an unknown date after receiving an unknown dose number of the Moderna COVID 19 vaccine. The rechallenge is not applicable considering the outcome of the events. Patient''s medical history of hypertension, chronic obstructive pulmonary disease and lung cancer remains as a confounder. The benefit-risk relation of the Moderna COVID 19 vaccine is not affected by this report.; Reported Cause(s) of Death: acute hypoxic respiratory failure; Septic shock


VAERS ID: 1867120 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (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: Hypertension; Lung cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: acute hypoxic respiratory failure; This literature-study case was reported in a literature article and describes the occurrence of ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) in an 81-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Hypertension and Lung cancer. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Acute hypoxic respiratory failure. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) to be possibly related. Treatment medications were not reported Concomitant medications were not reported Company Comment: This case concerns a 81-year-old, male patient, with medical history of hypertension and lung cancer, who experienced the fatal event of Acute respiratory failure. The event occurred on an unknown date after receiving an unknown dose number of the Moderna COVID 19 vaccine. The rechallenge is not applicable considering the outcome of the events. The medical history of hypertension and lung cancer remains as a confounder. The benefit-risk relation of the Moderna COVID 19 vaccine is not affected by this report. This case was linked to MOD-2021-371501, MOD-2021-371537, MOD-2021-371538, MOD-2021-371539, MOD-2021-371540, MOD-2021-371542, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email with a regulatory authority and contains significant information.; Sender''s Comments: This case concerns a 81-year-old, male patient, with medical history of hypertension and lung cancer, who experienced the fatal event of Acute respiratory failure. The event occurred on an unknown date after receiving an unknown dose number of the Moderna COVID 19 vaccine. The rechallenge is not applicable considering the outcome of the events. The medical history of hypertension and lung cancer remains as a confounder. The benefit-risk relation of the Moderna COVID 19 vaccine is not affected by this report.; Reported Cause(s) of Death: acute hypoxic respiratory failure


VAERS ID: 1867121 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory failure
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (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: Atrial fibrillation; Congestive heart failure; Hypertension; Lung cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: acute hypoxic respiratory failure; This literature-study case was reported in a literature article and describes the occurrence of ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) in a 66-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Hypertension, Congestive heart failure, Atrial fibrillation and Lung cancer. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Acute hypoxic respiratory failure. It is unknown if an autopsy was performed. Possible The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered ACUTE RESPIRATORY FAILURE (acute hypoxic respiratory failure) to be possibly related. Treatment medications were not reported Concomitant medications were not reported Company Comment: This fatal regulatory case concerns a 66-year-old, male patient with medical history of Hypertension, Congestive heart failure, Atrial fibrillation and Lung cancer who experienced the unexpected fatal event of ACUTE RESPIRATORY FAILURE. The event occurred unknown days after a dose of Moderna Covid 19 vaccine. The rechallenge is not applicable The medical history and concurrent conditions remain as confounders. The benefit-risk relationship of Moderna Covid 19 vaccine is not affected by this report. This case was linked to MOD-2021-371501, MOD-2021-371537, MOD-2021-371538, MOD-2021-371539, MOD-2021-371540, MOD-2021-371541, MOD-2021-371543 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email with FTA received from SARA team and contains significant information.; Sender''s Comments: This fatal regulatory case concerns a 66-year-old, male patient with medical history of Hypertension, Congestive heart failure, Atrial fibrillation and Lung cancer who experienced the unexpected fatal event of ACUTE RESPIRATORY FAILURE. The event occurred unknown days after a dose of Moderna Covid 19 vaccine. The rechallenge is not applicable The medical history and concurrent conditions remain as confounders. The benefit-risk relationship of Moderna Covid 19 vaccine is not affected by this report.; Reported Cause(s) of Death: acute hypoxic respiratory failure


VAERS ID: 1867122 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiogenic shock
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (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? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Atrial fibrillation; Chronic kidney disease; Chronic obstructive lung disease; Congestive heart failure; Hypertension; Type 2 diabetes mellitus
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Cardiogenic shock; This literature-study case was reported in a literature article and describes the occurrence of CARDIOGENIC SHOCK (Cardiogenic shock) in an 82-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Hypertension, Congestive heart failure, Atrial fibrillation, Chronic kidney disease, Chronic obstructive lung disease and Type 2 diabetes mellitus. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced CARDIOGENIC SHOCK (Cardiogenic shock) (seriousness criteria death, hospitalization and medically significant). The reported cause of death was Cardiogenic shock. It is unknown if an autopsy was performed. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered CARDIOGENIC SHOCK (Cardiogenic shock) to be possibly related. Concomitant product and treatment medication use was not provided by the reporter. Company Comment: This case concerns an 82-year-old female patient, with medical history of hypertension, congestive heart failure and atrial fibrillation, who experienced the fatal event of CARDIOGENIC SHOCK. The event occurred on an unknown date after receiving a dose of unknown number of the Moderna COVID 19 vaccine. Date of death was not reported, and it is unknown if an autopsy was performed. The rechallenge is not applicable considering the outcome of the events. Patient''s medical history of hypertension, congestive heart failure and atrial fibrillation remains as a confounder. The benefit-risk relation of the Moderna COVID 19 vaccine is not affected by this report. This case was linked to MOD-2021-371501, MOD-2021-371537, MOD-2021-371538, MOD-2021-371539, MOD-2021-371540, MOD-2021-371541, MOD-2021-371542 (Patient Link). Most recent FOLLOW-UP information incorporated above includes: On 03-Nov-2021: Follow up received by safety 03-Nov-2021 included an Email with FTA received from SARA team and contains significant information. Added correspondence contact in general tab; medical relevant history in patient tab.; Sender''s Comments: This case concerns an 82-year-old female patient, with medical history of hypertension, congestive heart failure and atrial fibrillation, who experienced the fatal event of CARDIOGENIC SHOCK. The event occurred on an unknown date after receiving a dose of unknown number of the Moderna COVID 19 vaccine. Date of death was not reported, and it is unknown if an autopsy was performed. The rechallenge is not applicable considering the outcome of the events. Patient''s medical history of hypertension, congestive heart failure and atrial fibrillation remains as a confounder. The benefit-risk relation of the Moderna COVID 19 vaccine is not affected by this report.; Reported Cause(s) of Death: Cardiogenic shock


VAERS ID: 1867125 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: More vaccinated people are dying of COVID-19; Based on the current case data, this case has been classified as invalid. This spontaneous case was reported by a consumer and describes the occurrence of COVID-19 (More vaccinated people are dying of COVID-19) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. No Medical History information was reported. On an unknown date, the patient received dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, the patient experienced COVID-19 (More vaccinated people are dying of COVID-19) (seriousness criterion death). The reported cause of death was covid-19. It is unknown if an autopsy was performed. Concomitant medications were not provided. No Treatment information was provided. Company Comment: This case concerns a patient of an unknown age and gender with no relevant medical history reported, who experienced the unexpected event of COVID-19. The event occurred on an unknown number of days after the first dose of mRNA-1273 Moderna vaccine and had a fatal outcome, with death occurring after an unknown number of days. No autopsy report was disclosed. The rechallenge was not applicable since the patient died. The benefit-risk relationship of mRNA-1273 Moderna vaccine is not affected by this report. Further information was requested.; Sender''s Comments: This case concerns a patient of an unknown age and gender with no relevant medical history reported, who experienced the unexpected event of COVID-19. The event occurred on an unknown number of days after the first dose of mRNA-1273 Moderna vaccine and had a fatal outcome, with death occurring after an unknown number of days. No autopsy report was disclosed. The rechallenge was not applicable since the patient died. The benefit-risk relationship of mRNA-1273 Moderna vaccine is not affected by this report. Further information was requested.; Reported Cause(s) of Death: COVID-19


VAERS ID: 1867659 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-06-01
Onset:2021-06-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Blood test, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-08
   Days after onset: 129
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: fatigue
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penecillan, dairy
Diagnostic Lab Data: Blood test for anemia
CDC Split Type:

Write-up: death


VAERS ID: 1867933 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: California  
Vaccinated:2021-10-21
Onset:2021-11-10
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-11-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 034C21A / UNK UN / -

Administered by: Other       Purchased by: ?
Symptoms: Back pain, Condition aggravated, Dyspnoea, Malaise, Pulse absent, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-11-10
   Days after onset: 0
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: Back pain could not walk, checked in to the hospital for four days, a week after the first Moderna shot
Other Medications: Eliquis, blood thinner,
Current Illness: Lower Back pain
Preexisting Conditions: January 2021, went hospital complaining chest pain and leg was swollen and numb. was put on blood thinners . DIAGNOSED with a pulmonary embolism from hip replacement November 14, 2020. March 29, 2021 he went to hospital with the severe back pain, couldn''t walk, checked in for the days, he had his first Moderna shot March 23, 2021. Second 4/20/201 and then the booster while still on Eliquis.
Allergies:
Diagnostic Lab Data: Back pain, collapse, not feeling well
CDC Split Type:

Write-up: Patient said he "was not feeling well", night before and in the morning. Went to work at 8:30 am and collapsed while on the phone at work at 11:10 am. Had heavy breathing and retrieved a pulse while on ambulance but then lost pulse at arrival of hospital.


VAERS ID: 1868510 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-17
Onset:2021-09-22
   Days after vaccination:217
Submitted: 0000-00-00
Entered: 2021-11-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOW / 2 UN / UN

Administered by: Other       Purchased by: ?
Symptoms: Anxiety, Asthenia, COVID-19, Confusional state, Death, Depressed level of consciousness, Feeling abnormal, Hypertension, Hypoxia, Impaired driving ability, Malaise, Moaning, Oxygen saturation decreased, Respiratory tract congestion, Road traffic accident, SARS-CoV-2 test positive, Speech disorder, Walking aid user
SMQs:, Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypertension (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospice Nurse'' Note on 9/21/2021: "This nurse received a phone call from a very close friend of hers reporting that her husband?s uncle Has Covid and took a very bad turn this afternoon. Patient does not want to go to the hospital and does not want to be on any machines. He is a 98 year-old. He is a bachelor and has been living alone since his sister died that he used to live with. He has been alert and oriented and able to live alone with someone just checking in on him. Several months ago his nephew who is his caretaker moved him to a home right down the street from them so it would be closer and making caring for him easier. He was able to walk with a walker. He does not drive anymore since he had an accident a months ago. He has no children and his siblings are dead. He has been able to go to church and he would go on Friday night to play cards with a few other couples in the town down the road. He started having some Covid symptoms on Sunday, 9/12. He was a little congested and said he just did not feel good. Thursday he could not get off the couch and was so weak. He had them call the priest and he did visit and gave pt his last rites. Pt?s Nephew?s daughter did a Home Covid test on pt Thursday, 9/16 and he tested positive for Covid. Patient has been vaccinated. He did go Saturday and have the antibody infusion and he was gradually regaining his strength and almost back to his former activity they said. He took a shower on Saturday and was able to get it out by himself. He also was able to sit up on the couch and watch the ball game on Sunday. Yesterday morning he was doing pretty good and able to sit up and go to the bathroom and then about 3 o?clock this afternoon they went to check on him and could not arouse him. His oxygen level was down to 75% and his heart rate was 35. Before that his oxygen level had only gotten down to 94% at its lowest. Patient told them he did not want to go to the hospital . When they called this nurse they were just beside theirself and did not know what to do. Patient was anxious and moaning and confused. They could not get him settled. ?Hen? is a patient of Dr. It was so late in the day but they were afraid that something might happen to him during the night and they would not know what to do and they would not be able to have any medication and that patient would have to be taken to the hospital and that is not what he wanted. This nurse called RN at the care center and She did get a hold of Dr. He was still in the office and so was Dr. Dr. called back and said that pt could admitted him under the diagnosis of Covid, hypoxia, and hypertension. She wold also cover pt." Hospice Nurse'' Note on 9/22/2021 @ 06:50 CDT: "Pt?s great niece called and reported that pt?s O2 sat were down to 72% and his HR was 131. At 5:30 this am his O2 sat was in the 80s and was staying up in the 80s all night until now. They have been struggling to keep the O2 nc on pt during the night. He was alert enough to tell them that he did not want the O2 on. The morphine has helped pt but it does not last long. He keeps asking for his nephew. He says hat he wants up to the bathroom and then says no. When he does sleep he makes noises and he is very anxious and jabbering. He is drinking small sips of water. This nurse will visit soon." Pt expired later on that day. Nurse''s note @14:06 CDT: "Post mortem care provided. Controlled medications disposed of per protocol. Company contacted and patient ruled out due to age. Provisional Report completed and signed by pt?s nephew and great niece. Request put in the system and to contact nephew to set up date and time. Body released to Funeral Home. Emotional support provided throughout visit. Informed family of bereavement services."


VAERS ID: 1869207 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-11
Onset:2021-10-31
   Days after vaccination:293
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chest X-ray abnormal, Cough, Death, Dyspnoea, Influenza virus test, Pyrexia, Respiratory syncytial virus test, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (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: 2021-11-13
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HTN, HLD, DM, DVT, CKD, obesity
Allergies:
Diagnostic Lab Data: COVID-19, Flu, RSV by NAA positive for SARS-COV-2 on 10/31/21
CDC Split Type:

Write-up: Pt received Moderna vaccines on 01/11/2021 and 02/08/2021. Pt presented to the ED from an assisted living facility on 10/31/21 with complaints of cough, fever, and SOB. Pt''s oxygen saturation was found to be at 88% and pt was placed on 4L nasal cannula. CXR was consistent with COVID pneumonia. On 11/12/21 pt was placed on hospice services. Pt expired on 11/13/2021


VAERS ID: 1869327 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-11-11
Onset:2021-11-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 066F21A / 3 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-15
   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: Lorazepam 0.5mg q4hrs prn restlessness/anxiety, Morphine sulfate concentrate solution 20 mg/ml- give 0.25 ml q 30 minutes PRN breakthrough pain/air hunger and 0.5 ml q 4hr prn pain, air hunger.
Current Illness: HEART FAILURE, HOSPICE/PALLATIVE CARE, PROTEIN CALORIE MALNUTRION, PAIN, ANXIETY DISORDER, DRY EYE SYNDROME, SHORTNESS OF BREATH, DEMEMTIA WITHOUT BEHAVIORAL DISTURBANCE, ESSENTIAL HYPERTENSION, HYPOTHYROIDISM, GLAUCOMA, MACULAR DEGENERATION, CONSTIPATION, MAJOR DEPRESSIVE DISORDER, DEPENCE ON SUPPLEMENTAL 02, HEARING LOSS, BILATERAL
Preexisting Conditions: HEART FAILURE, MACULAR DEGENERATION , 02 DEPENDANCE WITH SOB, HTN, GLAUCOMA AND MACULAR DEGENERATION
Allergies: PCN and calamine
Diagnostic Lab Data: None due to hospice status
CDC Split Type:

Write-up: On 11/12/21 @ approximately 1:11 pm resident 02 saturation decreased to 84%. rebounded after breathing treatment to 91% but residents overall condition continued to decline. 02 increased to 3 liters with orders to titrate up to 6 liters. This resident was a hospice patient and had been having recent episodes of aspiration. Condition continued to decline and resident expired on 11/15/21 @ approximately 9:44 am


VAERS ID: 1869372 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-10-25
Onset:2021-10-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arrhythmia, Cardiac monitoring, Cardioversion, Dyspnoea, Electrocardiogram abnormal, Electroencephalogram, Endotracheal intubation, Mechanical ventilation, Pulse absent, Resuscitation, Ultrasound scan, Ventricular hypokinesia
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-28
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: nothing
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: 10/26/21 Cardiac monitor, Oxygen, Ventilator, EKG, EEG, bloodwork, ultrasound,
CDC Split Type:

Write-up: At her home, dyspnea, pulselessness, 1:30 am 10/26/21, treatment 911 per husband, CPR until relieved by medics, EKG indicated pulseless cardiac arrhythmia treated with cardio-conversion X3, intubated, transported to the Emergency Room. Probable rhythm capable of some cardiac output.


VAERS ID: 1869411 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-11-10
Onset:2021-11-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O54C21A / 3 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Flu like symptoms
Other Medications: Indapamide Rosuvastatin
Current Illness: Macular Degeneration diagnosis
Preexisting Conditions: COPD Hypercholesterolemia
Allergies: N/A
Diagnostic Lab Data: Medical Examiner decided no need.
CDC Split Type:

Write-up: Headache 8PM on 11/10/21, found dead the next morning unsure of connection.


VAERS ID: 1869417 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-15
Onset:2021-10-31
   Days after vaccination:230
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Hypertension, Hypothyroidism, BPH, Depression
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fully vaccinated against Covid-19 and is deceased from covid related pneumonia illness. Patient died on 10/31/2021


VAERS ID: 1869491 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-09-08
Onset:2021-09-15
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Death, Headache, Immediate post-injection reaction, Toxicologic test, Unresponsive to stimuli, Vision blurred
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Lens disorders (broad), Retinal disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol as needed
Current Illness: None known
Preexisting Conditions: None known
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Immediately following the first Moderna vaccine, Patient was experiencing headaches and blurred vision. The decedent was admitted to Hospital on 9/12/2021, transported by EMS from home. According to patient, she had just finished cooking lunch when she heard a loud thud. She found patient on the bathroom floor unresponsive. Patient had no known medical conditions. He died at Hospital on 9/15/2021. An autopsy and toxicology testing was completed by the County Coroner''s Office.


VAERS ID: 1869633 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-09-24
Onset:2021-10-19
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-10-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg daily albuterol 2 puffs inhaled every 4 hours as needed furosemide 20 mg daily Spiriva Handihaler 1 puff inhaled daily Oxygen 2 lpm via nasal cannula
Current Illness:
Preexisting Conditions: COPD Tobacco abuse Lower extremity edema
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death- unexplained


VAERS ID: 1869650 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-20
Onset:2021-08-10
   Days after vaccination:171
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-20
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt admitted with AHRF secondary to COVID pneumonia, pt was already intubated; PMH: CHF, CKD, COPD , CAD; refused remdesivir due to kidney disease; pt''s condition worsened and he passed away in the hospital


VAERS ID: 1869664 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-05-03
Onset:2021-05-20
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 2 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, COVID-19 pneumonia, Death, Dyspnoea, Fall, Hypoxia, Interstitial lung disease, Oxygen saturation decreased, SARS-CoV-2 test positive, Subdural haematoma
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (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), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Accidents and injuries (narrow), 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), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-07-06
   Days after onset: 47
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: Had subdural hematoma from fall on 5/23/2021 Death certificate: "ACUTE RESPIRATORY FAILURE_INTERSTITIAL LUNG DISEASE_COVID-19" Not LTCF. PCR(+) 5/23/21. On 5/21: Admitted to hospital with subdural hematoma due to fall, diagnosed with Covid PNA. 6/15: Hospitalized again, EMS called for low O2 sats in the 70s, dx of Covid, ARF w/hypoxia, SOA. Fully Vaccinated (Moderna): 3/31/21 and 5/3/21. DC support covid-19.


VAERS ID: 1869710 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-08
Onset:2021-08-12
   Days after vaccination:185
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Condition aggravated, Cough, Death, Dyspnoea, Oxygen saturation decreased, Positive airway pressure therapy, Respiratory tract congestion, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-15
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt brought to ED with c/o difficulty breathing and congested cough; states was diagnosed positive for COVID 2- 3 wks prior to coming to ED; positive COVID test in ED; pt experiencing A Fib while in ED; admitted to hospital and placed on BiPAP; PMH: chronic AFib, DM2, CAD, diverticulitis; pt unable to progress towards weaning from O2 without desaturation; comfort measures instituted with pt''s failing condition; once weaning protocol was initiated, the pt died in the hosp


VAERS ID: 1869715 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Unknown  
Location: Kentucky  
Vaccinated:2021-03-18
Onset:2021-06-29
   Days after vaccination:103
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 2 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Cough, Death, Dyspnoea, Idiopathic pulmonary fibrosis, Oropharyngeal pain, Rhinorrhoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Interstitial lung disease (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (narrow), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-08-12
   Days after onset: 44
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CAD, depression, GERD, h/o drug abuse, HTN, kidney stones, OA, thyroid disease, idiopathic pulmonary fibrosis, DDD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: "IDIOPATHIC PULMONARY FIBROSIS_COVID-19 PNEUMONIA," Not LTCF. Ag(+) 6/29/21. S/S: cough, rhinorrhea, difficulty breathing, sore throat, symptoms noted to have resolved on unknown date. Dx: idiopathic pulmonary fibrosis. 8/9/21-8/12/21: Admitted to hospice for IV symptom management of ongoing dyspnea related to pulmonary fibrosis. C/M: chronic lung disease, CAD, DDD, GERD, HTN, OA, thyroid disease, frequent UTIs. No covid-19 on PMH. MRG reviewed as covid-19 related death. Consistent with DC. PROBABLE CASE. Fully Vaccinated 2/18/21 & 3/18/21 (Moderna).


VAERS ID: 1869769 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-11-05
Onset:2021-11-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 034F21A / 3 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-06
   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: Allegra, Vitamin C, Aspirin, folic acid. Lasix, Lomotil, melatonin, metoprolol, midodrine, ondansetron, miralax, Pro- Stat AWC, Renal Caps, sucroferric oxyhdroxide, velphoro, and vitamin b complex
Current Illness: ESRD, on hemodialysis, perinephric abscess, secondary hyperparathyroidism of renal origin
Preexisting Conditions: ESRD/ hemodialysis, anemia
Allergies: cortisone
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received booster shot of Moderna covid vaccine on 11/5/2021. On 11/6/2021 at approx. 0930, pt was found to be unresponsive and asystolic at the nursing home. Last known well was 0600. After pt was found unresponsive and asystolic, CPR was started and pt was then taken to hospital via squad where resuscitative efforts were continued by ambulance staff and hospital staff. Pt was pronounced dead at 1013 on the morning on 11/6/21


VAERS ID: 1869829 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-11-01
Onset:2021-11-04
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939906 / 3 UN / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR UJ745AC / UNK UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Cough, Death, Dyspnoea, Loss of consciousness, Resuscitation, SARS-CoV-2 test negative, Wheezing
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-10
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Cytomel 5mcg, Vitamin D3 5,000IU, AREDS, Omega 3 1200mg, MSM, Magnesium 400mg, CoQ10 200mg, Synthroid 112mcg, Spironolactone 25mg, Losartan/HCTZ 100/25mg, Amlodipine 5mg,
Current Illness: Cough caused by slight tickle in her throat
Preexisting Conditions: Hypothyroidism, hypertension, hyperlipidemia, osteoarthritis, glaucoma
Allergies: Lipitor
Diagnostic Lab Data: Negative covid test 11/4/21
CDC Split Type:

Write-up: Pt developed a cough with wheezing and shortness of breath day 3 post vaccine. She saw our medical practice for care on day 4 post vaccine. On Wednesday 11/10/21 (day 9 post vaccine) she had a "coughing fit" and lost consciousness. EMS was dispatched and attempted to resuscitate patient but she died shortly there after at the Emergency department.


VAERS ID: 1869927 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-08-16
Onset:2021-09-13
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0819E21A / 1 UN / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fatigue, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-09-24
   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: Venlafaxine HCl ER, Tylenol
Current Illness: Recent c/o nausea/vomiting, and fever.
Preexisting Conditions: Migraines, anxiety and insomnia.
Allergies: Unknown to family.
Diagnostic Lab Data: N/A.
CDC Split Type:

Write-up: General malaise, fatigue.


VAERS ID: 1869970 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-11-02
Onset:2021-11-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014F21A / 3 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Agitation, Breath sounds abnormal, Confusional state, SARS-CoV-2 test negative, Urine analysis normal, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-11
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Olmesartan medoxomil, bisoprilol, eliquis, lasix, potassium chloride, levothyroxine, pregabalin, and Tylenol PRN.
Current Illness: None.
Preexisting Conditions: Hypertension, atrial fib, systolic congestive heart failure.
Allergies: No known allergies.
Diagnostic Lab Data: Negative for COVID-19, negative for U/A. Dates tested unknown (sometime between 11/03 and 11/11).
CDC Split Type:

Write-up: (From interview with Charge Nurse): Patient became very confused on 11/03/2021. On 11.04.2021 She developed wheezing and had diminished lung sounds, and became agitated and more confused. POA agreed to put her on hospice care. No treatment apart from hospice.


VAERS ID: 1870002 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-02
Onset:2021-11-14
   Days after vaccination:257
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-11-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CKD,
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dose 1 given 1/29/2021 Moderna lot # 010M20A Patient died of Covid 19, respiratory failure


VAERS ID: 1870029 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-19
Onset:2021-11-11
   Days after vaccination:237
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031A21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Atrioventricular block complete, Death
SMQs:, Conduction defects (narrow), Hypokalaemia (broad)

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

Write-up: Dose 1 2/19/2021 Moderna Lot # 024M20A Patient died of complete heart block, not a covid related death


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