National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

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

This is page 4 out of 48

Result pages: prev   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48   next


VAERS ID: 1007033 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-22
Onset:2021-02-01
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Decompressive craniectomy, Fatigue, Glomerular filtration rate, Headache, Platelet count normal, SARS-CoV-2 test negative, Subdural haematoma, Surgery, White blood cell count increased
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Accidents and injuries (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: ? acetaminophen (TYLENOL) 500 mg tablet, Take 500 mg by mouth once daily as needed for mild pain (level 1-3)., Disp: , Rfl: ? amLODIPine (NORVASC) 10 mg tablet, Take 10 mg by mouth every evening. , Disp: , Rfl: ? ascorbic acid (VITAMI
Current Illness: History of headaches
Preexisting Conditions: Memory impairment, headaches, hypertension, prostate cancer, prior stroke
Allergies: None
Diagnostic Lab Data: 2/1/2021: WBC 11.1, PLT 229, GFR $g60, COVID Rapid PCR test was negative.
CDC Split Type:

Write-up: Patient presented to emergency room on 2/1/2021 with a chief complaint of having a chronic headache and fatigue following receipt of the Moderna vaccine 10 days prior. Following examination by the physician, the patient was diagnosed with an acute subdural hematoma. The patient subsequently underwent decompressive surgery, however demonstrated worsening neurologic status over the next several days and ultimately expired on 2/4/2021.


VAERS ID: 1008041 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-12
Onset:2021-01-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Disorientation, Fall, Pruritus, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Acetaminophen, bisacodyl supplement, levsin (hyscyamine)
Current Illness: gout
Preexisting Conditions: congestive heart failure diagnosis, alzheimers
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: itchy skin, swelling, disorientation that led to a fall


VAERS ID: 1009813 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-01
Onset:2021-01-25
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient became immobile on 1/25/21 (4 days after receiving Moderna COVID-19 vaccine). He died on 1/27/21


VAERS ID: 1009866 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown new pt
Preexisting Conditions: unknown
Allergies: penicillins
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: pt was given vaccine on the afternoon of 01-29-2021. Pt was administered the moderna covid-19 shot into the deltoid muscle of this pt. Pt was observed and left pharmacy. on 2-6, pts daughter calls pharmacy, and says the night of 1-29, after recieveing the vaccine, her mother had a hemmorhagic stroke and passed away


VAERS ID: 1010114 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Guam  
Vaccinated:2021-01-28
Onset:2021-02-03
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: anemia, NIDDM, ESRD on Hemodialysis, AFib, CAD S/P CABG, COPD , HTN, recently diagnosed with COVID in September, 2020.
Preexisting Conditions:
Allergies: unknown
Diagnostic Lab Data: Presumptive negative for COVID
CDC Split Type:

Write-up: Patient passed away (Dead on Arrival on presentation to ER) on 02/03/2021


VAERS ID: 1010989 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-04
Onset:2021-01-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Anaphylactic reaction, Death, Dyspnoea, Hypertension, Intracranial aneurysm, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Arthritis; Hypertension
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Brain aneurysm; Anaphylactic reaction; Collapsed; BP sky rocketed; Shortness of breath; A spontaneous report was received from a consumer concerning a 69-year-old female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and experienced blood pressure skyrocketed, shortness of breath, loss of consciousness, massive anaphylactic reaction, and brain aneurysm. The patient''s medical history, as provided by the reporter, included high blood pressure and arthritis. Products known to have been used by the patient, within two weeks prior to the event, included an antihypertensive. On 04 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. Twenty-two minutes later she had a massive anaphylactic reaction. She experienced shortness of breath, blood pressure skyrocketed, and loss of consciousness. She was taken to the emergency room. The patient had a brain aneurysm and never recovered. No treatment information was provided. The patient died on 04 Jan 2021. The cause of death was reported as brain aneurysm. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 69-year-old, female patient with a medical history of hypertension, who experienced fatal, serious, unexpected events of Anaphylactic reaction, hypertension, dyspnea, loss of consciousness and brain aneurysm. The events occurred 22 minutes after the first dose of mRNA-1273 was administered. No treatment information was provided. The patient never recovered and died. The cause of death was reported as brain aneurysm. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. Additional information has been requested.; Reported Cause(s) of Death: Brain aneurysm


VAERS ID: 1011362 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-28
Onset:2021-01-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD/013L20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: COPD Diabetes
Allergies:
Diagnostic Lab Data: An autopsy is being performed
CDC Split Type:

Write-up: Patient''s son came to the vaccine clinic today 2/8/2021, stated that his father 2/24/1948 passed away the same day as the vaccine.


VAERS ID: 1011487 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-02-06
Onset:2021-02-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Life support, Resuscitation, Syncope, 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: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, albuterol, Norvasc, Eliquis, Voltaren, Neurontin, lidocaine, Cozaar, Mevacor, Lopressor, Prilosec, Miralax, Senna, Renvela, Kayexolate, Incruse Ellipta, Vit. B complex, Coumadin
Current Illness:
Preexisting Conditions: ESRD (dialysis fistula), peripheral vascular disease (R mid-foot amputation), cardiac disease (pace-maker), malnutrition (cachexic), possible liver disease (distended abdomen)
Allergies: Protein Supplement
Diagnostic Lab Data: CPR/ ACLS initiated on 2/6/2021
CDC Split Type:

Write-up: Received Covid vaccine in am. Last seen by family at 17:30 pm and observed to be well. About an hour later he collapsed, unresponsive. A 911 call was initiated at 18:29. Paramedics arrived to find the patient in cardiac arrest. CPR/ACLS was initiated, but resuscitation was unsuccessful. Pt. was transported to MC where he was pronounced dead at 19:32. There was no sing of an injection site reaction, nor of allergic reaction..


VAERS ID: 1011577 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-02-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Death, Increased bronchial secretion, Productive cough, Rhinorrhoea, Secretion discharge, Swelling face
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: albuterol sulfate nebulization hyoscyamine sulfate atropine sulfate lorazepam concentrate morhpine sulfate metolazone lasix benadryl robitussin levothyroxine fluocinonide cream nystatin cream remeron spironolactone tylenol extra strength tr
Current Illness: Was started on hospice between first dose of vaccine (1/7/21) and second dose (2/4/21), primarily for inability to control fluid balance due to heart failure and kidney failure. Started to have increased edema and respiratory symptoms (nasal drainage, raspy voice but denied sore throat) and tested negative for COVID twice starting 1/5/21 and 1/7/21 (day of first vaccine), and once again after the vaccine, increased confusion at that time and continued between vaccination. Later the nasal drainage was attributed to fluid overload. UTI on 1/11/21. Hospice referral by MD on 1/15/21.
Preexisting Conditions: History of type 2 diabetes, benign prostatic hyperplasia, heart failure, hypertension, constipation, vitamin D deficiency, hypothyroidism, chronic kidney disease stage 3, insomnia, tinea corporis, macular degeneration, polyosteoarthritis, UTIs. Short term memory difficulties. Resided in LTCF for 3 years prior to death.
Allergies: no known allergies
Diagnostic Lab Data: None performed due to hospice status.
CDC Split Type:

Write-up: Resident expired on 2/5/21 at 03:35pm, about 25 hours after second dose of vaccine. At breakfast, resident was spitting a lot of secretions, coughing up liquids from nose and phlegm, facial swelling, which were all symptoms that he was struggling with prior to both doses of COVID vaccine, but had increased more than prior incidences on 2/5/21. Gurgling noted in upper airways, hyscolamine given, bath given to loosen secretions, morphine given. Family notified and came into facility for compassionate care visit around 1300. 1400 HR was 3 and RR was 2, but increased back to 60 and 12 within 20 minutes. Then resident expired at 1535.


VAERS ID: 1011732 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-30
Onset:2021-02-03
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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 passed away with in 60 days of receiving COVID vaccine series


VAERS ID: 1011774 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-03
Onset:2021-02-06
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / SC

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASPRIN CLOPIDOGREL LISINOPRIL NITROQUICK FINASTERIDE AMLODPINIE PRAVASTATIN TAMSULOSIN
Current Illness: CAROTID ARTERY STENOSIS CORONARY ARTERY DISEASE PACEMAKER CABG, 4-VESSEL BPH
Preexisting Conditions: SAME AS ABOVE
Allergies: NONE KNOWN
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Cardiac arrest resulting in death on the third day post vaccine administration, 0224. Reported syncopal event post toileting. Rescue measures attempted but not successful. Time of death 0358, 02/06/2021.


VAERS ID: 1011834 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-02-06
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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 passed away within 60 days of receiving COVID vaccine series


VAERS ID: 1011894 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-29
Onset:2021-02-04
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away within 60 days of receiving COVID vaccine


VAERS ID: 1011929 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-21
Onset:2021-01-27
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / UNK AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Death, Dyspnoea, Dyspnoea exertional, Fatigue, Lethargy
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: none
Current Illness: none
Preexisting Conditions: hypercholesterolemia
Allergies: none
Diagnostic Lab Data: The coroners office has not confirmed with us a cause of death yet and continues to investigate her death. They have not shared with the family any results from medical or laboratory tests related to their post-mortem analysis.
CDC Split Type:

Write-up: Within a few days, my mother started reporting profound fatigue and shortness of breath while conducting routine household activities. She no longer had to energy for her daily exercise walks and became increasingly lethargic. She died in her sleep while taking an afternoon nap on Thursday, February 4th. I am highly concerned this could be a vaccine related.


VAERS ID: 1011935 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-06
Onset:2021-02-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cough, Death, Dyspnoea, Fatigue, Malaise, Oxygen saturation decreased, Resuscitation
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: No known drug/food allergies
Diagnostic Lab Data: Pulse Ox #1 (home) - 92% (2/8 PM) Pulse Ox #2 (home) - 90% (2/8 PM) Pulse Ox #3 (emergency department) - 60% (2/8 PM) *All results were patient reported
CDC Split Type:

Write-up: Patient received his second dose of Moderna COVID vaccine on 2/6 at 12:40PM. Patient was observed for 15 minutes post-vaccination with no adverse events. On the evening of 2/6 (time unknown) the patient began to develop dry cough and fatigue. He was checked by a physician at that time (who was a family member). Patient continued to feel unwell into Sunday. His lungs were clear when checked Sunday afternoon (time unknown). At approximately 5:30pm on 2/7 the patient began experiencing sudden onset shortness of breath. A pulse ox was conducted at that time and it was 92%, and again shortly thereafter and it was 90% (as reported by family member). 9-1-1 was contacted at this time. CPR was initiated when he arrived at the emergency department, pulse ox was 60% (as reported by family member). The patient passed away shortly thereafter on 2/8/2021.


VAERS ID: 1012047 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-01
Onset:2021-02-06
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acidosis, Cardiac arrest, Encephalopathy, Endotracheal intubation, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine Besylate; Antacid Suspension; Atorvastatin Calcium; Atropine Sulfate; Clozaril; Cyanocobalamin; metformin HCl; Metoprolol Tartrate; Tylenol
Current Illness: DMII
Preexisting Conditions: Tobacco use, Schizophrenia, DMII, Bipolar, HTN, COVID 19 hx,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden death 2/7/21 @ 0309 Started acute encephalopathy & required intubation Soon after intubation went into cardiac arrest Likely severe acidosis.


VAERS ID: 1012604 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-11
Onset:2021-02-05
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1012612 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 33
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol apixiban diclofenac exenatide finasteride furosemide lantus novolog liptor lotrel metoprolol succinate pantoprazole levothyroxine tasulosin tiotropium-olodaterol
Current Illness: COPD exacerbation 2 weeks prior
Preexisting Conditions: Atrial fibrillation on anticoagulation benign prostatic hyperplasia CKD stage 3 Chronic obstructive pulmonary disease - on baseline 2L NC supplemental O2 Gastro-esophageal reflux disease Hyperlipidemia Hypertension Hypothyroidism Obstructive sleep apnea Type 2 diabetes mellitus asbestosis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized on 31 Jan for COVID pneumonia after 3 days of increasing baseline supplemental O2 requirements and dyspnea and ultimately died on comfort care on 3 Feb 2021.


VAERS ID: 1012894 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-22
Onset:2021-02-05
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fatigue, Headache, Nausea, Pain
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen Amiodarone 100mg Diclofenac 1% gel Furosemide 40mg tablet Hydralazine 50mg tablet Metoprolol 100mg tablet Potassium Chloride 10meqER tablet Warfarin 2.5mg tablet
Current Illness: Anxiety A. Fib Cardiac Pacemaker Cerebral Infaction CHF Urinary Incontinence
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1-2 days after vaccine, pt developed weakness, fatigue, body aches, nausea, headache and poor appetite. Pt was admitted to the hospital on 2/5/21 and death occured on 2/6/21


VAERS ID: 1013041 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-15
Onset:2021-01-31
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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-Patient doesn''t not regularly use our pharmacy
Current Illness: None
Preexisting Conditions: Heart failure
Allergies: Penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccine was administered on 1/15/2021 and death occurred on 1/31/2021.


VAERS ID: 1013051 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-24
Onset:2021-02-06
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Facial paralysis, Hemiparesis, Ischaemic stroke
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 7
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81mg, Citalopram 10mg, Furosemide 40mg, Insulin glargine, Losartan 50mg, Metoprolol 25mg, Vitamin B-12 1000mcg
Current Illness:
Preexisting Conditions: Dementia, Congestive Heart Failure, Diabetes, Osteoarthritis
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 2/6/21 at 6:00PM, resident experienced sudden left facial droop, left arm and left leg weakness. She was sent to hospital and they confirmed she had an acute ischemic stroke.


VAERS ID: 1013087 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-23
Onset:2021-01-30
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown-Patient does not regularly use our pharmacy
Current Illness: None
Preexisting Conditions: Heart problems
Allergies: Penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient received vaccine on 1/23/2021 and death occurred on 1/30/2021.


VAERS ID: 1013095 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-02-03
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: See list below. Flomax 0.4 mg 1 Cap P.O. QD Tylenol 500mg 2 tabs PO PRN Carbidopa/levodopa 25-100mg PO 3 tab PO TID CoQ10 1 cap PO QD B12 1 tab PO QD Omega-3 Fatty Acids-Vitamin E 1,000mg 1 Cap PO QD Timolol 0.25% 1 gtt OU BID Finasterid
Current Illness: Unknown.
Preexisting Conditions: See list below. Glaucoma, Hyperlipidemia, Inguinal Hernia, Hx-Gi bleed, Mandibular salivary gland removal- 2012, Hx-TIA, Hypertension, Lumbar disc disease, Parkinsonism, Pancreatitis history
Allergies: No known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was technically a resident of retirement community, however, he chose to live independently at home at his current home. Only his spouse actually resides at retirement community. Patient received the second dose of the Moderna vaccine via pharmacy vaccination clinic at retirement community on 2/3/2021. He was found deceased in his home by a certified nursing assistant on 2/4/2021 at approximately 10:00am.


VAERS ID: 1013145 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-05
Onset:2021-02-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Fatigue, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient texted a friend on 2/7/2021 c/o arm pain and feeling tired. I don''t know if he was taken to a hospital. Autopsy today.


VAERS ID: 1014628 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-03
Onset:2021-02-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20R / 1 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: a long list
Current Illness: none
Preexisting Conditions: melanoma, skin cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 8 hours.


VAERS ID: 1014740 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Lisinopri, Sertraline, pravastatin, alendronate, Cetirizine, Vitamin D3,
Current Illness: no acute illnesses
Preexisting Conditions: HTN, Cavernous hemangioma of liver, RBBB, hx of bilateral carotid bruits, hx of squamous cell carcinoma of right hand, arthralgia of both knees, spondylolisthesis at L3-L4, DDD thoracic, ovarian cyst, hx of pneumonia, cholelithiasis w/o obstruction, liver lesion, depression, hyperlipidemia, hypercalcemia, vitamin d deficiency, osteoporosis, former smoker, depression
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient found down at home with agonal respirations and per EMS asystole, received 2 rounds of epi at her house with return of spontaneous pulses, lost pulse again in route to ER and another round of epi was given, CPR in progress when arrived at hospital. Prior to this patient''s husband states he heard her fall in the bathroom but did not immediately check on her as he states that this has happened before. He checked on her 10 min later and that''s when he found her unconscious. Daughter called 911 and she began CPR. No previous complaints of headache, chest pain, back pain, fever or chills. Husband states patient was drinking that evening which is not unusual for her. Patient died at hospital.


VAERS ID: 1014774 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-13
Onset:2021-01-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: None Reported
Allergies: None Reported
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: We were informed the patient passed away 2 days after receiving the vaccine. We do not have any details about what happened, we were informed by one of his employees. We have no knowledge that this had anything to do with the vaccination in any way.


VAERS ID: 1014865 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-23
Onset:2021-02-02
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Malaise, Pneumonia, Renal failure, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (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: 2021-02-03
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: Tested positive for Covid in November
Preexisting Conditions: Muscular dystrophy
Allergies: n/a
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: He had not been feeling well after his second Covid vaccination (on 01/23/2021) and was found unresponsive in his room at the nursing home (late evening on 02/02/2021). He was taken to a hospital where they did tests and he had pneumonia and kidney failure, but he was being transferred to a larger hospital when he arrested and died (02/03/2021)


VAERS ID: 1015465 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-21
Onset:2021-02-07
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ELO140 / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EL1283 / 2 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Heart rate abnormal, Pulse absent, Respiratory arrest, Unresponsive to stimuli
SMQs:, 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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: acetaminophen [OTC] tablet; 500 mg; amt: 500 MG; oral Special Instructions: 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED As Needed PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6, PRN 7, PRN 8, PRN 9, PRN 10 03/14/2020- Open Ended Prescription Artifi
Current Illness: U07.1 2019-nCoV acute respiratory disease (Primary) N39.0 Urinary tract infection, site not specified (Admission) K21.9 Gastro-esophageal reflux disease without esophagitis G89.4 Chronic pain syndrome E66.01 Morbid (severe) obesity due to excess calories M54.2 Cervicalgia F41.9 Anxiety disorder, unspecified (History of) G47.00 Insomnia, unspecified E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E03.9 Hypothyroidism, unspecified F06.30 Mood disorder due to known physiological condition, unspecified I50.22 Chronic systolic (congestive) heart failure I10 Essential (primary) hypertension M81.0 Age-related osteoporosis without current pathological fracture Z95.0 Presence of cardiac pacemaker F39 Unspecified mood [affective] disorder C85.84 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb C82.94 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb F31.62 Bipolar disorder, current episode mixed, moderate K59.09 Other constipation Z45.2 Encounter for adjustment and management of vascular access device D64.9 Anemia, unspecified Z79.01 Long term (current) use of anticoagulants Z51.81 Encounter for therapeutic drug level monitoring M17.9 Osteoarthritis of knee, unspecified M15.0 Primary generalized (osteo)arthritis I87.2 Venous insufficiency (chronic) (peripheral) F31.9 Bipolar disorder, unspecified C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites I73.9 Peripheral vascular disease, unspecified F32.9 Major depressive disorder, single episode, unspecified I89.0 Lymphedema, not elsewhere classified Q24.5 Malformation of coronary vessels I42.8 Other cardiomyopathies E03.9 Hypothyroidism, unspecified J30.9 Allergic rhinitis, unspecified Z86.718 Personal history of other venous thrombosis and embolism R33.9 Retention of urine, unspecified K42.9 Umbilical hernia without obstruction or gangrene Z90.89 Acquired absence of other organs R20.8 Other disturbances of skin sensation L03.111 Cellulitis of right axilla I87.2 Venous insufficiency (chronic) (peripheral) Z87.81 Personal history of (healed) traumatic fracture H04.121 Dry eye syndrome of right lacrimal gland R42 Dizziness and giddiness R53.81 Other malaise F48.2 Pseudobulbar affect R06.02 Shortness of breath H26.9 Unspecified cataract C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site H53.2 Diplopia E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene G89.4 Chronic pain syndrome E78.5 Hyperlipidemia, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G60.8 Other hereditary and idiopathic neuropathies K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding I48.91 Unspecified atrial fibrillation J02.9 Acute pharyngitis, unspecified (Preliminary) F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features Z46.89 Encounter for fitting and adjustment of other specified devices R09.81 Nasal congestion Z46.89 Encounter for fitting and adjustment of other specified devices M25.562 Pain in left knee L53.9 Erythematous condition, unspecified R29.3 Abnormal posture F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified T81.30XA Disruption of wound, unspecified, initial encounter R05 Cough (Preliminary) F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features S28.222A Partial traumatic amputation of left breast, initial encounter Z48.3 Aftercare following surgery for neoplasm F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features R41.841 Cognitive communication deficit N63.0 Unspecified lump in unspecified breast H25.012 Cortical age-related cataract, left eye (Preliminary) H25.011 Cortical age-related cataract, right eye (History of) H25.091 Other age-related incipient cataract, right eye Z23 Encounter for immunization Z74.1 Need for assistance with personal care M62.81 Muscle weakness (generalized) K59.00 Constipation, unspecified I49.9 Cardiac arrhythmia, unspecified E55.9 Vitamin D deficiency, unspecified (History of) L23.9 Allergic contact dermatitis, unspecified cause (History of) F33.8 Other recurrent depressive disorders (History of) Z11.1 Encounter for screening for respiratory tuberculosis D51.9 Vitamin B12 deficiency anemia, unspecified (History of) R13.11 Dysphagia, oral phase N18.31 Chronic kidney disease, stage 3a G44.021 Chronic cluster headache, intractable (Preliminary) C50.912 Malignant neoplasm of unspecified site of left female breast
Preexisting Conditions: U07.1 2019-nCoV acute respiratory disease (Primary) N39.0 Urinary tract infection, site not specified (Admission) K21.9 Gastro-esophageal reflux disease without esophagitis G89.4 Chronic pain syndrome E66.01 Morbid (severe) obesity due to excess calories M54.2 Cervicalgia F41.9 Anxiety disorder, unspecified (History of) G47.00 Insomnia, unspecified E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E03.9 Hypothyroidism, unspecified F06.30 Mood disorder due to known physiological condition, unspecified I50.22 Chronic systolic (congestive) heart failure I10 Essential (primary) hypertension M81.0 Age-related osteoporosis without current pathological fracture Z95.0 Presence of cardiac pacemaker F39 Unspecified mood [affective] disorder C85.84 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb C82.94 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb F31.62 Bipolar disorder, current episode mixed, moderate K59.09 Other constipation Z45.2 Encounter for adjustment and management of vascular access device D64.9 Anemia, unspecified Z79.01 Long term (current) use of anticoagulants Z51.81 Encounter for therapeutic drug level monitoring M17.9 Osteoarthritis of knee, unspecified M15.0 Primary generalized (osteo)arthritis I87.2 Venous insufficiency (chronic) (peripheral) F31.9 Bipolar disorder, unspecified C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites I73.9 Peripheral vascular disease, unspecified F32.9 Major depressive disorder, single episode, unspecified I89.0 Lymphedema, not elsewhere classified Q24.5 Malformation of coronary vessels I42.8 Other cardiomyopathies E03.9 Hypothyroidism, unspecified J30.9 Allergic rhinitis, unspecified Z86.718 Personal history of other venous thrombosis and embolism R33.9 Retention of urine, unspecified K42.9 Umbilical hernia without obstruction or gangrene Z90.89 Acquired absence of other organs R20.8 Other disturbances of skin sensation L03.111 Cellulitis of right axilla I87.2 Venous insufficiency (chronic) (peripheral) Z87.81 Personal history of (healed) traumatic fracture H04.121 Dry eye syndrome of right lacrimal gland R42 Dizziness and giddiness R53.81 Other malaise F48.2 Pseudobulbar affect R06.02 Shortness of breath H26.9 Unspecified cataract C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site H53.2 Diplopia E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene G89.4 Chronic pain syndrome E78.5 Hyperlipidemia, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G60.8 Other hereditary and idiopathic neuropathies K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding I48.91 Unspecified atrial fibrillation J02.9 Acute pharyngitis, unspecified (Preliminary) F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features Z46.89 Encounter for fitting and adjustment of other specified devices R09.81 Nasal congestion Z46.89 Encounter for fitting and adjustment of other specified devices M25.562 Pain in left knee L53.9 Erythematous condition, unspecified R29.3 Abnormal posture F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified T81.30XA Disruption of wound, unspecified, initial encounter R05 Cough (Preliminary) F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features S28.222A Partial traumatic amputation of left breast, initial encounter Z48.3 Aftercare following surgery for neoplasm F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features R41.841 Cognitive communication deficit N63.0 Unspecified lump in unspecified breast H25.012 Cortical age-related cataract, left eye (Preliminary) H25.011 Cortical age-related cataract, right eye (History of) H25.091 Other age-related incipient cataract, right eye Z23 Encounter for immunization Z74.1 Need for assistance with personal care M62.81 Muscle weakness (generalized) K59.00 Constipation, unspecified I49.9 Cardiac arrhythmia, unspecified E55.9 Vitamin D deficiency, unspecified (History of) L23.9 Allergic contact dermatitis, unspecified cause (History of) F33.8 Other recurrent depressive disorders (History of) Z11.1 Encounter for screening for respiratory tuberculosis D51.9 Vitamin B12 deficiency anemia, unspecified (History of) R13.11 Dysphagia, oral phase N18.31 Chronic kidney disease, stage 3a G44.021 Chronic cluster headache, intractable (Preliminary) C50.912 Malignant neoplasm of unspecified site of left female breast
Allergies: Iodinated Contrast- Oral and IV Dye, Penicillins (PCN)
Diagnostic Lab Data:
CDC Split Type:

Write-up: DISCOVERED UNRESPONSIVE WITHOUT PULSE, RESPIRATIONS, HEART BEAT ON 2/7/21 AT 0435 A.M. RESIDENT WAS DNR STATUS.


VAERS ID: 1015630 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: 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: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died of a heart attack; A spontaneous report was received from a consumer concerning a 56-year-old male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and died due to a heart attack. The patient''s medical history was not provided. Products known to have been used by the patient, within two weeks prior to the event, included additional medications. On an unknown date, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. - On an unknown date, the reporter stated the patient received Moderna''s COVID-19 vaccine and sometime after he was found dead by his bedside around 02:30 am. The patient died on an unknown date. The cause of death was due to a heart attack. Plans for autopsy were not provided.; Reporter''s Comments: This case concerns a 56 year old, male patient, who experienced fatal unexpected event of myocardial infarction. The event occurred on an unspecified date after mRNA-1273 (Lot# Unknown). Treatment details not provided. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Additional information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1015687 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-08
Onset:2021-02-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, Cardiac arrest, Cough, Death, Dyspnoea, Headache, Intraosseous access placement, Laryngeal mask airway insertion, Oxygen saturation decreased, Pulse absent, Pulseless electrical activity, Pyrexia, Respiratory arrest, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: lipitor, pepcid, uloric, prozac, synthroid, lisinopril, troprol xl, multivitamin, niacin, nifedical xl, ranexa, demadex, xarelto
Current Illness: none
Preexisting Conditions: a fib, HTN, CAD, PTSD, CHF, anxiety, gout, reflux, high cholesterol, obese, hypothyroidism.
Allergies: nknda or food allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Almost immediate headache per wife. Developed fever around 4 pm. Headache all day. Took Tylenol at 4 and 10 pm. Gradual development of SOB and cough. Temp of 101.4 at 10 pm. pulse ox 92% at 10 pm. Went to sleep, woke up at 0050 with increasing SOB. Pulse ox 82%. Used albuterol inhaler, wife called emergency services at 0113. EMS arrived around 0130 to patient''s home. pulse ox 86%, coughing, sob, hard time breathing. Walked to stretcher. Became unresponsive. Found to have no pulse, stopped breathing. CPR initiated at about 0140. King airway placed in field, I/O in left tibia. Patient from PEA to asystole, to vfib, to asystole. ACLS followed. Unrecoverable asystole and patient time of death 0213.


VAERS ID: 1015773 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-01
Onset:2021-02-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: aspirin 81 mg,
Current Illness: skin rash
Preexisting Conditions: Demenita, GERD, Heart failure, Kidney disease, stage 3,
Allergies: Lisinipril, Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away in her sleep. No s/s of adverse events leading up to the residents death. Resident was previously declining- MD stated the vaccine had nothing to do with the death.


VAERS ID: 1015996 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-14
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 30
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: Family reported patient expired 1/31/2021.


VAERS ID: 1016097 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-20
Onset:2021-02-08
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: Amlodipine, carvedilol, clopidrogrel, cyclobenzaprine, docusate sodium, ferrous sulfate, guaifenesin, norco, insulin nph, levothyroxine, magnesium, metformin, nitrostat, rosuvastatin, spironolactone, tramadol, warfarin
Current Illness:
Preexisting Conditions: CABG-2014, CAD, HTN, hyperlipidemia, systolic murmur, type 2 diabetes, diabetic neuropathy, cervical dystonia, benign essential tremor, degenerative disc disease, intermittent claudication, PVD, former smoker-greater than 30 pack year, cervical spinal stenosis, long-term use of anticoagulant
Allergies: Hydrochlorothiazide, ACE inhibitors, Lisinopril, Valsartan, Angiotensin Receptor blockers
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 02/08/21


VAERS ID: 1016155 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Align Capsule 1 capsule QD Aspirin 81 mg QD Cholecalciferol 125 mcg QD Donepezil HCl 10 mg QHS Ensure Max Protein BID Furosemide 20 mg QD Potassium Chloride ER 10 MEQ BID Proventil HFA TID
Current Illness: Acute Exacerbation CHF Cellulitis of intergluteal fold due to decubitus ulcer
Preexisting Conditions: Unspecified Dementia without Behavioral Disturbance Edema Hypokalemia Chronic Bronchitis Heart Failure Vitamin D Deficiency Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris History of Aortic Stenosis LBBB
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 2/7/2021 at 0630, resident found in recliner without pulse or respirations. Resident had not been found to have any adverse reactions to the vaccine between the time of the vaccine on 2/4 until found deceased on 2/7.


VAERS ID: 1016605 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Sepsis
SMQs:, 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? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Sepsis; A spontaneous report was received from a consumer post , concerning an approximately 55-year-old, male physician who received Moderna''s COVID-19 vaccine (mRNA-1273) and developed sepsis, resulting in death. There was no medical history provided. There were no concomitant medications provided. On an unknown date (Thursday), the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. According to the post, two days after vaccine administration, the patient died of sepsis on Saturday. Action taken with mRNA-1273 in response to the event was not applicable. The event, sepsis, was considered fatal. The patient''s date of death was not provided. The cause of death was reported as sepsis.; Reporter''s Comments: This case concerns a 55-year-old, male subject, who experienced a serious unexpected event of Sepsis. Sepsis occurred after first dose of mRNA-1273 vaccine administration. On an unknown date, two days after vaccine administration, the patient died of sepsis. Treatment for the event was not provided. The patient''s medical history was not provided. The patient is a physician. Concomitant product use was not reported. Very limited information regarding this event has been provided at this time and no definite diagnosis or autopsy report have been provided. Based on the current available information and temporal association between the use of the product and the start date of the event of Sepsis, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Sepsis


VAERS ID: 1016709 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-08
Onset:2021-02-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Dyspnoea at rest, Hypopnoea, Oral pain, 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), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: OXYCONE, LASIX, FLOMAS, CEPHALEXIN,EFFEXOR, EXELON, SEROQUEL, OMEPRAZOLE
Current Illness: ACUTE RESPIRATORY FAILURE, PALLATIVE CARE
Preexisting Conditions: ATRIAL FIBRILLATION, ALZHEIMERS, CHARLES BONNET SYNDROME, NON RHEUMATIC MITRAL VALVE DISORDER
Allergies: PENICILLIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: ON 02/08/2021 AROUND 0600 RESIDENTCOMPLAINED OF MOUTH PAIN AND RECEIVED OXYCODONE. DURING THE COURSE OF THE MORNING, RESIDENT EXHIBITED A FEW EPISODES OF LABORED/SHALLOW BREATHING AND SOB AT RESTING. 0XYGEN SATURATION RATE WAS 93-98% ON ROOM AIR, LUNG SOUNDS CLEAR IN ALL LOBES AND PULSE AND TEMPERATURE WITHIN NORMAL RANGE. AS THE DAY PROGRESSED, VITAL SIGNS REMAINED STABLE BUT RESIDENT CONTINUED TO HAVE PERIODS OF SOB/LABORED BREATHING.FAMILY AND NURSE PRACTIONER UPDATED AND THE ORDER WAS RECEIVED TO SEND PATIENT TO MEDICAL CENTER ER FOR EVALUATION PER AMBULANCE. RESIDENT TRANSPORTED AT 1425. RESIDENT RETURNED FROM THE ER AT 1830 ON HOSPICE CARE WITH THE DIAGNOSIS OF: ACURE RESPIRATORY FAILURE WITH HYPOXIA AND END OF LIFE DECISION MAKING. RESIDENT WAS MADE COMFORTABLE AND MONITORED DURING THE NIGHT AND EXPIRED AT 0630 ON 02/09/2021.


VAERS ID: 1017051 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Anaemia, Cardiac failure congestive, Cardio-respiratory arrest, Chest pain, Death, Dyspnoea, Intensive care, Pulseless electrical activity, Transfusion, Vasopressive therapy
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Haematopoietic erythropenia (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: coronary artery disease with prior two-vessel CABG in 2006, Ischemic cardiomyopathy, hypertension, hyperlipidemia, bilateral carotid artery disease, paroxysmal atrial fibrillation, systolic heart failure, pulmonary hypertension, and moderate -severe aortic stenosis, ulcerative
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt received vaccine on 2/3. early on 2/4 developed chest pain, dyspnea, and was seen in ED and diagnosed with acute exacerbation of CHF and NSTEMI type 2, and anemia. on 2/5 transfusion was started and pt developed worsening dyspnea and then PEA arrest. Pt achieved ROSC and was transferred to the cardiac intensive care unit where he required vasopressor support. he subsequently declined and died on 2/7


VAERS ID: 1017176 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Missouri  
Vaccinated:2020-12-30
Onset:2021-01-05
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Atrial fibrillation, Blood pressure decreased, Cardiac failure congestive, Cardiomyopathy, Death, Laboratory test abnormal, Multiple organ dysfunction syndrome, Oedema peripheral, Oxygen saturation decreased, Urinary incontinence
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Apixaban, Aspirin, Atorvastatin, Budesonide, Carvedilol, Docusate, Ferrous Gluconate, Furosemide, Lisinopril, Omperazole, Tiotropium Bromide inhaler, Amlodipine, Tylenol, Albuterol, Naproxen
Current Illness: Hypertension, Chronic ischemic heart disease, COPD, Atrial Fibrillation, Cardiomyopathy, Edema, Dementia, Anemia, Hyperlipidemia
Preexisting Conditions: COPD, Chronic ischemic heart disease, A fib, Hypertension
Allergies: NKA, NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had Covid-19 in October of 2020. He recovered. He received the vaccination on 12/30/2020 with no complaints. On 01-05-2021 it was noted to he was incontinent of urine and bilateral lower extremity edema. Lab work was completed showed acute kidney injury. He had decreased blood pressure and oxygen saturations on 01-06-2021 He was admitted to the hospital with rapid progression of symptoms and suggested multi-system failure. He had a long cardiac history. On 01-14-2021 he passed away with a diagnosis of Cardiomyopathic CHF, A.Fib contributory.


VAERS ID: 1017339 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-30
Onset:2021-02-05
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, SARS-CoV-2 test negative, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (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), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.


VAERS ID: 1017660 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-10
Onset:2021-01-26
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

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

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

Write-up: Patient contracted COVID and was hospitalized. He later died- respiratory failure secondary to COVID-19 pneumonia. This was not related to a vaccine adverse event, but reporting based on requirements.


VAERS ID: 1017960 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-03
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy.


VAERS ID: 1017971 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-02
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


VAERS ID: 1017974 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-01
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


VAERS ID: 1017978 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-01
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


VAERS ID: 1018126 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-04
Onset:2021-02-08
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: chronic conditions listed below
Preexisting Conditions: per wife-diabetes, hypertension, hypercholesterolemia, depression, cvd, previous stroke
Allergies: na
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccination on 2/4. Patient''s wife reported that he felt a slight soreness in his arm the day following the shot, but had no other symptoms. On 2/8 he passed away. Wife reports that it was related to his heart and they never made it to a hospital. The wife also reported that the patient had been in poor health prior to the vaccination


VAERS ID: 1018146 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-28
Onset:2021-02-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Intracranial aneurysm
SMQs:, Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, carpidopa-levodopa, colchicine, januvia, sertraline HCL, finasteride, valsartan, febuxostat, daily vitamin centrum, vitamin d
Current Illness: None
Preexisting Conditions: Type 2 diabetes, BPH, gout, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Four days later, my father had a severe brain aneurysm.


VAERS ID: 1018448 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-02-01
Onset:2021-02-06
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: aspirin 81 mg qd. vitamin D. duloxetine, cymbalta 20 mg qd. Jalyn one daily. ferrous sulfate. namenda. spiriva inhaler. zinc 50 mg qd
Current Illness: none
Preexisting Conditions: dementia. hx stroke. carotid disease. emphysema. hyperlipidemia. BPH
Allergies: oxycodone. penicillin. simvastatin
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/6/2021 stroke. 2/8/2021 he died


VAERS ID: 1019669 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Connecticut  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: heart failure with EF of 20-30%, coronary artery disease, type two diabetes, obstructive sleep apnea, diabetic nephropathy
Allergies: sulfonamides
Diagnostic Lab Data:
CDC Split Type:

Write-up: the following morning the patient became unresponsive while taking a shower, became asystolic and died despite about an hour of ACLS and 8 rounds of epi


VAERS ID: 1019964 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-07
Onset:2021-02-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Ferrous sulfate, Proteinex, Tylenol, Eliquis, Aspirin, Lipitor, Vitamin D3, Cholestyramine, finasteride, flavoxate, lactobacillus, loratadine, magnesium oxide, metoprolol, protonix, miralax, potassium cl, Tamsulosin, acetic acid (for foley)
Current Illness: Peg tube placement Malignant neoplasm of esophagus
Preexisting Conditions: Attention and concentration deficit, Hyperlipidemia, Acute embolism thrombosis of Deep veins or upper extremity, cognitive communication deficit, cerebral infarction, Dysphagia, Thrombocytopenia, Obstructive and reflux uropathy, Hypomagnesemia, Allergic rhinitis, GERD, Hydronephrosis with renal and ureteral calculous obstruction, Benign prostatic hyperplasia with lower urinary tract symptoms, anemia, ulcerative pancolitis, cerebral cysts, chronic obstructive pyelonephritis, hypo-osmolality and hyponatremia, HTN, Vascular dementia with behavioral disturbances, DM II, Moderate protein-calorie malnutrition, Vitamin D deficiency, Folliculitis, Hypokalemia, Aphasia following cerebral infarction, metabolic syndrome
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: The resident received his COVID-19 Moderna vaccination on 2/6/2021 2:11 pm and expired on 2/7/2021 at 6:04 am. There were no signs or symptoms of vaccination reaction leading up to death.


VAERS ID: 1019979 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Death, General physical health deterioration, Hypoxia, Mechanical ventilation, Oxygen saturation abnormal, Respiratory distress, Tachycardia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 12
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: ALBUTEROL HFA (8.5GM) 90 MCG INHA Exp: 05/06/2021 SIG: 90mcg Inhalation every four (4) to six (6) hours as needed x 180 day(s) -- Limited to two (2) canisters every six (6) months Artificial Tears Ophthalmic Solution 1.4 % Exp: 02/23/2021 S
Current Illness: Vitamin Deficiency
Preexisting Conditions: GERD, COPD, HTN, Hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: Patient was assessed at hospital and transferred to another facility on 2/3/21. At this time, the COVID protocol was followed. His condition deteriorated and he was placed on a vent 2/9/21. He was pronounced deceased 2/10/21 at 0610.
CDC Split Type:

Write-up: Patient received the Moderna COVID vaccine 1/28/21. He was tested for COVID 19 on 1/29/31. Results were received 1/30/21, at which time he was evaluated and found to be hypoxic with tachycardia. He was sent to the local ER and returned this same day. On 2/2/21, he was evaluated by the provider, who sent him to the emergency room with acute respiratory distress and poor O2 sats


VAERS ID: 1020002 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-19
Onset:2021-02-05
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Albuterol, Bumetanide, Metolazone, Candesartan, Carvedilol, Gabapentin, Insulin Pantoprazole, Tamsulosin, Warfarin
Current Illness: CHF
Preexisting Conditions: CHF, DM, CAD, CKD, Sleep apnea, COPD
Allergies: cyclobenzaprine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Given First Moderna covid vacc 1/19/2021. Doing well on multiple contacts from health care providers, then 2/5/2021 was driving, pulled over to the side of the road into a yard, got out of the car and told an observer that he could not breathe, collapsed face down in the snow, EMS called, unable to revive him.


VAERS ID: 1020018 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 AR / IM

Administered by: Public       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: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient reported to be unresponsive on the morning after receiving his second dose of Moderna COVID-19 vaccine. Patient had expired during the night.


VAERS ID: 1020079 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-14
Onset:2021-01-31
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Symbicort, sotalol, mexilitine, tiotropium, carbidopa/levodopa, aripiprazole, allopurinol, citalopram, insulin, pantoprazole, pravastatin, tamsulosin, tioptropium, warfarin, bumetanide, bupropion
Current Illness:
Preexisting Conditions: Ischemic Cardiomyopathy, Coronary Artery Disease (MI x2 1989 and 1995), VT (ablation 2009) with Boston Scientific ICD Sick Sinus Syndrome (PPM), Type 2 Diabetes, Chronic Kidney Disease, Hypertension, Hyperlipidemia Peripheral Vascular Disease, Parkinson''s Disease Antiphospholipid Antibody Syndrome Heparin Induced Thrombocytopenia
Allergies: Heparin Atorvastatin
Diagnostic Lab Data: Related to hospital stay. Unavailable currently.
CDC Split Type:

Write-up: Received Moderna covid vaccination 1/14/2021. 1/16/2021 received report of cough and difficulty breathing. Proceeded to hospital and was diagnosed Covid+ on testing. Continued to decline, died 1/31/2021.


VAERS ID: 1020195 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-12
Onset:2021-01-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, COVID-19, Colonoscopy normal, Condition aggravated, Death, Dyspnoea, Occult blood negative, Oesophagogastroduodenoscopy normal
SMQs:, Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Allopurinol, amlodipine, Atorvastatin, carvedilol, ipratropium, asa
Current Illness: None
Preexisting Conditions: HTN, Osteoarthritis, brain aneurysm
Allergies: None
Diagnostic Lab Data: Per hospital record which is currently unavailable
CDC Split Type:

Write-up: Received Moderna #1 on 1/12/2021. 1/15/2021 developed worsening shortness of breath. Went to hospital and diagnosed with anemia, 4 negative fecal tests, neg EGD and colonoscopy. Discharged and readmitted (circumstances unknown for this episode) then readmitted a third time 1/20/2021 for shortness of breath. Diagnosed covid + at third hospitalization and continued to get worse. He died 1/23/2021.


VAERS ID: 1020227 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-02-05
Onset:2021-02-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: ALENDRONATE SODIUM 70MG TABLET (4''S) TAKE ONE (1) TABLET ACTIVE BY MOUTH ONE TIME EACH WEEK WITH WATER 30 MINUTES BEFORE EATING OR TAKING OTHER MEDICATIONS CALCIUM W/ VITAMIN D 600/500 SLOW RELEASE TAKE 2 TABLETS ACTIVE BY MOUT
Current Illness: Pt had COVID with symptom onset 1/27/21, pos test 1/28/21 admitted to Hosptial and was treated w/ remdesivir at , discharged 1/30 on Dexamethasone 6mg daily, no need for O2 supplement. First moderna COVID vaccine was 1/5/21.
Preexisting Conditions: 1)*AU SEVERE LOSS 2)Anemia - 3)Tubular adenoma of colon - 4)*SCLERAL PLAQUE EXCISION OS - STILL PO 2+ MONTH 5)Osteoarthritis - bilateral knees...worse in right knee -QUALIFIERS: Severity Moderate to severe 6)Chronic obstructive lung disease - 7)Onychomycosis - x10 -QUALIFIERS: Severity Mild to moderate Clinical course Chronic 8)Artificial lens present - OU 9)Hypermetropia - OD 10)Presbyopia - OU 11)Regular astigmatism - OD 12)Arcus of cornea - OU 13)Scarred macula - OS 14)Osteoporosis - 15)Osteoarthritis of knee - 16)Hypothyroidism - 17)Benign prostatic hyperplasia - 18)Hip pain, Right - Had right hip fracture pinning and has post traumatic DJD 19)Chronic pain - 20)Dry eyes - 21)Sensorineural hearing loss, Bilateral - 22)Nonexudative age-related macular degeneration, Bilateral -
Allergies: Allergies: CODEINE
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This is the patient who passed away 2d after his second COVID vaccine. Of note, the 2/8 telephone note makes it sound like he was hospitalized at time of death - that is incorrect. His daugther listed as EM contact works in the eye clinic here. He had mild illness, completed 10d isolation but missed his scheduled booster dose on 2/2 due to isolation. He was called on 2/5 when there was a booster visit cancellation and received his booster dose on that day. His daugther reported that he was doing fine and looking well on 2/7 AM, ate breakfast, shortly after stood up and just collapsed.


VAERS ID: 1020684 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-13
Onset:2021-01-16
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Anticonvulsant drug level decreased, Blood pressure abnormal, Death, Heart rate abnormal, Pneumonia, Seizure
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (broad), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: history of seizure disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine at Public Health Clinic. Patient ended up having a seizure 3 days later and ended up in the hospital. Found to have right lobe pneumonia and low depakote level. Patient noted to have multiple seizures at hospital, issues with stabilizing HR and BP, and passed away on 1/20/21.


VAERS ID: 1020702 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-01-20
Onset:2021-02-09
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide, Hydroxyzine, Mirena, Ocrevus, Prednisone, triamcinolone acetonide, valacyclovir, vitamin D 3
Current Illness:
Preexisting Conditions: calcaneal spur displacement of intervertebral disc without myelopathy female stress incontinence foot pain hand joint pain herpes simplex low back pain menorrhagia multiple sclerosis neck pain numbness of lower limb peripheral edema polyneuropathy
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Passed away the morning of 2/9/21.


VAERS ID: 1020724 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-21
Onset:2021-02-02
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID19,
Preexisting Conditions: hypertension and Coronary Artery Disease
Allergies: codeine, penicillin
Diagnostic Lab Data: COVID19 Roche LIAT PCR test - Detected
CDC Split Type:

Write-up: Patient sent to the ED or sudden onset of shortness of breath on 02/02/2021. Per documentation by the MD, the patient had COVID19 "several weeks ago" and the nursing facility felt like he had recovered. A rapid test done in the ED was negative. When the patient worsened and seemed to be following the same path as other COVID patients, a send out PCR test was done, which was positive. The patient worsened and passed away that same day (02/05/2021) I was not made aware that the patient had the vaccine on 01/21/2021 until Monday 02/08/2021.


VAERS ID: 1020749 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-01-13
Onset:2021-01-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cyanosis, Death, Myocardial infarction
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: HTN, Diabetes, High Cholesterol
Allergies: Unknown
Diagnostic Lab Data: No test, lab, nor autopsy.
CDC Split Type: MS0032021

Write-up: Patient had no reaction at the clinic. Patient is a medical doctor whose partner called in this death. States patient had no complaint on 1/13 nor 1/14 while at work. States patient died at home on 1/15 a.m. Physician who stated she was called to the patient''s home @ 0157 1/15/2021 and found cyanotic from head to toe. State girlfriend found him sitting in the chair a few minutes before they called her. The Coroner did not order autopsy. Did not sent patient to the hospital. Sent him directly Funeral Home. Death Certificate Number 123-2021-002593 list cause of death as pending. I spoke with the patient''s primary doctor who gave me the history of HTN, Diabetes, & High Cholesterol. States he had not seen this patient since April 2020. They were also friends and he was not aware of any medical problems. The Coroner state she thinks patient has a heart attack. Neither the Coroner nor PMD think death was related to COVID Vaccine. Informed both that MSDH would have to complete VAERS. Both voiced understanding.


VAERS ID: 1020830 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Aortic aneurysm rupture, Death
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UTO
Current Illness: Leaking Aortic Aneurysm -
Preexisting Conditions: Aortic Aneurysm
Allergies: None
Diagnostic Lab Data: Hospitalization with testing - UTO
CDC Split Type:

Write-up: This resident of the assisted living facility received his Covid-19 Moderna (1st) vaccination and he has a leaking Aortic Aneurysm which resulted in hospitalization and he entered into Hospice care on 1.30.2021 and passed away on 1.30.2021.


VAERS ID: 1021038 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had passed since the first dose was given.


VAERS ID: 1021045 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / UNK RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had passed since the first dose was given.


VAERS ID: 1021052 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had passed since the first dose was given.


VAERS ID: 1021058 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had passed since the first dose was given.


VAERS ID: 1021171 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol, ASA, Zyrtec, D3, CPAP, Zetia, FeSO4, Flonase, Lantus, Atrovent solution, Losartan, Melatonin, Reglan, Metoprolol Succinate, Pantoprazole, Paroxetine, Polyethylene Glycol, Sucralfate, Tamsulosin, Stiolto Respimat
Current Illness: Hypertension, chest pain x 1 month, nausea (1/18/21 primary care visit); memory loss, small left cerebellar infarct (neurology 2/1/21)
Preexisting Conditions: HTN, CAD, cerebellar dysfunction, claudication, old myocardial infarction, COPD/dyspnea/sleep apnea, hx thoracic aortic aneurysm, CHF, DM II (insulin dependent), CKD stage 3, anemia, irregular heartbeat, PVC, hx of smoking, atelectasis, BPH, vascular dementia, angina of effort, GERD/abnormal barium swallow/DM gastroparesis, dyslipidemia, depression
Allergies: Statin intolerance (muscle tightening)
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient received first dose of Moderna COVID-19 vaccine on 2/3/21. Primary Care physician received call from coroner''s office 2/8/21 asking for information contributing to cause of death. Per Primary Care Physician notes, wife states she and patient took turns shoveling snow on 2/4/21. On one trip back into the house she found him unresponsive on the floor and called 911. Paramedics were unable to revive patient and he passed away (2/4/21).


VAERS ID: 1021919 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-06
Onset:2021-01-17
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen therapy, Renal failure, Urinary retention
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Heart disease, unspecified; Renal disease
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; kidney failure (unable to urinate); shortness of breath; required oxygen; A spontaneous report was received from consumer concerning an 87-year-old, female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced shortness of breath, kidney failure and death. The patient''s medical history included advanced kidney and heart disease. No relevant concomitant medications were reported. On 06 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Lot: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 17 Jan 2021, the husband reported that the patient experienced adverse events. Symptoms included shortness of breath and kidney failure (unable to urinate). The patient was admitted to the hospital and discharged to hospice. Oxygen was administrated for shortness of breath. Action taken with mRNA-1273 in response to the events was not applicable. On 20 Jan 2021, the patient died. The cause of death was unknown. Autopsy details were unknown.; Reporter''s Comments: This case concerns a 87-year-old, female patient with the medical history of advanced kidney and heart disease, who experienced fatal unexpected event of dyspnea, renal failure and death. The events of dyspnea and renal failure occurred 12 days and the event of death occurred 15 days after the first dose of mRNA-1273 (Lot: unknown). The patient was admitted to the hospital and discharged to hospice. Oxygen was administrated for shortness of breath. The cause of death was unknown. Autopsy details were unknown. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. However, the history of advanced kidney and heart disease may remain as confounder. Additional information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1021926 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: 2021-01-18
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data: Test Date: 20210108; Test Name: Covid-19 test; Test Result: Positive ; Result Unstructured Data: Positive
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Positive result; A spontaneous report was received from a consumer concerning a female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed COVID-19 and passed away. The patient''s medical history was not provided. Concomitant product use was not reported. On 05 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient had a positive COVID-19 test. On 18 Jan 2021, the patient passed away. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 18 Jan 2021. The cause of death was not reported.; Reporter''s Comments: This spontaneous report concerns a female patient who experienced COVID-19 and passed away. The event of COVID-19 occurred 4 days after the first and only dose of the mRNA-1273 vaccine administered and death occurred 14 days after administration of the mRNA-1273 vaccine. Based on the information provided and the known etiology of COVID-19, it is unlikely to be associated with mRNA-1273 vaccine administration. With no definite information on the clinical details of the death, it is difficult to adequately assess a causal association with mRNA vaccine. Main field defaults to ?possibly related''; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1022440 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-23
Onset:2021-02-01
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute myocardial infarction, Chest pain, Death, Dyspnoea, Pericarditis
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: None
Current Illness: None
Preexisting Conditions: HTN, hyperlipidemia, pericarditis (diagnosed in 2014)
Allergies: None
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: The decedent experienced severe chest pain and dyspnea approximately nine days following the first series of the vaccine. He reported to family members that he was having a "severe reaction" to the vaccine and believed it was acute pericarditis due to the same symptoms he experienced prior. He reported that on 2/1/21 around 0300 hours, the symptoms were the most severe and he was going to seek medical attention, but did not. He waited till the convenient store opened and purchased OTC Tylenol for relief of symptoms. He continued to have dyspnea and chest pain up until 2/9/21, when he called 911 complaining of chest pain and was found to have a STEMI; subsequently died at Hospital in the ER.


VAERS ID: 1022552 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-14
Onset:2021-01-21
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died of cardiac arrest on 01/21/2021


VAERS ID: 1022918 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatine abnormal, Blood urea abnormal, Cardiac failure congestive, Cardiomegaly, Chest X-ray abnormal, Death, Feeling hot, Hiatus hernia, Hypoxia, Leukocytosis, Pleural effusion, Pulmonary oedema, Pulmonary vascular disorder, Renal failure, Spinal fracture, Urinary tract infection, Vomiting, White blood cell disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Alprazolam, Furosemide, Keflex, Losartan, Metoprolol, Protonix
Current Illness: Urinary Tract Infection
Preexisting Conditions: Atrial fibrillation, heart failure, Gerd, Dysphagia, PVD, dementia, anxiety disorder, osteoarthritis
Allergies: Ciprofloxacin, Shellfish
Diagnostic Lab Data: Labs and radiology examinations with abnormal results
CDC Split Type:

Write-up: Resident complained of feeling "hot" at supper time. Had emesis an hour or so later. Became hypoxic and was transferred to the hospital emergency room. Her evaluation in the ED revealed continued presence of UTI, leukocytosis (19.8), and renal insufficiency (BUN 22 Cr. 1.3) BP 99/63; P 74; Temp 98.1; RR 16; and O2 sat of 95% with 2 LPNC (she is typically on RA). CXR reported changes most consistent with CHF with cardiomegaly and bilateral pulmonary vascular prominence. Bibasilar pleural effusions greater on the right than left with pulmonary edema. Large hiatal hernia and likely old chronic wedge defromities involving the mid thoracic vertebral body. She was admitted for IV antibiotics. She expired 2/6/2021


VAERS ID: 1023061 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-30
Onset:2021-02-08
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Axillary pain, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: Levothyroxine 100 mcg tab once a day
Current Illness: pt had teeth pulled for possible dental implants , non ulcer dyspepsia, treated for diverticulitis 1/6/21
Preexisting Conditions: COPD; hypothyroidism; cricopharyngeal achalasia post surgical treatment, aortic atherosclerosis, hx of perforated ulcer from aspirin use
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received the vaccine on 1/30/21 Pt reported symptoms of left armpit pain to wife on 2/7/21, went to work 4 am 2/8/21 and found face down, dead at work later that morning. Pt worked at a pet store, per wife he did complete his tasks and generally comes home by 7:30 am. Wife called when pt did not come back home and he was found dead.


VAERS ID: 1023673 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-14
Onset:2021-01-22
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 19
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: HTN, HLD, diabetes type II, iron deficiency anemia, GERD, BPH, COPD
Allergies: unknown
Diagnostic Lab Data: Patient tested positive by rapid PCR on 1/22/2021 through in-house hospital lab for COVID-19.
CDC Split Type: KYIR ID 5405946

Write-up: Patient was vaccinated on 1/14/2021. On 1/22/2021, patient tested positive for COVID-19 and admitted to the hospital for acute hypoxemic respiratory failure, COVID-19 pneumonia, and severe ARDS. Patient was intubated on 1/23/2021 and later died on 2/10/2021 after being extubated and placed on comfort measures.


VAERS ID: 1023791 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram Oxalate,amlodipine,aspirin,cyanocobalamin,docusate sodium,ergocalciferol,evothyroxine,Melatin,multivitamin,pravastatin,loratadine,senna,Protonix,carvedilol,Lokelma,lidocaine adhesive patch,buprenorphine ,hydralazine,Miralax,hy
Current Illness: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Preexisting Conditions: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Allergies: methadone, morphine, nortriptyline
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DIED WITHIN 5 DAYS OF RECEIEVING THE 2ND DOSE, EXPERIENCED GENERALIZED WEAKNESS.


VAERS ID: 1023840 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-08
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ziprasidone, divalproex, haloperidol, allopurinol, Lisinopril, atorvastatin, aspirin, carvedilol
Current Illness: Hypertension, Morbid Obesity, DMII, Neuropathy, Cardiomyopathy, Hyperurecemia, Glaucoma, Polyp, Foliculitis, Bi-Polar disorder.
Preexisting Conditions: Same as above.
Allergies: NKDA, NKA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was administered Moderna Covid-19 Vaccine on 2/4/2021. Pt exhbited no symptoms of an adverse reaction of any sort. Pt was ambulating alert and attentive. Pt was observed for the alloted 15 mins by pharmacist and case worker who had escorted pt to vaccination clinic. It was reported that Either on sunday 2/7/2021 or monday 2/8/2021 pt had passed away. Circumstances revolving patient death is still unknown.


VAERS ID: 1023948 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-02-06
Onset:2021-02-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Alanine aminotransferase increased, Aspartate aminotransferase increased, Bacterial test positive, Blood sodium decreased, Blood urine present, Cardio-respiratory arrest, Death, Decreased appetite, Fatigue, Feeling abnormal, Lymphocyte count increased, Neutrophil count increased, Prothrombin time prolonged, Resuscitation, Troponin increased, Urine abnormality, Urine analysis abnormal, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Proteinuria (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin C 500 mg daily Bisacodyl 10 mg daily Calcium Carbonate/Vitamin D 500/200 twice daily Clomipramine 100 mg twice daily Divalproex DR 1000 mg twice daily Levothyroxine 50 mcg daily Lisinopril 10 mg twice daily Metoprolol Succinate ER 5
Current Illness: No
Preexisting Conditions: Intellectual Disability Disorder Behavior Disorder (OCD/IED) Hypertension Hyperlipidemia Hypothyroidism Constipation Osteopenia
Allergies: Carbamazepine Loxapine Sulfa Antibiotics Tetracyclines Penicillins
Diagnostic Lab Data: 02/09/21: Urinalysis showed trace blood, cloudy and 2+ bacteria Na= 125 WBC = 13.6 Lymphocytes 6.7 ANC = 10.7 Labs from hospital showed elevated troponin = 155; PT = 22.6; ALT = 405, AST = 205
CDC Split Type:

Write-up: 02/08/21--2 days after vaccine--Resident stated that she "didn''t feel good" (She is developmentally delayed and less able to communicate how she feels than those in the community) and stopped eating most foods; also had fatigue. Vitals, coloring, & behavior were normal. 02/09/21--Belly was firm and mildly distended (although she stated it didn''t hurt); she coded this evening and CPR was performed before EMT could transport her to the hospital. 02/10/21--Resident passed.


VAERS ID: 1023979 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-01
Onset:2021-02-10
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: Medications Azopt 1% ophthalmic suspension, 1 drops, Eye-Both, BID bacitracin/neomycin/polymyxin B topical, 1 appl, Topical, BID, PRN Briviact, 50 mg, 5 mL, Oral, BID calcium carbonate 600 mg (elemental Ca 240 mg) oral tablet, 600 mg,
Current Illness: Dehydration Leukocytosis Dysphagia UTI - Sepsis-resolved Hypernatremia Paroxysmal atrial fibrillation with sick sinus syndrome; S/P pacemaker placement 12/29/20 Acute kidney injury secondary to hypovolemia Macrocytic anemia
Preexisting Conditions: Active Problems Coloboma of iris Atrial fibrillation Mild to moderate hearing loss Dysphagia Peripheral vascular disease Dementia with behavioral disturbance Seborrhea Lagophthalmos Benign prostatic hyperplasia Chronic constipation Gastroesophageal reflux disease Osteopenia Epilepsy Profound ID (IQ <20) ASCVD risk Age-related nuclear cataract, left eye Cardiomegaly Chronic Ileus and megacolon Chronic conjunctivitis Chronic diastolic (congestive) heart failure Chronic obstructive pulmonary disease, unspecified Colostomy and ileostomy status Cyst of right kidney, acquired Dementia with behavioral disturbance Dry eye syndrome of bilateral lacrimal glands Hypocalcemia Hypothyroidism Hypovitaminosis D Iron deficiency anemia Mild hearing loss Mood disorder Nonexudative age-related macular degeneration, left eye, intermediate dry stage Obstructive sleep apnea (adult) (pediatric) Ogilvie''s syndrome Other seasonal allergic rhinitis Presence of cardiac pacemaker 12/29/2020 Primary open-angle glaucoma, bilateral, moderate stage Proteinuria Recent weight gain Recurrent UTI - urinary tract infection Recurrent hypernatremia and dehydration Sick sinus syndrome Sick sinus syndrome s/p pacemaker 12/29/20
Allergies: NKDA
Diagnostic Lab Data: autopsy results are pending
CDC Split Type:

Write-up: Moderna administered 02/01/21. Patient expired 02/10/2020 unexpectedly


VAERS ID: 1024325 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: N/A
Current Illness: SHINGLES ABOUT A MONTH AGO
Preexisting Conditions: AFIB, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL
Allergies: LATEX
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed away on February 5, 2021. There was no reaction after the shot was given, the patient''s son said the death was not related to the vaccine. The patient had a bad case of shingles about a month prior to receiving the vaccine which the son said had been hard on the patient, the patient was also 90 years old. Per the son, the patient''s doctor had wanted the patient to get the vaccine. Due to the close proximity of the date the vaccine was given and the date Patient passed away we wanted to complete the VAERS form.


VAERS ID: 1024420 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Decreased appetite, Headache, Nausea, Pain in extremity, Psychomotor hyperactivity, Pyrexia, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Akathisia (broad), 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 (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Heart Disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had the first Moderna Covid vaccine on Thursday 1/21/2021. She had a bit of sore arm on that day and the day after. On Saturday 1/23/2021, she had a fever of 100.5 F (11AM), nausea, light headache and chills. The temperature went down after she took ibuprofen. Patient''s husband enrolled her to V-Safe to report all the adverse effects she experienced. On Sunday 1/24/2021, her temperature was 98.3F. She still had nausea and no appetite. She and her husband watched a football game in their bedroom upstairs. Husband noticed that his wife was pacing around the room many times. At 7Pm, Husband went downstairs for dinner but she refused to come down to eat. He went upstairs around 8pm, TV was still on. He turned off TV and went down stairs again thinking his wife felt as sleep while watching TV. He went back upstairs for bed around 10:30 PM. Husband said his wife had a deviated septum so she would snore very loudly when asleep. He didn?t hear her snoring so he went to check on her and found her not responsive. Husband called emergency services. Paramedic came at 10:45 and said patient was passed. Husband sent many texts to V-safe after that to report the incident. No response was received from V-safe. Patient?s doctor told her husband that she died due to cardiac arrest.


VAERS ID: 1024539 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-15
Onset:2021-01-28
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, COVID-19, Dyspnoea, Nausea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinol, citalopram, sodium bicarb., furosemide, ascorbic acid, folic acid, pravastatin, vitamin D2, levothyroxine, potassium chloride, calcium carbonate, b complex, omega 3s, prednisone, levocetirizine, tumeric, krill oil, metoprolol
Current Illness: shoulder pain, dermatitis, chronic kidney disease, edema, gerd, venous insufficiency, hypertension, RA, hypothyroidism, osteoporosis, depression, radiculopathy, rosacea.
Preexisting Conditions:
Allergies: alupent, coumadin, cephalexin, saccharin, gabapentin, codeine sulfate, sulpher, onion, perfumes and fragrances, adhesive.
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient tested positive for covid on 1/29/21. was hospitalized on 2/8/21 for shortness of breath, generalized weakness, nausea.


VAERS ID: 1024626 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-01
Onset:2021-02-06
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine,aspirin,losartan,metformin,pravastatin,polyethylene glyco,Colace,cholecalciferol
Current Illness: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Preexisting Conditions: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH ON 5TH DAY OF 2ND DOSE.


VAERS ID: 1024627 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 6
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: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda
Diagnostic Lab Data:
CDC Split Type:

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died


VAERS ID: 1024788 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.


VAERS ID: 1024790 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.


VAERS ID: 1024795 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.


VAERS ID: 1024853 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-30
Onset:2021-02-08
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Aspiration, Death, Fatigue, Haemorrhage, Nasopharyngitis, Nausea, SARS-CoV-2 test negative
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Chemo
Current Illness: Essential Thrombocytopemia Alzheimer?s
Preexisting Conditions: Essential Thrombocytopemia Alzheimer?s
Allergies: None
Diagnostic Lab Data: No medical tests or laboratory exams provided. Medical Examiner declined to physically view the body on site. Through photos or phone video declared death to be natural. Death certificate was later filled out by primary care physician who again did not examine her body or even know the details of her death.
CDC Split Type:

Write-up: Feb 8 states she had a cold. Feb 9 added stomach ache and nausea. Feb 9 visited urgent care facility for exam and Covid-19 test. Rapid test results were negative. Appeared tired but fine. Told to go home and rest. Feb 10 at 9:00 am found dead on the floor in pool of blood and aspirated. Excessive blood in toilet, pooled on floor and hallway rug.


VAERS ID: 1025472 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-10
Onset:2021-02-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dialysis, Fatigue, Peripheral coldness, Pulse absent, Unresponsive to stimuli
SMQs:, Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), 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: 2021-02-10
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID19 vaccine at clinic at 11:52 am, discharge post treatment stable. Got home around 2:30 pm went to bed. He usually got tired post dialysis. He did not wake up at 6 pm. His wife went check on him. found patient cold and unresponsive. 911 pulseless PEA. ER Medical hospital. Pronounced death at 7:40 pm


VAERS ID: 1025079 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: albuterol-ipratropium 2.5mg-0.5mg/3mL nebulizer QID amiodarone 100mg PO daily amlodipine 2.5mg PO daily PRN high blood pressure aspirin 81mg PO daily Symbicort 160mcg-4.5mcg/inh 2 puffs BID calcitriol 0.25mcg PO on M-W-F carvedilol 12.5m
Current Illness: None known
Preexisting Conditions: Aortic Stenosis Coronary Artery Disease asthma Hypertension cardiac pacemaker COPD Chronic kidney disease diastolic heart failure hyperlipidemia thrombocytopenia
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient found by family in his home deceased on the morning of 02/10/2021.


VAERS ID: 1025081 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arteriosclerosis, Autopsy, Condition aggravated, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 5mg, asprin 81mg, atorvastin 10mg, cinacalet 120mg daily, sevelamer 800mg, Nephrocaps (MVT)
Current Illness:
Preexisting Conditions: ESRD on HD, HCV cirrhosis, refractory ascites, CAD, CHF (EF15%-20%), hyperparathyroidism
Allergies: Bactrin, NSAIDS
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reported adverse reactions from 1st or 2nd vaccine doses Patient died on 2/6/2021 at Correctional facility- autopsy was performed at medical examiner''s office. The COD was artherosclerotic cardiovascular disease


VAERS ID: 1025330 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Oxygen saturation decreased, Pneumonia aspiration, Vomiting
SMQs:, Acute pancreatitis (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg po daily, docusate 100 mg BID,Eliquis 5 mg po BId, Omeprazole 20 mg po daily,Zinc 220mg po daily
Current Illness: None
Preexisting Conditions: Dementia
Allergies: None
Diagnostic Lab Data: I have been told by his daughter that he had aspiration pneumonia.
CDC Split Type:

Write-up: On 1/26 at breakfast table began vomiting. Continued thru am when at noon a caregiver did his O2 saturation and found it was 75%. This was confirmed, and resent sent to ER .


VAERS ID: 1025398 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-05
Onset:2021-02-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: COPD, type II diabetes, HTN
Allergies: Latex, Abilify, Gadolinium contrast media
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 2/5. We were told on 2/9 that the patient visited another emergency department on 2/6 but no information was given as to what prompted that visit. She was sent home. Daughter found her on 2/6 or 2/ 7 unresponsive and she died.


VAERS ID: 1025493 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-02-09
Onset:2021-02-11
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Multiple prescription medications, but drug/dose/directions are unknown.
Current Illness: Cancer
Preexisting Conditions: Cancer
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient expired on the morning of 2/11/2021. No known adverse events prior to death. Patient was observed for 20 to 25 minutes after administration of vaccine and reported experiencing no signs or symptoms of adverse events at that time.


VAERS ID: 1026233 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-18
Onset:2021-02-02
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Immune thrombocytopenia, Platelet count decreased
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Plaquenil 200 mg bid/ mirtazapine 30 mg qhs / amlodipine 2.5 mg daily / atorvastatin 80 mg daily / Lasix 40 mg daily / imdur 30 mg qam/ losartan 100 mg daily / Plavix 75 mg daily/ NTG 0.4mg prn/ levothyroxine 150 mcg daily
Current Illness: none
Preexisting Conditions: hypothyroidism,/ acute on chronic diastolic heart failure / polymyalgia rheumatica / hx of cva / hx of CABG/ gerd / bph/ polyarthritis
Allergies: hayfever / Darvocet / norco
Diagnostic Lab Data: plt count of 1,000
CDC Split Type:

Write-up: patient developed autoimmune thrombocytopenia


VAERS ID: 1026379 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-09
Onset:2021-02-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: OXYMETAZOLINE HCL 0.05% NASAL SPRAY DISCONTINUED 30 02/09/2021 02/09/2021 02/09/2021 1 USE 1 SPRAY NASAL TWICE A DAY MAX OF 3 DAYS OF USE** DOCUSATE NA 50MG/SENNOSIDES 8.6MG TAB DISCONTINUED 60 02/09/2021 01/20/2021 01/21/2021
Current Illness: HTN-Iron def-h/o PE-chronic renal failure
Preexisting Conditions: HTN-Iron def-h/o PE-chronic renal failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient 6 hours post vaccination


VAERS ID: 1026396 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-14
Onset:2021-01-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Ageusia, Death, Decreased appetite
SMQs:, Taste and smell disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient experienced loss of taste and lack of appetite. Passed away on 1/23/21.


VAERS ID: 1026443 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-02-09
Onset:2021-02-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amalodopine, Treesiba, Metoprolol, Prevastatin, Telmisarta-HTZ
Current Illness: Unknown
Preexisting Conditions: High Blood Pressure, Adult Onset Diabetes Mellitus
Allergies: None
Diagnostic Lab Data:
CDC Split Type: MS0152021

Write-up: Received first 1/15/2021 with no adverse reaction. Received 2nd dose 2/9 @ 0846 with no adverse reaction or report of feeling ill. Traveled to store and arrived approx. 2 hours after receiving vaccine. Daughter stated patient felt well and had to go to the restroom to have BM. Collapsed in bathroom. Transported by ambulance to Hospital @ 1439 in cardiac arrest. Was in PEA and went in v fib back to PEA. Resuscitation efforts initiated and patient expired with time noted at hospital records at 15:11.


VAERS ID: 1026451 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-01
Onset:2021-02-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired 2/2/2021 one day after the vaccine


VAERS ID: 1026499 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Body temperature increased, Cardio-respiratory arrest, Chills, Death, Pulse absent, Tremor, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (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), Parkinson-like events (broad), 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 (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Lactulose, Lasix, Megestrol Acetate, Metoprolol Tartrate, Spironolactone, Lasix, Vitamin B12, Rifaximin, Milk Thistle, Tramadol
Current Illness: Enterococcus UTI, acute on chronic systolic and diastolic heart failure
Preexisting Conditions: ,chronic kidney disease stage 3, cirrhosis, HTN, hypomagnesemia, hypothyroidism, neurocognitive disorder, hx of hepatic encephalopathy
Allergies: Carvedilol, Tizanidine, Augmentin, ACE inhibitors, Bees
Diagnostic Lab Data: None done at facility
CDC Split Type:

Write-up: Resident reviewed for incident. Resident received the second dose of the Moderna Covid-19 vaccine lot# 016M20A Exp 5/2/2021 on 2/5/2021 from clinic through pharmacy. Resident had her temp/O2 taken on AM shift and was 98.6/93%, beginning PM shift 98.4/95%. A few hours later noted that resident to have chills and was shaking RN assessment completed and vitals taken resident noted to have temp of 102.2, oxygen 95%, pulse 110. Resident alert and oriented at that time and talking to staff. Reported findings to APNP with order to send to ER. 911 called, residents brother updated. Upon EMT arrival RN went down to residents room with EMT and resident had an emesis as resident was getting cleaned up resident went unresponsive. Pulse noted to still be present at that time, resident did briefly respond to sternal rub and then went unresponsive again. Resident full code and EMT transferred to gurney and said that if they lost a pulse in route that they would transfer to hospital B instead of hospital A being the closest facility. RN called brother and gave update. Facility notified from Hospital that resident had passed away.


VAERS ID: 1026534 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: senna, pantoprazole, vit D2, fluoxetine, folic acid, melatonin, metoprolol
Current Illness:
Preexisting Conditions: , HTN, CKD, Alzheimer''s
Allergies: ciprodex
Diagnostic Lab Data:
CDC Split Type:

Write-up: resident had a stroke, sent to the hospital and died 4 days later


VAERS ID: 1026581 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-15
Onset:2021-02-04
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       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: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: tetanus toxoid
Other Medications: Spironolactone, amlodipine, tamsulosin, losartan, pantoprazole, tadalafil, propranolol
Current Illness: He had sudden death on Feb 4th. Unclear if this could be related to vaccination but since it was close in timing report has been filed.
Preexisting Conditions: Hyperparathyroidism s/p surgical correction in 2020, MGUS, Idiopathic peripheral neuropathy, gout, OSA
Allergies: Erythromycin, PCN, Hmg-coa reductase inhibitors, nifedipine, tetanus toxoids, tetracyclines
Diagnostic Lab Data:
CDC Split Type:

Write-up: He had sudden death on Feb 4th. Unclear if this could be related to vaccination but since it was close in timing report has been filed. No known immediate reaction to vaccination.


Result pages: prev   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48   next

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?EVENTS=ON&PAGENO=4&PERPAGE=100&VAX=COVID19&VAXMAN=MODERNA&DIED=Yes


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166