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

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

Government Disclaimer on use of this data



Case Details

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VAERS ID: 1026671 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Agitation, Death, Intensive care, Malaise, Pneumonia
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Eosinophilic pneumonia (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: 2021-01-08
   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: unknown
Current Illness: none reported
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: Patient has not been reported as a COVID related death, no information on status of testing for COVID in the hospital.
CDC Split Type:

Write-up: The vaccine was administered at the patient''s residence in an assisted living facility. The morning following the vaccination staff report that she was very agitated and stated she did not feel well. They called an ambulance and she was transported to a local ER, staff report that it was not at the hospital that the patient is usually seen by when when she has issues and they were concerned that the facility did not have her medical history to treat her properly. The patient''s grandson reported back to the assisted living director that the patient was diagnosed with asymptomatic pneumonia, was transferred to the ICU and passed away in the night.


VAERS ID: 1026752 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-02-03
Onset:2021-02-06
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Seizure, Ventricular fibrillation, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (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? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Plavix Furosemide Amiodarone Humulin Lantus Levothyroxine NTG SL Pepsid Spironolactone Alprazolome Isosorbide Trazadone Nystatin topical Hydroxyuria Sertraline
Current Illness:
Preexisting Conditions: Heart Disease Hx of Triple Bypass surgery Atrial Fib CAD Diabetes GERD Hyperlipidemia HTN Hypothyroid Idiopathic Small Intestine Ulcers PAD Polycythemia
Allergies: Ace Inhibitor Allergy Morphine- Adverse Rxn
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed vomiting, seizure and cardiac arrest, V Fib


VAERS ID: 1026841 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness:
Preexisting Conditions: Dementia, Hyperlipidemia, Hypertension, Osteoarthritis, Cerebral Infarction, COPD
Allergies: Aloe, Tetracycline
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident passed away this morning. No signs or symptoms prior to his death of an issue with the vaccine. He was an end stage dementia resident at the nursing home.


VAERS ID: 1027141 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
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: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acidophilus Capsule BID, Metamucil (Generic) 1 packet/day, Metformin HCL 500 Generic BID, Omeprazole 20 mg Daily, Potassium Cloride ER 20 MEQ tablet PO daily with breakfast, Prenatal Vitamin plus low iron daily with breakfast, Tamsulosin Hc
Current Illness: None, Last prior illness was November 2020 he had Cdiff and was at Hospital but per facility the patient was fully recovered from this.
Preexisting Conditions: Forgetfulness/Mild Dementia, Diabetes, Obese, Urinary Flow Issues all per facility and MAR
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The patient reported feeling well. I discussed with him the Covid-19 vaccine and he was able to state that he wanted it and to sign his consent form. The facility reported they had discussed this with him and he had agreed prior to my visit.


VAERS ID: 1027158 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 500 mg oral tablet, 500 mg= 1 tabs, Oral, TID, 1 refills ammonium lactate 12% topical lotion, 1 app, Topical, BID, 2 refills calcium (as carbonate)-vitamin D 600 mg-400 intl units oral tablet, 1 tabs, Oral, BID, 4 refills C
Current Illness: CKD-4 Dementia Incontinence of stool Insomnia Skin breakdown right gluteus
Preexisting Conditions: Chronic insomnia CKD Constipation Dementia Hepatitis B non-immune Onychomycosis Osteoporosis NOS Stool incontinence x2 ( 2 months and one week ago while out on stret) TIBC - Total iron binding capacity low Tinea pedis Vitamin B12 deficiency Vitamin D deficiency
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: death. Per son pt was not feeling well after the vaccination "like her legs were weak." Son found the mom in her bed 1am on 2/12/2021 unresponsive.


VAERS ID: 1027300 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-06
Onset:2021-02-11
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Nausea, Vomiting
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: 2021-02-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None known
Preexisting Conditions: Aortic aneurysm, aortic stenosis, CAD, HTN, CHF, A-Fib, HLD, Ischemic heart failure, pacemaker, V-Fib, PVD, palpitations, hypotension, and small bowel obstruction.
Allergies: Unknown
Diagnostic Lab Data: None known.
CDC Split Type:

Write-up: Nausea, vomiting and generalized weakness.


VAERS ID: 1027502 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-14
Onset:2021-01-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Resuscitation, 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: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Symbicort, Xanax, Albuterol, Flomax, Polyethylene glycol
Current Illness: N/A
Preexisting Conditions: COPD
Allergies: N/A
Diagnostic Lab Data: No tests were taken. No autopsy completed unless I paid them $5000
CDC Split Type:

Write-up: My dad received his first COVID vaccine on January 14, 2021. On January 16, 2021 he ate breakfast around 7:00 am and went back to his room. When the staff checked on him around 8:00 am they found my dad unresponsive. His blood pressure was over 220 and his pulse was 43. They began manual CPR until the paramedics arrived, but my dad died.


VAERS ID: 1027757 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-25
Onset:2021-01-28
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: 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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1027967 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-15
Onset:2021-01-20
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Coagulopathy, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), 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: 2021-01-22
   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: none
Preexisting Conditions: PMH: Acquired Deformity of toe- Hallux Rigidus, Actinic Keratosis, Anemia Macrocytic, Atherosclerosis, Atopic Dermatitis, Atrophy testis, Bph Local W/urinary Obstruct with LUTS, Cerumen Spondylosis, Cervicalgia, CKD stage 2, Colonic Diverticulosis, Dyspepsia, Dysphagia, Epitaxis, Esophageal Reflux, Hearing loss, Hepatic Cyst, Impaired fasting glucose, Lumbar spondylosis, Male Erectile Disorder, Microscopic Hematuria, Migraine,
Allergies: unconfirmed childhood allergy to penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccination on 1/15/2021. Hemorrhagic Stroke on 1/20 , then diagnosed with complicated idiopathic coagulopathy


VAERS ID: 1028596 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041220A / 2 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose increased, Death, Fatigue, Hypersomnia, Somnolence
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: insulin, cardizem, aggrenox, potassium, aspirin 81mg, zofran 4mg, trimethoprim, gabapentin, colon health, AREDS, biotin, gas-x, tylenol, vitamin D3
Current Illness:
Preexisting Conditions: diabetes, arthritis, PVC''s, macular degeneration, diseased colon, thyroid partially removed
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: *extreme* fatigue. could not awaken for more than few seconds. When briefly awake she was coherent and not confused. slept deeply from 4pm and could not wake to eat or drink. No fever, bp normal, blood oxygen ok. Blood sugar at 11pm was 230. Gave her 15u lantus at 11pm (normally 25u). Was sleeping at 2:30am but had died at next check at 3:30am.


VAERS ID: 1031176 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-02
Onset:2021-02-12
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Hyperventilation, Muscle rigidity, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient received Covid vaccine on 2/2/21, person reports his legs were more rigid with some sweating the day of the vaccination with leg rigidity that was slowly improving. No other adverse effects reported for following 7 days. Person states he had vomiting episode earlier this week, person states he had no other symptoms before or after the vomiting episodes. On morning of 2/12/21, person reports patient got up ready for breakfast with no issues. She says he asked for chorizo and oatmeal but she laughed and said don''t you mean chorizo and eggs. He said yes. They got him into W/C and he was rolling himself into dining room got stuck in hallway. She says he took several breaths then 3 very deep breaths and passed away. She called 911 they took his VS but he has passed. She told them to leave him along no resuscitation.


VAERS ID: 1029003 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-07
Onset:2021-01-10
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Fatigue, Feeding disorder, General physical health deterioration, Hypersomnia, Moaning, Pain, Speech disorder, Unresponsive to stimuli, Wound secretion
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: advanced leukoaraiosis with moderate cerebral atrophy, htn, right breast carcinoma, spinal stenosis
Allergies: none
Diagnostic Lab Data: None. She was on hospice services since being admitted to the nursing home three years earlier.
CDC Split Type:

Write-up: I video chatted with her Thursday after receiving the vaccine. My mom was in poor health but she was talking in complete sentences and responded appropriately. She was upright in bed and made eye contact. She smiled and denied pain. By Sunday, she was extremely weak and unable to sip water with a straw. Her health had changed dramatically and rapidly. She moaned in pain and was very fatigued. Her condition continued to deteriorate over the week and she stopped talking and was constantly sleeping. They started antibiotics for the oozing cancer lesion and then morphine for pain and end of life care. She passed away on January 22nd which was 15 days post vaccination.


VAERS ID: 1029068 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-07
Onset:2021-02-08
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other       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: 2021-02-09
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Mental health, dementia
Preexisting Conditions:
Allergies: No known
Diagnostic Lab Data: Covid-19 positive
CDC Split Type:

Write-up: Patient was given vaccine the following day he died ,


VAERS ID: 1029335 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-02-09
Onset:2021-02-14
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Eplerenone Amiloride KCl Entresto Metolazone Bumex Tamsulosin ASA Docusate prn
Current Illness: none
Preexisting Conditions: Coronary Artery disease with 2 stents Congestive Heart Failure Hyperaldosteronism History of Pulmonary embolus HTN Hyperlipidemia
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiopulmonary arrest


VAERS ID: 1029412 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-02
Onset:2021-02-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NA
Current Illness: None
Preexisting Conditions: None
Allergies: none
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Death


VAERS ID: 1029511 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol 500mg as needed Zyrtec 10mg daily Lysine 500mg daily Nyquil/Dayquil as needed Pepcid 20mg at bedtime
Current Illness: None
Preexisting Conditions: None, never sick
Allergies: None
Diagnostic Lab Data: Jan. 27 2021 when taken to the E.R
CDC Split Type:

Write-up: Developed severe shortness of breath.


VAERS ID: 1029514 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-06
Onset:2021-02-09
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / IM

Administered by: Public       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: unknown
Current Illness: acid reflux
Preexisting Conditions: acid reflux
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: patient deceased


VAERS ID: 1029554 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-17
Onset:2021-02-01
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Pharmacy       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: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died suddenly on 2/1/21 from unknown causes according to his son.


VAERS ID: 1029783 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Delaware  
Vaccinated:2021-01-21
Onset:2021-01-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Chest pain, Death, Dementia, Peripheral coldness, Somnolence, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 7
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: CLOTRIMAZOLE TOPICAL 1% cream topical 1 app applied topically BID COLACE sodium 100 mg capsule oral 1 cap(s) orally daily MELATONIN 10 mg capsule oral 1 cap(s) orally once a day (at bedtime) MEMANTINE 10 mg tablet oral 1 tab(s) orally BID P
Current Illness: Progressive decline in ability to ambulate. Appetite and oral intake has continued to decline over the past 2 weeks.
Preexisting Conditions: A 90-y/o lady with medical history of CAD, Vitamin D Deficiency, Dementia, GERD, Hypertension, Incontinence, and Osteoarthritis.
Allergies: PCN
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Shortly after receiving the Moderna COVID-19 vaccine, patient complained of chest and stomach pain, then became very sleepy and fainted. RN was unable to obtain a manual BP; Apical pulse 36. Pulse Ox in the 70s. She was placed in bed and eventually regained consciousness. Her pulse ox improved to the 90s. BP 92/55. Her only complaint was that her hands were cold. Medical Director believes it was vasovagal syncopy due to receiving the vaccine. Patient died on 1/28/2021, due to progressive dementia.


VAERS ID: 1030025 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Oklahoma  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No adverse event history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient was died. The patient''s medical history was not provided. Concomitant product use was not provided. On an unknown date, the patient received his first dose of mRNA-1273 (Lot number unknown) for prophylaxis of COVID-19 infection. On an unknown date, the patient was died. Treatment of this event was not provided. The patient was died. The cause of death was not provided. Autopsy details were not provided.; Reporter''s Comments: This case concerns a male patient (unknown age), who experienced event of death (cause unknown). The event occurred on an unknown date after the first and last dose of mRNA-1273 vaccine administration. Autopsy and cause of death were not reported. Based on the current available limited information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded and the events are assessed as possibly related.; Reported Cause(s) of Death: Death


VAERS ID: 1030273 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2020-12-30
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-30
   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:
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: Death; A spontaneous report was received from a reporter concerning a patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. The patient received their first of two planned doses of mRNA-1273 on 28 Dec 2020 intramuscularly for prophylaxis of COVID-19 infection. On 30 Dec 2020, 2am the patient passed away. Administrator marked as natural causes. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. The outcome of the event was fatal. The patient died on 30 Dec 2020. The cause of death was reported as unknown. The reporter did not provide an assessment for the event, passed away.; Reporter''s Comments: This case concerns a patient of unknown age and gender. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot 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. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1030323 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / UNK - / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood potassium normal, Blood sodium normal, Carbon dioxide normal, Cardio-respiratory arrest, Death, Fall, Haemoglobin decreased, Laboratory test, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (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), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (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: Albuterol Alirocumab Asprin Atrorvastatin Calcium Budesonide-Formoterol Fumarate Calcitriol Calcium Acetate Carvedilol Clopidogrel Bisulfate Erogcalciferol Ezetimibe Fluticasone-Salmetrol Lasix Glucagon Hydralazine Insulin Ipratropium inhal
Current Illness: Asymptomatic COVID Hospital for Polymosis January
Preexisting Conditions: ESRD Diabetes Type 2 Heart disease CHF CAD CABG
Allergies: Niacin
Diagnostic Lab Data: 2/3 labs potassium 4.5, sodium 137, CO2 29, hgb 9.7
CDC Split Type:

Write-up: Patient had COVID vaccination on 2/3 with no adverse s/s before leaving unit. Upon coming to treatment Friday 2/5 he reported to the RN that he had fallen on thursday 2/4 due to "getting up fast" did not hit head or hurt anything per RN discussion. Began treatment without difficulty. About 3/4 way through treatment was talking with staff and became unresponsive - code was called and pt expired after 30 minute resuscitation efforts.


VAERS ID: 1030468 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Blood creatinine increased, Blood potassium increased, Brain natriuretic peptide increased, C-reactive protein increased, Death, Hyperkalaemia, Hypotension, Hypoxia, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: Lisinopril, Flomax, Sotalol, simvastatin, Xarelto, Requip, Omeprazole, symbicort, Albuterol Aerosol, Furosemide.
Current Illness: ACUTE KIDNEY FAILURE, QUESTION SEPSIS, CHF, ATRIAL FIBRILLATION, COPD, GERD, RESTLESS LEG SYNDROME, HISTORY OF PROSTATE CANCER, HYPERTENSION, CURENT TOBACCO USAGE
Preexisting Conditions: COPD, CHF, ATRIAL FIBRILLATION, GERD, RESTLESS LEG, HISTORY OF PROSTATE CANCER, HYPERTENSION
Allergies: none
Diagnostic Lab Data: potassium 7.2, creatinine 4.3, CRP 50. BNP 3230. WBC 10,200.
CDC Split Type:

Write-up: Pt presents to ER with increased weakness, hypoxia, history of COPD, but not oxygen dependent., hypotension. Acute Kidney failure noted in labs, not previously diagnosed , new hyperkalemia. BP 73/39, HR 67. dopamine initiated, and switched to Levophed. Oxygen Sat 86%, requiring 10 L O2. Transferred from this critical access hospital to another Hospital. Expires later 2-13-2021


VAERS ID: 1030557 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-02-10
Onset:2021-02-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aortic aneurysm rupture, Death, Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan/HCTZ 100/25mg Alendronate Sodium 70mg
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: According to her husband, approximately 3 hours after vaccine, patients clasped and was instantly unconscious. She was pronounced dead upon arrival to hospital and physician told husband that she had suffered a burst abdominal aneurysm and passed immediately. Nothing was out of ordinary during vaccination and during 15 minute wait time after.


VAERS ID: 1030586 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-11
Onset:2021-02-14
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / ID

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This individual''s employer informed our facility that he passed away at his home on 2/14/2021. Since he was not brought into our hospital, we do not have information regarding other health conditions or active medications. Since this individual received his second covid vaccine three days prior, this was reported to Moderna in addition to this VAERS report being completed. The coroner for County can be contacted.


VAERS ID: 1030701 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-08
Onset:2021-02-12
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: pregabalin, metoprolol succ, losartan, rosuvastatin, furosemide, duloxetine, Eliquis, ferrex, diltiazem, latanoprost
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown, husband reported hospitalization 02/12 and deceased 02/15


VAERS ID: 1030712 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Decreased appetite, Depressed level of consciousness, Fatigue, Food refusal, Loss of consciousness, Pyrexia, Respiratory rate increased
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination


VAERS ID: 1030787 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Echocardiogram abnormal, Electrocardiogram ST segment elevation, Nausea, Pulseless electrical activity, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Hypokalaemia (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: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still.
CDC Split Type:

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21


VAERS ID: 1030852 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died; A spontaneous report was received from a reporter concerning a unknown patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. 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 patient passed away. No treatment information was provided. Action taken with RNA-1273 in response to the event was not applicable. The patient died on unknown date. The cause of death was reported as unknown. Autopsy details were unknown.; Reporter''s Comments: This case concerns a patient of unknown age and gender. The patient''s medical history was not provided. The fatal, unexpected event of death occurred on an unknown date after the administration of the first dose of mRNA-1273 on an unknown date. The cause of death was reported as 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 event, a causal relationship cannot be excluded. Additional information regarding the autopsy report, date of the mRNA administration, day of death, medical information and details of concomitant product are all required for further assessment of causality.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1031544 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-11
Onset:2021-02-14
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Imaging procedure, Loss of consciousness, Subdural haemorrhage
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alendronate 70mg tab Clopidogrel 75mg tab Donepezil 5mg tab Hydrochlorothiazide 12.5mg Lactobacillius tabs Levothyroxine 75mcg tab Lostartan 50mg tab Citrucel PO Metoprolol tartrate 25mg tab Pantoprazole 40mg tab Rosuvastsatin 10mg tab Tria
Current Illness: Diagnosed with subdural hemorrhage at time of incident
Preexisting Conditions: Hyperlipideia Hx stroke Hypothyroidism Gastric ulcer HTN Stress incontinence Uterine cancer Late onset Alzheimer''s Osteopenia Osteoarthritis Varicose veins in legs Venous insufficiency Adjustment disorder with anxiety
Allergies: Ibandronic acid- nausea and vomiting Sulfa- nausea and vomiting Risedronate Environmental- pollen Nitrofurantoin macro Ezetimibe-Simvastatin Codeine- anxiety Erythromycin- nausea
Diagnostic Lab Data: Imaging 2/13-2/14
CDC Split Type:

Write-up: Patient family had been noticing onset confusion for a few weeks prior to vaccine and event. Patient was taken to ED when found unconscious and died of a subdural hemorrhage a few days after vaccine clinic at retirement home.


VAERS ID: 1031593 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-11
Onset:2021-02-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Hypersomnia
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Calcitriol 0.25mcg, glyburide 2.5mg, atorvastatin 40mg, nitroglycerin 0.4mg, furosemide 40mg, isosorbide ER 60mg, warfarin 5mg, gabapentin 300mg, allopurinol 100mg
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On February 11, 2021 around 10:15 am, patient was given the Moderna brand COVID-19 vaccination. After his vaccination, he was instructed to wait around for 15 minutes after the administration of the vaccine. During this time, there were no reported issues with the patient. On February 15, 2021 around 9:15am, patient''s wife called the pharmacy and spoke with the pharmacist informing her that patient had passed away in his sleep on Saturday evening. Patient''s wife inquired about whether death may have been caused by an adverse reaction to the vaccine. During the call patient''s wife mentioned that patient slept a lot the day of the vaccine and the day after. patient''s wife mentioned that patient woke up Saturday to eat breakfast and lunch. She states that later that evening, she found patient asleep and cold which she then realized that he''d passed away.


VAERS ID: 1031629 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-08
Onset:2021-02-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 7+ RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Death, Diet refusal, Fluid intake reduced, General physical health deterioration, Haematemesis, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

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: Amlodipine, Fentanyl Transdermal, Gabapentin, Lorazepam, Metoprolol, Morphine, Omeprazole, ONdansetron, Miralax, Tylenol, Ibuprofen
Current Illness: Compression fracture
Preexisting Conditions: Abdominal Aortic Aneurysm, Constipation, Malnutrition, Peripheral Vascular Disease
Allergies: GI upset from Fentanyl, No other food or drug allergies
Diagnostic Lab Data: No lab or other tests performed at request of family as patient was on hospice palliative care.
CDC Split Type:

Write-up: Patient became nauseated about 10 minutes after vaccine administered, this subsided but returned several hours after the vaccine was given. She continued with intractable nausea and vomiting for about 24 hours. This patient was enrolled in hospice and she continued to decline and refused to eat or drink. She was taking Ibuprofen due to intractable back pain. Her emesis was coffee ground color. After this her condition continued to decline until her death


VAERS ID: 1031767 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration pleural cavity, Confusional state, Death, Hypotension, Oxygen saturation decreased, Pleural effusion, Pneumonia, Septic shock, Staring
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Polyethylene Glycol 3350 Powder Calcium-Vitamin D Tablet 500-200 MG-UNIT (Calcium Carb-Cholecalciferol) Lidocaine Patch 4 % Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Melatonin Tablet 3 MG traMADol HCl Tablet 50 MG Ferrous Glucona
Current Illness: ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION POLYNEUROPATHY, UNSPECIFIED GENERALIZED ANXIETY DISORDER LOCALIZED EDEMA GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS INSOMNIA, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DYSPHAGIA, UNSPECIFIED DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED WEAKNESS MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING HYPERLIPIDEMIA, UNSPECIFIED AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OLD MYOCARDIAL INFARCTION HISTORY OF FALLING PERSONAL HISTORY OF PEPTIC ULCER DISEASE BARIATRIC SURGERY STATUS PRESENCE OF LEFT ARTIFICIAL KNEE JOINT PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
Preexisting Conditions: ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION POLYNEUROPATHY, UNSPECIFIED GENERALIZED ANXIETY DISORDER LOCALIZED EDEMA GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS INSOMNIA, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DYSPHAGIA, UNSPECIFIED DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED WEAKNESS MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING HYPERLIPIDEMIA, UNSPECIFIED AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OLD MYOCARDIAL INFARCTION HISTORY OF FALLING PERSONAL HISTORY OF PEPTIC ULCER DISEASE BARIATRIC SURGERY STATUS PRESENCE OF LEFT ARTIFICIAL KNEE JOINT PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
Allergies: Dilaudid
Diagnostic Lab Data: Resident hospitalized; Dx: pneumonia with septic shock. Thoracentesis for large pleural effusion performed in hospital. Resident expired on 2/4/2021.
CDC Split Type:

Write-up: 1/31/2021 12:50 Nursing Note Note Text: Res had low BP, low O2 sats, 30 breaths per minute, eyes open wide, making confused utterances. Started supplemental oxygen via NC, 2L, then 3L. Sats went up to 93% for a while, Sprvsr called. Unable to auscultate Left lung sounds. Called to update Res daughter. Called to page NP, writer went back to assess Res and O2 sats were 88%, turned O2 to 4LPM, called 911 for transport to Hospital ED. Left around 1030. NP called back afterwards, was updated. Family updated that Res was sent to Hospital ED. Note Text: Received phone call from daughter as well as information from hospital. Resident has pneumonia with septic shock. She is on abx and had thoracentesis performed for large pleural effusion. [linked]


VAERS ID: 1031993 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-12
Onset:2021-02-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Influenza like illness
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unkown
Current Illness:
Preexisting Conditions:
Allergies: KNDA or other allergies listed
Diagnostic Lab Data: When check on next morning by staff patient was deceased.
CDC Split Type:

Write-up: Patient reported mild flu like symptoms from vaccination later that evening. Next morning LTCF staff found pt deceased


VAERS ID: 1032252 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-26
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, 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: 2021-01-30
   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: MetFORMIN HCl Tablet 500 MG bid with meals GlipiZIDE Tablet 5 MG bid ac meals PROSTAT SUGAR FREE 30cc tid ROBITUSSIN DM 10ml q4hrs prn Lipitor Tablet 10 MG (Atorvastatin Calcium qd at 5pm NX: DIABETIC ICE CREAM (EXTRA DESSERT) two times a
Current Illness: Loss of appetite and generalized body weakness
Preexisting Conditions: DM Type 2
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident tested COVID-19 confirmed positive a few days after covid vaccination.


VAERS ID: 1032265 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-27
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Hypotension, Oxygen saturation decreased, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: PROSTAT SUGAR FREE Give 30 cc orally three times a day for SUPPLEMENT WITH MEDPASS TO PROVIDE 45G DSS 100 MG Give 1 tablet orally one time a day for (STOOL SOFTENER) HOLD FOR LBM HEALTHSHAKE 4OZ. PO three times a day for (SUPPLEMENT) BET
Current Illness: NONE
Preexisting Conditions: ANEMIA DEMENTIA HYPERLIPIDEMIA HYPERTENSION GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident tested NEGATIVE for COVID-19 last 1/25/2021. She was on monitoring for desaturation and low blood pressure on Jan. 27,2021


VAERS ID: 1032279 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-29
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: General physical health deterioration, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin C Tablet 500 MG (Ascorbic Acid) Give 1 tablet orally two times a day for (SUPPLEME NX: ICE CREAM two times a day @ LUNCH AND DINNER HEALTHSHAKE 4OZ. PO three times a day for SUPPLEMENT BETWEEN MEALS ARTIFICIAL TEARS Instill 1 dr
Current Illness: NONE
Preexisting Conditions: ATHEROSCLEROTIC HEART DSE DEMENTIA HLD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident tested NEGATIVE for COVID-19 on 1/25/2021. She was on monitoring for declining in condition on 1/29/2021.


VAERS ID: 1032303 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-07
Onset:2021-02-01
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Condition aggravated, Decreased appetite, General physical health deterioration, SARS-CoV-2 test negative
SMQs:, Guillain-Barre syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: PUREED diet, Pureed texture DIET: DOUBLE PORTION @ ALL MEALS DIET: EXTRA PROTEIN ENTREE three times a day @ BREAKFAST, LUNCH AND DINNER NX: GLUCERNA 1.5 120CC three times a day for (SUPPLEMENT) WITH MEDPASS Zinc Sulfate Tablet 220 (50 Zn)
Current Illness: On monitoring for declining in condition, loss of appetite and generalized body weakness on2/1/2021
Preexisting Conditions: Hemiplegia & Hemiparesis on left non-dominant side Atherosclerotic heart Dse. Type 2 Diabetes Mellitus Cerebral Infarction PAF Thyroid Disorder Hypertension Cerebral edema GERD Occipital Neuralgia
Allergies: NKA
Diagnostic Lab Data: labs were ordered prior rto admitting to Hospice Care. NEGATIVE for COVID-19 on 2/1/2021.
CDC Split Type:

Write-up: On monitoring for declining in condition, loss of appetite and generalized body weakness on2/1/2021. Was confirmed COVID-19 positive 4/23/2020.


VAERS ID: 1032321 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-19
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Regular diet, Regular texture NX: 2CAL HN 120CC 1 CAN PO three times a day WITH MEDPASS DIET: RICE PORRIDGE ALL MEALS PER RESIDENT''S REQUEST three times a day NX: 4OZ. HEALTHSHAKE PO three times a day BETWEEN MEALS Docusate Sodium Capsu
Current Illness: none
Preexisting Conditions: Wedge Compression Fracture of T-11-T12 Atrial Fibrillation BPH GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident has shortness of breath on 1/19/2021 and was transferred to Hospital 1/20/2021


VAERS ID: 1032327 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-04
Onset:2021-02-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: SARS-CoV-2 test negative, Weight decreased
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: PUREED diet, Pureed texture NX: ICE CREAM (EXTRA DESSERT) two times a day @ LUNCH AND DINNER PROSTAT SUGAR FREE Give 30 cc orally two times a day for SUPPLEMENT WITH MEDPASS TO PROVIDE 30GRAMS PROTEIN AND 200CNX: HEALTHSHAKE 4OZ. PO thre
Current Illness: None
Preexisting Conditions: Heart Failure Chronic Kidney Dse. Dementia Atheroschlerotic Heart Dse. Anemia Hypothyroidism Major Depressive Disorder Nonrheumatic aortic valve stenosis Cardiomegaly Hypertension Dysphagia Osteoporosis
Allergies: Fosamax, Linzess
Diagnostic Lab Data: tested NEGATIVE for COVID-19 on 2/8/2021 Has completed and fully vaccinated last 1/7/2021 and 2/4/2021.
CDC Split Type:

Write-up: On monitoring for weight loss .


VAERS ID: 1032575 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-01-19
Onset:2021-01-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chills, Death, Dyspnoea, Malaise, Myalgia, Pyrexia, Respiration abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Two days later passed away; difficulty breathing, shortness of breath; difficulty breathing, gurgling; Not feeling well; Achiness; Severe fever; Chills; A spontaneous report was received from a physician concerning a 56-year-old female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed fever, chills, achiness, shortness of breath, gurgling and unresponsive. The patient''s medical history was not provided. Concomitant product use was not provided. On 19 Jan 2021, prior to the onset of the events, the patient received their second of two planned doses of mRNA-1273 (Lot 042L20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. After receiving the vaccine on 19 Jan 2021, the patient experienced fever, chills, shortness of breath, gurgling and achiness. On 21 Jan 2021, the patient was found unresponsive. Emergency medical services were called to perform life saving measures however, they were unsuccessful. No further treatment information was provided. The patient died on 21 Jan 2021. The cause of death was reported as unknown. An autopsy was planned.; Reporter''s Comments: This case concerns a 56-year-old, female, who experienced a serious event of death, with many other events after receiving second dose of mRNA-1273 (Lot# 042L20A). Very limited information regarding these events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1032873 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-13
Onset:2021-02-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Death, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Lipitor, Calcium, Plavix, Cardura, Finasteride, Prozac, Metoprolol, Sinemet, Januvia, Flomax, Vitamin B12, Vitamin C, Vitamin D3
Current Illness: Had Covid 19 in Dec. 2020, Tested negative at beginning of Feb. 2021. No other illness.
Preexisting Conditions: Type 2 diabetes. Controlled hypertension.
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: He had rigors starting 6 pm the day after the vaccination. He was treated with one 500 mg tylenol. He had increased wheezing but did not complain of SOB. At 0400 the next morning, he died.


VAERS ID: 1033155 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-02-11
Onset:2021-02-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

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

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone, Rosuvastatin, Prevacid, Zetia, ASA, MVI, Nitroglycerin, Metformin, Potassium, Bumex, Apixaban, Omega 3, Metoprolol, Midodrine,
Current Illness: Generalized ischemic myocardial dysfunction, lower leg edema with cellulitis
Preexisting Conditions: Ischemic Cardiomyopathy, Diabetes, Combined Systolic/Diastolic Heart Failure, Edema, Ventricular Tachycardia, Pacemaker, Stroke, Myocardial Infarction, Hyperlipidemia, Hypertension, Obesity, Coronary arteriosclerosis, Paroxysmal atrial fibrillation, Left ventricular thrombus, Cardiorenal Sydrome, Bilateral lower leg cellulitis
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccine given in clinic per protocol - patient monitored for 15 minutes, no adverse reactions noted at the time. Patient stated he felt fine following 15 minute monitoring time. Patient left facility- it was later reported that pt had a fall at home. Upon review of pt''s medical record - Pt''s wife had to initiate CPR and call EMS for transportation and life saving measures enroute to the Emergency Room. Pt was intubated as pt was in asystole upon arrival to the ER, ACLS was continued, pt was noted to have a traumatic brain injury from his fall at home, and pt was pronounced dead at 1620.


VAERS ID: 1033263 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-02-14
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1033448 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Pneumonia, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Blood Thinners Pyschotropics
Current Illness: Had Covid-19 one month prior
Preexisting Conditions: Irregular Heart Asthma pneumonia prone
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever by the next day, difficulty breathing, pneumonia, and then DEATH within a few days. (Died 02/01/2021)


VAERS ID: 1033466 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Resuscitation
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: 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: Asthma/COPD, Diabetes mellitus (DM), Hypertension (HTN), Renal Disease (e.g. CKD, HD, ESRF), A-fib, pulmonary hypertension, chronic loculated empsyema, chronic aspiration pneumonitis, pacemaker, chronic anticoagulation
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 70 yo man with multiple severe medical comorbidities received his first dose of Moderna COVID-19 vaccination without incident. 8.5 hours later, he was noted by his family to be in his usual state of health. 9.5 hours after the vaccination, he was found down by his family in cardiac arrest. Resuscitation attempts were not successful, and the patient died.


VAERS ID: 1033472 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Resident coded and expired; A spontaneous report was received from a consumer concerning a patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and coded and expired. The patient''s medical history was not provided. No concomitant product use was reported. On an undisclosed date, the patient received their first of two planned doses of mRNA-1273 (Lot number: not provided) for prophylaxis of COVID-19 infection. On undisclosed date, the patient coded and expired. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on an undisclosed date. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: MEDICAL COMMENT: MOD 2021 009822 DEATH NOS This case concerns a patient of unknown age and gender who received their first of two planned doses of mRNA-1273 (Lot number: not provided) for prophylaxis of COVID-19 infection and had died. Very limited information regarding this event has been provided at this time to make a proper medical assessment, therefore, the causality is unlikely related to the vaccine in this case of death not otherwise specified. No contact information provided. Follow up is not expected.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1033607 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-12
Onset:2021-02-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 UN / -

Administered by: Military       Purchased by: ?
Symptoms: Death, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin, anti depressant, baby aspirin.
Current Illness: Allergies
Preexisting Conditions: Diabetes, circulation problems, awaiting stent surgery on neck artery.
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vomiting, death.


VAERS ID: 1034146 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-13
Onset:2021-02-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 01620A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: N/A
Current Illness: WAS NOT REPORTED AT TIME OF VACCINATION
Preexisting Conditions:
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC Split Type:

Write-up: ARRIVED AT EVENT, CONSENT FORM COMPLETED, DID NOT REPORT HE HAD BEEN ILL, DID NOT REPORT THAT HE TOOK ANY FEVER REDUCING MEDICATIONS


VAERS ID: 1034192 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-02-01
Onset:2021-02-03
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cerebral small vessel ischaemic disease, Death, Intestinal infarction, Intestinal ischaemia, Intraventricular haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Ischaemic colitis (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Fosamax, Cosopt soln, Emollient, Xalantan soln, Effient, Zocor
Current Illness: Glaucoma, HLD
Preexisting Conditions: Glaucoma, HLD
Allergies: none
Diagnostic Lab Data: Too numerous to include
CDC Split Type:

Write-up: Patient presented with spontaneous IVH of small vessel origin with essentially no past medical history. She then acutely developed mesenteric ischemia. Died due to all dead small bowel which also appeared to be small vessel disease and not embolic/thrombotic. This process started one week after


VAERS ID: 1034349 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase increased, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bicarbonate increased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood gases abnormal, Blood glucose increased, Blood magnesium increased, Blood methaemoglobin, Blood potassium normal, Blood sodium decreased, Blood urea normal, Carbon dioxide decreased, Carboxyhaemoglobin decreased, Confusional state, Death, Differential white blood cell count, Electrocardiogram normal, Eosinophil count normal, Eosinophil percentage, Fibrin D dimer increased, Fraction of inspired oxygen, Full blood count, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Hypotension, Influenza A virus test negative, Influenza B virus test, International normalised ratio increased, Lymphocyte count, Lymphocyte percentage, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mental status changes, Metabolic function test, Methaemoglobin urine absent, Monocyte count decreased, Monocyte percentage, N-terminal prohormone brain natriuretic peptide increased, Neutrophil count, Neutrophil percentage, Nucleated red cells, Oxygen saturation normal, PCO2 decreased, PO2 increased, Platelet count decreased, Protein total normal, Prothrombin time prolonged, Red blood cell count decreased, Red cell distribution width normal, Respiratory distress, SARS-CoV-2 test negative, Troponin I increased, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: Amlodipine 2.5 mg BID Metformin 500 mg BID Losartan 100 mg qd Simvastatin 10 mg qd Levothyroxine 50 mcg qd torsemide 20 mg qd
Current Illness: Unknown
Preexisting Conditions: Congestive heart failure Hypertension Type 2 Diabetes Chronic venous insufficiency Hypothyroidisn Coronary artery disease Dyslipidemia
Allergies: None
Diagnostic Lab Data: BLOOD GAS, ARTERIAL Result Value Ref Range Puncture Site Right Radial Allen''s Test Pos pH Measured 7.111 (LL) 7.350 - 7.450 pCO2, Measured 27.9 (L) 35.0 - 45.0 mmHg PO2 Measured 143.9 (H) 80 - 100 mmHg Bicarbonate 8.7 (LL) 20.0 - 26.0 mmol/L Base Deficit 19.4 (H) 0.0 - 3.0 mmol/L Carboxyhemoglobin 0.2 (L) 0.5 - 1.5 % Methemoglobin 0.0 0.0 - 1.5 % O2 Saturation 98 94 - 99 % FiO2 60 COMPREHENSIVE METABOLIC PANEL W GFR Result Value Ref Range Sodium 131 (L) 136 - 145 mmol/L Potassium 4.7 3.5 - 5.1 mmol/L Chloride 100 98 - 107 mmol/L CO2 (Bicarbonate) 10 (LL) 21 - 32 mmol/L Anion Gap 21 (H) 3 - 12 mmol/L Glucose 488 (HH) 70 - 99 mg/dL BUN 25 6 - 25 mg/dL Creatinine 2.01 (H) 0.40 - 1.00 mg/dL GFR Est-Other 21 (L) $g60 See Cmnt GFR Est-African American 25 (L) $g60 See Cmnt Calcium 9.0 8.2 - 10.2 mg/dL Total Protein 6.6 6.4 - 8.2 g/dL Albumin 3.2 3.2 - 4.7 g/dL Total Bilirubin 1.1 0.1 - 1.3 mg/dL Alkaline Phosphatase 71 26 - 137 U/L AST 47 (H) 0 - 37 U/L ALT 36 15 - 65 U/L TROPONIN I Result Value Ref Range Troponin I 0.09 (H) 0.00 - 0.05 ng/mL N-TERM PRO-BRAIN NATRIURETIC PEPTIDE (PROBNP) Result Value Ref Range NT Pro BNP 1,580 0 - 1,800 pg/mL MAGNESIUM Result Value Ref Range Magnesium 2.6 (H) 1.5 - 2.5 mg/dL CBC WITH AUTOMATED DIFFERENTIAL Result Value Ref Range White Blood Cell Count 6.8 4.0 - 11.0 K/uL Red Blood Cell Count 3.37 (L) 3.90 - 5.40 M/uL Hemoglobin 9.9 (L) 11.7 - 15.5 g/dL Hematocrit 30.9 (L) 35.0 - 47.0 % MCV 92 80 - 100 fL MCH 29.4 27.0 - 33.0 pg MCHC 32.0 31.0 - 36.0 g/dL RDW 14.1 <16.4 % Platelet Count 144 (L) 150 - 400 K/uL Differential Type Automated Neutrophil % 72 % Lymphocyte % 25 % Monocyte % 3 % Eosinophil % 0 % Basophil % 0 % Abs. Neutrophil 4.8 2.0 - 8.0 K/uL Abs. Lymphocyte 1.7 1.0 - 5.1 K/uL Abs. Monocyte 0.2 0.0 - 0.8 K/uL Abs. Eosinophil 0.0 0.0 - 0.5 K/uL Abs. Basophil 0.0 0.0 - 0.2 K/uL NUCLEATED RBC AUTO 0.0 0.0 /100 WBC PROTHROMBIN TIME/INR Result Value Ref Range Prothrombin Time 16.1 (H) 12.1 - 14.7 sec INR 1.3 (H) 0.8 - 1.2 PARTIAL THROMBOPLASTIN TIME Result Value Ref Range PTT 26.3 23.3 - 36.2 sec D-DIMER,QUANTITATIVE Result Value Ref Range D Dimer, Quant 2.70 (H) <0.50 ug(FEU)/mL INFLUENZA A & B NAAT Result Value Ref Range INFLUENZA A RNA Not Detected Not Detected INFLUENZA B RNA Not Detected Not Detected CORONAVIRUS 2019 NAA(COVID-19,SARS2) Result Value Ref Range SARS-COV-2, NAA Not Detected Not Detected ECG interpretation : junctional rhythm, regular, no ST elevation or depressions, diffuse T wave flattending, no marked QT prolongation. Interpreted contemporaneously by me.
CDC Split Type:

Write-up: Patient awoke on 2/12/21 with altered mental status, confusion, respiratory distress, was taken to hospital by ambulance. Per ED notes from ED attending Pt presented with hypotension and respiratory distress. DNR status, patient given comfort measures and passed away in ED at 11:24 am on 2/12/21.


VAERS ID: 1034985 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Kentucky  
Vaccinated:2021-01-04
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: 4 Nurshing home patients Died; A Spontaneous report was received from a pharmacist concerning 4 nursing home patients of unspecified age and gender who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patients'' medical histories were not provided. No relevant concomitant medications were reported. On unspecified dates, 4 nursing home patients received their first of two planned doses of mRNA-1273 (Lot # 039K20A) for prophylaxis of COVID-19 infection. A pharmacist reported that they just learned 4 nursing home patients died after the first dose of the Modern vaccine. The patients were buried, and no autopsies were conducted. The pharmacist suspected latent Covid-19 on the patients and that the vaccine precipitated this outcome. No treatment information was provided. Action taken with the second dose of mRNA-1273 in response to the event was not applicable. The event 4 nursing home patients died was fatal.; Reporter''s Comments: This case concerns 4 nursing home patients of unspecified age and gender who received their first dose of Moderna''s COVID-19 vaccine (mRNA-1273)Lot # 039K20A) and died. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: died


VAERS ID: 1035505 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away with an hour to hour and 1/2 of receiving vaccine; A spontaneous report was received from a consumer concerning a patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away with an hour to hour and 1/2 of receiving vaccine. The patient''s medical history, as provided by the reporter, included COVID-19. No relevant concomitant medications were reported. On unknown date, 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 an unknown date, the patient passed away within an hour and a 1/2 of receiving the vaccine. Per the nursing home staff, they did not expect the patient to make it many more days. The patient was unresponsive in the room when the shot was given. The patient was 14+ days post COVID. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on an unknown date. The cause of death was unknown.; Reporter''s Comments: This case concerns a patient, who experienced event of death (unknown cause). The event occurred an hour to hour and 1/2 after the first and last dose of mRNA-1273 vaccine administration. Based on the current limited available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded and the event is assessed as possibly related. However, Per the nursing home staff, the patient was 14+ days post COVID and they did not expect the patient to make it many more days. The patient was unresponsive in the room when the shot was given.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1035845 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-03
Onset:2021-02-11
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

Administered by: Public       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: Unknown
Current Illness: Not sick at time of vaccination, unknown prior.
Preexisting Conditions: Unknown
Allergies: none
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: We were informed by EMS that the patient was found deceased on 2/11/2021 at her home. EMS states she was dead for some time, no medical care given.


VAERS ID: 1035866 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-11
Onset:2021-02-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: DOXAZOSIN TAB,ORAL 2MG TAKE TWO TABLETS BY MOUTH TWICE A DAY FOR BLOOD PRESSURE DABIGATRAN CAP,ORAL 150MG TAKE ONE CAPSULE BY MOUTH TWICE A DAY LABETALOL TAB 200MG T
Current Illness: None
Preexisting Conditions: Chronic atrial fibrillation [Chronic atrial fibrillation, unspecified] Hyperlipidemia [Hyperlipidemia, unspecified] Benign essential hypertension [Essential (primary) hypertension] GERD - Gastro-esophageal reflux disease [Gastro-esophageal reflux disease without esophagitis] Carcinoma of colon [Carcinoma in situ of colon] Rosacea [ROSACEA]
Allergies: Simvastatin Influenza
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt died on 2/15/21. On 2/13/21, pt complained of muscle aches.


VAERS ID: 1035872 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 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: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive at 8 am on 2/12; patient was deceased


VAERS ID: 1035878 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-13
Onset:2021-02-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: Aspirin, Atorvastatin
Current Illness: AIED; CHF; Type 2 DM; HTN; Chronic Renal Failure; Lung CA
Preexisting Conditions: See above
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Daughter called to report that the patient died on 02/15/2021. No report of symptoms from the vaccine on 02/13/2021


VAERS ID: 1036047 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-16
Onset:2021-01-24
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac assistance device user, Death, Pulse absent, Resuscitation, Seizure like phenomena, 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), Convulsions (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: 2021-01-24
   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: acetaminophen (TYLENOL) 325 MG tablet Apixaban (ELIQUIS) 5 MG TABS tablet atorvastatin (LIPITOR) 40 MG tablet B-Complex TABS cetirizine (ZYRTEC) 10 MG tablet Chlorhexidine Gluconate (BIOPATCH PROTECTIVE DISK/CHG) (Dressing) MISC Cholecalcif
Current Illness: Hospitalized 12/20 - 12/24/2020 Discharged to home with home care services Hospital Course 12/20 - 12/24/20: 74-year-old male with multiple medical problems presented to the ED with sudden shortness of breath and some palpitations. He was seen in the emergency room after being transported to the ED on CPAP was found to be febrile to 101 tachycardic tachypneic put on BiPAP in ED. EKG showed atrial flutter with left bundle branch block no ST segment elevations COVID-19 was negative RSV and flu was negative chest x-ray showed pneumonia in the right lower lobe. Subsequent chest x-ray showed bilateral lower lobe airspace disease consistent with pneumonia Patient also had a CT abdomen in the ED showing left pleural effusion . The CT report is attached which also showed a right renal cyst with calcification and needs to be followed up in 6 months with a renal protocol CT rest of it was negative. He was started on supplemental oxygen IV antibiotics. Patient was started on Rocephin and azithromycin is significantly improved but off the oxygen and is very eager to leave today patient also had an echocardiogram which revealed an EF of 55 to 60% LV wall motion was normal left atrium was severely dilated. Status post bioprosthetic aortic valve replacement which was in place. He was continued on Eliquis During his hospital course there were no complications. Discharged home today with follow-up. I have elected to send him home on 5-7 days of Levaquin patient reports he is does not tolerate Augmentin well
Preexisting Conditions: Anxiety ? Atrial fibrillation ? CHF (congestive heart failure) ? COPD (chronic obstructive pulmonary disease) ? Coronary artery disease ? Diabetes mellitus, type II ? Gangrene of toe of left foot ? GERD (gastroesophageal reflux disease) ? Hyperlipidemia ? Hypertension ? Insomnia ? Myocardial infarction Oct 2012 ? Osteoarthritis ? Peripheral vascular disease
Allergies: penicillin diazepam
Diagnostic Lab Data:
CDC Split Type:

Write-up: Short version The patient has long-standing health issues. The patient received the first dose of Moderna COVID-19 vaccine on 1/16/2021 (unknown location). The patient suffered an event in his home on 1/24/2021. CPR and treatment was begun and he was transported to the ED. He was pronounced dead in the ED at 0846. Long version 70-year-old male with past medical history of CAD with pacemaker, A. fib, COPD, hypertension/hyperlipidemia presenting in cardiac arrest. 911 call at 0724. Per EMS, patient was witnessed by family to have seizure-like activity and then collapsed and became unresponsive. Patient was noted by family to be pulseless and CPR was started right away. Patient received two doses of epi by police were on scene first (AED defibrillation x2) and six doses of epi (plus 6 more AED shocks) by EMS when they arrived. Patient had CPR performed for 45 minutes prior to arriving at the hospital. On route, patient had episodes of paced rhythm and V. fib. Patient received one amp of bicarb and one amp of calcium en route. Patient also received 300 mg of amiodarone en route. Arrived in ED at 0810 Patient received ongoing compressions, shocks and additional medications (epinephrine x6, lidocaine IV, sodium bicarbonate) until time of death called at 0846 in the ED.


VAERS ID: 1036098 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-01-31
Onset:2021-02-07
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Haemorrhage, International normalised ratio increased, Urinary tract infection, Urine analysis abnormal
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: coumadin 5 mg, clopidogrel 75 mg, atorvastatin 20 mg, citalopram 10 mg, levothyroxine 75 mcg, lisinopril-hctz 20-12.5 mg, melatonin 5 mg
Current Illness:
Preexisting Conditions: Hypothyroidism; History of coronary artery stent placement; Essential hypertension; Current use of long term anticoagulation
Allergies: NKDA
Diagnostic Lab Data: INR test on 2/10/2021- results INR 12 Urinalysis 2/10/2021- results- abnormal
CDC Split Type:

Write-up: Patient received the vaccine on 1/31/2021. Patient complained of bleeding 2/7/2021. Went to clinic where labs were conducted. Patient had an INR of 12. Previous INR results were normal prior to vaccination. Patient was also diagnosed with UTI and given antibiotics. Patient was encouraged to go to ER. Patient died on 2/12/2021.


VAERS ID: 1036345 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Ageusia, Death, Lethargy, Malaise, Nausea, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: levothyroxine
Current Illness: none
Preexisting Conditions: thyroid issues
Allergies: crab allergy, none others
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed lethargy and malaise several hours after vaccine with a low grade fever. The following morning she reported to her husband inability to taste food or drink. She developed nausea and vomiting which persisted from 1/30/21 through her death. She was found deceased in bed by her husband this morning.


VAERS ID: 1036418 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-21
Onset:2021-01-25
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal wall oedema, Acute kidney injury, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood potassium increased, Blood urea increased, Cardiac arrest, Central venous catheterisation, Computerised tomogram abnormal, Death, General physical health deterioration, Generalised oedema, Glomerular filtration rate decreased, Hypotension, Lung opacity, Oedema, Platelet count decreased, Pleural effusion, Pneumonia, Pulmonary oedema, Pulse absent, Resuscitation, SARS-CoV-2 test negative, Syncope, Troponin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic thrombocytopenia (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Meds as of 1/20/21: Aspirin 81 daily; Carvedilol changed to Metoprolol XL; CoQ10 daily; digoxin 3xweek; fluticasone propionate daily; furosemide 80 mg twice daily; Iron 325mg daily; L-Carnitine daily; lisinopril 2.5 daily; Metamucil plus; M
Current Illness: Outpatient hospital admit 12/20-12/21 with CHF exacerbation; BNP 2510, platelet count 99; total bili 2.3; BUN 26, Cr 1.42 and GFR 47. Repeat labs 12/31/20 BUN 28; Cr 1.52; GFR 44; 1/2/21 total bili 2.6; platelet count 89. PCP visit 1/7 noted pitting edema BLE and wife stated more confused lately diagnosis hypertension, elevated bilirubin, thrombocytopenia and shortness of breath, CXR 1/7 cardiomegaly, central vascular congestion, tiny bilateral pleural effusions and mucous plugging. Cardiologist visit 1/20/2021 with med changes.
Preexisting Conditions: Anemia, CABG, apnea; CHF; dysrhythmia; pacemaker/defibrillator; cardiomegaly; heart disease; aortic valve replacement; former smoker; ischemic cardiomyopathy; perivalvular leak of prosthetic heart valve
Allergies: No Known allergies
Diagnostic Lab Data: 1/25/21 Rapid COVID negative; Troponin 0.87; platelet count 92; BUN 50, Cr 2.96; GFR 20; SGOT 132; SGPT 102; Potassium 5.5 CT revealed ground glass opacities representing pneumonia versus pulmonary edema; diffuse body wall edema and pleural effusions. Pacemaker/defibrillator interrogated with no shocks or other events noted.
CDC Split Type:

Write-up: ER visit 1/25/21 patient walked into a prompt care and collapsed, witnessed and pulseless CPR with ROSC after 6-7mins, no shock no meds. Awake and speaking upon arrival to ER. 2 plus pitting edema ble ER diagnosis Anasarca, cardiac arrest, hypotension, elevated troponin I levels, Acute kidney injury and syncope. ER notes reveal a syncopal episode in the shower prior to collapse at prompt care. Central line placed and plan to ship to another facility, patient continued to decline despite dopamine and dobutamine expired in ER prior to transfer.


VAERS ID: 1036437 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-26
Onset:2021-02-17
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: None reported
Preexisting Conditions: None reported
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient is deceased. Family called the pharmacy on 2-17-21 to let us know he would not be coming for his second appointment. When the pharmacist tried to call the family back for more info, the phone number on file doesn''t work.


VAERS ID: 1036440 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-15
Onset:2021-01-27
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bladder cancer stage IV, Condition aggravated, Death
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown names of medication, chemo medications, HBP, CHF medications
Current Illness: Stage 4 bladder cancer
Preexisting Conditions: Stage 4 bladder cancer, CHF
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died at home in hospice care from complications of stage 4 bladder cancer


VAERS ID: 1036460 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 RA / IM

Administered by: Other       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: liver cancer
Preexisting Conditions: liver cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death 2-5-21


VAERS ID: 1036480 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-26
Onset:2021-02-02
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Endotracheal intubation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 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, levothyroxine, losartan, metformin, metoprolol, pravastatin, polyethlyene glycol
Current Illness: had a cough since 2/17/21
Preexisting Conditions: diabetes type 2, hypertension, hypothyroid, hyperlipidemia, MRSA,
Allergies: Sulfa causes a rash
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 2/2/21 after being admitted on 1/31/21 after receiving COVID19 Moderna Vaccine on 1/26/21. On initial report to the hospital patient reported having a cough for over 2 weeks (starting approx. 1/17/21). He had a postive COVID19 PCR on 1/31/21. Intubated on 1/31/21 and passed away on 2/2/21


VAERS ID: 1036585 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Rhode Island  
Vaccinated:2021-02-13
Onset:2021-02-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Aortic aneurysm, Arteriosclerosis, Asthenia, Cardiac arrest, Death, Hyperhidrosis, Myocardial infarction, Pulmonary embolism, Pulse absent, 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), 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), Embolic and thrombotic events, venous (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: 2021-02-15
   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: Metformin, Fenofibrate, Simvastatin, Terazosin
Current Illness: Unknown at this time; nothing noted on vaccine screening form
Preexisting Conditions: Essential HTN, Mixed hyperlipidemia, Diabetes Type 2, Osteoarthritis, Heart Murmur,
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient called EMS approximately 1pm on 2/15 with complaints of generalized weakness. Upon arrival EMS found her to be diaphoretic and she had a witnessed syncopal episode with question of v-fib and seizures. She became unresponsive and had no pulse. CPR was begun and she was transported to ED. She remained asystole throughout. CPR was initially continued in the ED for approximately 30 minutes and then stopped with Time of Death noted at 13:27. ED notes noted "suspect given history that patient experienced massive MI, PE or ruptured AAA". Death certificate notes indicate "signficant conditions contributing to death after cardiac arrest; ASCVD".


VAERS ID: 1036685 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-13
Onset:2021-02-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest discomfort, Chest pain, Death, Pain
SMQs:, Anaphylactic reaction (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

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

Write-up: Systemic: Body Aches Generalized-Medium, Systemic: Chest Tightness / Heaviness / Pain-Medium, Additional Details: Unknown if patient experienced adverse effects 2-13 or 2-14, patient called facility 2-15 reporting body aches and chest pressure and was told by facility to seek medical attention, she passed later that day


VAERS ID: 1036770 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-19
Onset:2021-02-10
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / SYR

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: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: generic multi vitamin
Current Illness: none
Preexisting Conditions: none, very healthy
Allergies: none
Diagnostic Lab Data: None, she was found in her bed dead in the morning. She had no prior health issues.
CDC Split Type:

Write-up: Feb 10th died in her sleep. No apparent reason.


VAERS ID: 1036787 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 - / IM

Administered by: Senior Living       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: late stage dementia
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: passed away 2 days after vaccine was given


VAERS ID: 1036881 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-01-11
Onset:2021-01-20
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Multiple cardiac medications including anticoagulation; medications for chronic lung condition
Current Illness:
Preexisting Conditions: Chronic cardiac conditions, chronic lung. Chronic smoker
Allergies: Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Myocardial Infarction


VAERS ID: 1036993 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-02-16
Onset:2021-02-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Known Prescription Meds dispensed at pharmacy: Oxycodone/Acet Prn, Gabapentin, Metoprolol, Pantoprazole, Tamsulosin, Atorvastatin, Clopidogrel, Montelukast, Trazodone, Do not have info on OTC or Dietary supplements
Current Illness:
Preexisting Conditions: Hx of migraine headaches
Allergies: noted on admin form: Ibuprofen
Diagnostic Lab Data: Daughter said there was going to be an autopsy because there was no apparent cause
CDC Split Type:

Write-up: Patient reported at review of questionnaire had headache that day. Temp was taken, 97.8, okay. proceeded. Conversing customer friend in store afterward. When timer went off, said he was fine, he and his wife left. Daughter called to store Wednesday morning, said Pt had passed away Tuesday, that it was unknown the cause, and just wanted to let us know. We did not take down her phone number and last name. The patient was a long time customer.


VAERS ID: 1037124 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-02-04
Onset:2021-02-16
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Loss of consciousness, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), 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), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix 75 mg daily lipitor 20 mg daily aspirin omeprazole
Current Illness: none
Preexisting Conditions: Coronary artery disease, stent placed GERD
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was at a gym watching his daughter. He slumped over unconscious. EMS was called. He was found to be in fine ventricular fibrillation and resuscitation efforts failed. He was brought to Hospital ED where he was pronounced dead. He had underlying cardiac disease but his family requested I report this event as possibly related to the recent COVID vaccination.


VAERS ID: 1037207 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Female  
Location: Utah  
Vaccinated:2021-02-01
Onset:2021-02-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Incoherent, Injection site pain, Liver function test abnormal, Malaise, Nausea, Pyrexia, Urinary retention, Vomiting
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), 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: 3
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: birth control, and she did do botox
Current Illness: none,
Preexisting Conditions: trigeminal neuralgia - has been in remission since she started doing botox
Allergies: sulfa drugs
Diagnostic Lab Data: contact shock trauma center and the medical examiner
CDC Split Type:

Write-up: She had pain in the injection site Tuesday night and then during Tuesday she got worse with nausea and some fever. By Wednesday she was complaining that she could not pee even though she was drinking a lot of fluids. She continued to complain it was the worst she ever felt and then at 0600 Thursday morning she woke us up and said she needed to go to the hospital. We arrived at the hospital just before 0700 and she immediately threw up in the trash can. We went into a treatment room and they took blood and started fluids as she became incoherent. She said she had taken Tylenol so they started a drug to counter that but her liver function was all wrong and they started to look for a hospital that could transplant a liver. She was air evade about 0930 to Medical center and just over 30 hours latter she was dead. There is a pending autopsy. She was a healthy 39 year old mother who got the shots because she worked as a surgical tech and she was the single mother of a 9 year old little girl.


VAERS ID: 1038633 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

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

Write-up: Moderna COVID vaccine administered 2/9/21. Patient expired in home on 2/10/21, at around 2100. Patient had h/o CVA in2001 with long standing sequelae. On day of administration, team attempted to draw lab specimen with vein finder, but patient was possibly Narrative: Moderna COVID vaccine administered 2/9/21. Patient expired in home on 2/10/21, at around 2100. Patient had h/o CVA in2001 with long standing sequelae. On day of administration, team attempted to draw lab specimen with vein finder, but patient was possibly dehydrated. CG/wife reported to APRN on 2/10/21, patient was sleeping and snoring and then began to sleep more quietly. She checked on patient and found that he had no pulse and had passed away


VAERS ID: 1037720 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Completed suicide
SMQs:, Suicide/self-injury (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
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Suicide; A spontaneous report was received from a consumer concerning a patient, of unknown age/gender, who received Moderna''s COVID-19 vaccine and experienced suicide. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. On unknown date, the patient received mRNA-1273 (Lot number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On an unknown date the patient experienced suicide. Treatment information was not provided. Action taken with the mRNA-1273 in response to the event was not reported. The patient died on unknown date. The cause of death was reported as suicide. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Suicide


VAERS ID: 1038147 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-28
Onset:2021-01-30
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Cerebrovascular accident, Death, Intensive care
SMQs:, Supraventricular tachyarrhythmias (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine, propranolol, levothyroxine
Current Illness: None
Preexisting Conditions: Hypertension, hypothyroidism
Allergies: Sulfa drugs
Diagnostic Lab Data: Admitted to the hospital Monday 2/1. Received 24 hours of ICU care, then transitioned to comfort measures. Passed away 2/11
CDC Split Type:

Write-up: Patient went into new-onset atrial fibrillation, resulting in a catastrophic stroke. Patient passed away on 2/11 as a result of the stroke.


VAERS ID: 1038253 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Florida  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died the next day; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and died the next day. The patient''s medical history was not provided. Concomitant medication use was not provided by the reporter. On 12 Jan 2021, approximately one day prior to the event, the patient received one of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 13 Jan 2021 the patient died. No additional information was provided in regards to the event. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on 13 Jan 2021. The cause of death was unknown.; Reporter''s Comments: This case concerns a male patient of unknown age. The medical history and concomitant medication were not provided. The patient died approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1038257 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-01-14
Onset:2021-01-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature abnormal, Death, Dyspnoea, Fatigue, Feeling abnormal, Limb discomfort, SARS-CoV-2 test, Swelling, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: CALCIUM ACETATE; RENVELA; GLIPIZIDE; OMEPRAZOLE; ASPIRIN (E.C.); VITAMIN D NOS; LOSARTAN; FUROSEMIDE; RIFAMPIN; SENSIPAR
Current Illness: Dialysis; TB
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210113; Test Name: COVID test; Test Result: Negative ; Result Unstructured Data: negative; Test Date: 20210118; Test Name: COVID test; Test Result: Positive ; Result Unstructured Data: per coroner
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; tired; nonresponsive; cold; difficulty breathing; swelling; sore arm; feeling weird and funny; A spontaneous report (United States) was received from a consumer concerning a 63 year old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient experienced limb discomfort, feeling abnormal, dyspnea, fatigue, swelling, unresponsive to stimuli, body temperature abnormal and the patient passed away . Medical history included treatment for tuberculosis and dialysis. Concomitant medication included calcium acetate, Renvela, glipizide, omeprazole, aspirin, vitamin D, losartan, furosemide, rifampin, and Sensipar. On 14 Jan 2021, the patient received the first of their first planned doses of mRNA-1273 (lot number 030L20A) for prophylaxis of COVID-19 infection. On 13 Jan2021, the patient tested negative for COVID-19). On 16 Jan 2021, the patient experienced a sore arm, and feeling weird/funny. On 17Jan2021, the patient experienced difficulty breathing and swelling. On 18 Jan 2021, the patient declined dialysis, was tired and wanted to lay down. At 8 am, the patient was found nonresponsive and cold and is believed to have passed away around 4 am. The coroner tested the deceased for COVID-19 and the test was positive. No autopsy was reported. No death certificate was issued at the time of the report but the reporter believes it will list cause of death as COVID complications. Action taken with the mRNA-1273 was not applicable. The outcome of the events of limb discomfort, feeling abnormal, dyspnea, fatigue, swelling, unresponsive to stimuli, body temperature abnormal, was fatal. On 18 Jan 2021, the patient was died. Cause of death was COVID-19. Autopsy details were not provided.; Reporter''s Comments: The events developed on four days after first dose of mRNA-1372. Dyspnea, unresponsive to stimuli, and death were consistent with infection in pandemic set up confounded by age of patient and refusal of dialysis Cause of death was reported as COVID-19. Autopsy details were not provided. Based on reporter''s causality the events are assessed as unlikely related to mRNA-1273.; Reported Cause(s) of Death: COVID-19


VAERS ID: 1038489 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-02
Onset:2021-02-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute kidney injury, Cardiac arrest, Death, Respiratory arrest
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Nonischemic cardiomyopathy, diabetes mellitus II, chronic back pain , HTN
Preexisting Conditions: Nonischemic cardiomyopathy, diabetes mellitus II, chronic back pain , HTN
Allergies: amoxicillin, ampicillin, tetanus toxoid
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient experienced a cardiac arrest 2 days after receiving the second dose of the Covid-19 vaccine. He later died on 2-17-2021 with complications including respiratory arrest and acute kidney failure.


VAERS ID: 1038517 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-03
Onset:2021-02-17
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, SARS-CoV-2 test negative
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: COVID negative via rapid test
CDC Split Type:

Write-up: Pt. received vaccine on 2/3/2021. Coded at home on 2/17/2021.


VAERS ID: 1038527 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Endotracheal intubation, Myoclonus, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: Unsure. Possibly the following from hospital EHR: albuterol sulfate 90 mcg/actuation inhalation 2 times daily PRN amlodipine besylate 10 mg oral Daily aspirin 81 mg oral Daily atorvastatin calcium 40 mg oral Daily carvedilol 6.25 mg oral 2
Current Illness: Arthritis hands Cardiovascular disease dyslipidemia Chronic bronchitis COPD (chronic obstructive pulmonary disease) Coronary artery disease History of transfusion Hypertension Myocardial infarction stent Peripheral vascular disease Psychiatric illness "feels depressed" on ocassion Renal artery stenosis TIA (transient ischemic attack) "short spurts" of tingling on face Urge incontinence of urine
Preexisting Conditions: Arthritis hands Cardiovascular disease dyslipidemia Chronic bronchitis COPD (chronic obstructive pulmonary disease) Coronary artery disease History of transfusion Hypertension Myocardial infarction stent Peripheral vascular disease Psychiatric illness "feels depressed" on ocassion Renal artery stenosis TIA (transient ischemic attack) "short spurts" of tingling on face Urge incontinence of urine
Allergies: epinephrine, penicillin, procaine per EHR
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per EMS/Hospital report patient had difficulty breathing and cardiac arrest with prolonged CPR (greater than 45 mins in the ER) who was resuscitated. Family subsequently arrived including son and daughter and all family members were in the ER room are in agreement that patient would not want further aggressive cares given her extremely poor prognosis in light of chronic debilitation with numerous medical issues and now a very long period of CPR. Hospital Course After updating family they stated patient would not want further aggressive cares given her grim prognosis and chronic severe and debilitating medical issues. She continued to have myoclonic jerking. She was extubated to comfort cares in the ER and did not pass immediately therefore brought to a room. She received comfort cares and passed away at 0450 with family present.


VAERS ID: 1038635 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Death, Dementia, Fall, Hip arthroplasty, Hip fracture, Hypothyroidism
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), Dementia (narrow), Acute central respiratory depression (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypothyroidism (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Arthritis (broad), Respiratory failure (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: Aspirin 81 mg enteric-coated q a.m. Plavix 75 mg po at bedtime Iron, Ferrex-150 25/1/150 tid with meals Folic acid 1 mg bid Metoprolol tartrate 25 mg bid MiraLAX 8.5 gm daily Synthroid 100 mcg a day Tamsulosin 0
Current Illness: A fall occurred on the day after vaccination; she fractured her hip in this fall. The physician reports she went into sudden and unexpected cardiac arrest during surgery and died. Patient had COVID-19 approx 11/06/2020. Possible urinary tract infection on admit for the fall
Preexisting Conditions: History of breast cancer (bilateral; patient is post-bilateral masectomy) Hypothyroid Dementia ("always confused about time and place") Recurrent urinary tract infections The patient was admitted August 2020 with suspected seizure but this was attributed to UTI and/or dementia) Hypertension Diffuse Arthritis Resident of assisted living facility
Allergies: Erythromycin Codeine
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient fell the day after receiving the Moderna COVID-19 vaccine. She broke her hip in this fall. During surgery to correct the broken hip, she went in to sudden and unexpected cardiac arrest. The anesthetist did not notice any ST changes or A fib; dysrhythmia was very unexpected. The patient had a DNR. She died at 13:00 on 02/07/2021. Causes of death are listed as 1. Cardiac Arrest 2. Recent hip fracture with hip placement 3. History of Breast Cancer 4. Hypothyroid and 5. Dementia


VAERS ID: 1038658 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: D.C.  
Vaccinated:2021-02-01
Onset:2021-02-08
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Death, Decreased appetite, Dyskinesia, Gait inability, Oxygen therapy, SARS-CoV-2 test negative
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Dyskinesia (narrow), Dystonia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), COVID-19 (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: atenolol, docusate, calcium/vitamin D, furosemide, tamoxifen, multivitamin, trazodone, vitamin b12, vitron C
Current Illness: ankle/leg wound healing and being treated topically
Preexisting Conditions: history of TIA, breast neoplasm, dementia
Allergies: none
Diagnostic Lab Data: Unclear if the Moderna vaccine was #1 or #2. Vaccination form states is was vaccine #1. But patient checked the box that she had received a vaccine in the past 2-8 weeks on the form. Patient had gone to hospital around 1/4/2021 for fever and had a negative covid test per nursing notes in chart.
CDC Split Type:

Write-up: 86yo female alert, stable with ankle abrasion eating 100% prior to vaccine in assisted living facility. On 2/1/2021, received Moderna vaccine. Starting thereafter, eating 50% on 2/2/21. Temperature was 98 tympanic. On 2/3, the leg abrasion started having moderate bleeding. On 2/4, the caregiver noted patient "not looking good, unable to talk, arms moving aimlessly, grasping". BP 95/41, temperature 98, oxygen on room air 92-93%. POA did not want hospital transfer. 2/5 Hospice started, oxygen given, morphine given. 2/5-2/8 comfort care given, patient responsive to tactile stimuli, resting, not taking oral medications or food. 2/8/2021 patient expired.


VAERS ID: 1038719 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Arizona  
Vaccinated:2020-01-30
Onset:2021-01-18
   Days after vaccination:354
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death attributed to unknown cause


VAERS ID: 1039028 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Death, Resuscitation
SMQs:

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

Write-up: Systemic: no issues during observation period-Severe, Additional Details: patient received moderna immunization during the morning of 2/17/2021. patient was found by facility staff at 2:38pm with no pulse CPR was started, aed was used and ems was called. time of death 3:15pm


VAERS ID: 1039090 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Anxiety, Blood pressure increased, Breath sounds abnormal, Cardiac arrest, Coronary artery disease, Death, Malaise, Pain in extremity, 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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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:
Current Illness:
Preexisting Conditions: GERD (Gastroesophageal Reflux Disease) Hypertension Previous Squamous Cell Skin Cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient came to the Emergency Room at approx 3:30 am on 02/03/2021 with pain in right arm (same arm the COVID vaccine had been administered in approx 12 hours earlier) and feeling generally unwell. Patient was concerned about possibility of gout flare or that something was wrong with her arm. Elevated blood pressure was noted; this was attributed to anxiety. She was evaluated, given 500 mg Tylenol, and discharged since the pain was decreasing and blood pressure was stabilized. Patient instructed to follow-up with physician. The next day, on 02/04/2021, the patient arrived at the Emergency Room by ambulance; cardiac arrest was the chief complaint. The patient''s daughter stated the patient had been "feeling generally poor and then suddenly collapsed." Daughter described "gurgling respirations" and being unresponsive. 911 was called, police arrived within 5 minutes and initiated CPR. Epinephrine, atropine, lidocaine and bicarb administered after arrival to Emergency Room. Shockable rhythm never demonstrated. Patient never recovered spontaneous respiration or movement. The death was called at 23:04. Coronary artery disease with cardiac arrest is the cause from the ER records; the coroner is putting COVID-19 vaccination in Part 1 of the death certificate.


VAERS ID: 1039271 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-02-11
Onset:2021-02-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Fall, Head injury, Injection site ulcer, Malaise, Neck pain
SMQs:, Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Arthritis (broad)

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

Write-up: Gentleman received his 1st Moderna dose on Thu. 2/11 at 0849. Vaccination protocol was completed. Pt reported feeling fine, no fever, and that he had no allergies which would prevent him from getting the vaccine. Pt played cards with friends later that day 2/11, but left at 1930 (normally plays late into evening) telling his companions he didn''t feel well and his neck hurt. A welfare call was completed on Sat. 2/13, and the patient was found deceased in the bathroom by his son. It appears patient fell off toilet and hit his head on the tub. Pressure ulcer present under injection site. The presumed time of death was Thur. evening.


VAERS ID: 1039304 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-29
Onset:2021-02-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood sodium normal, Blood urea increased, Body temperature increased, Death, Dysphagia, Gastrointestinal tube insertion, Pneumonia, Respiratory tract congestion, SARS-CoV-2 test negative, White blood cell count increased
SMQs:, Acute renal failure (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amantadine HCl Tablet 100 MG, Fluticasone Propionate Suspension 50 MCG/AC, Metoprolol Tartrate Tablet,Rotigotine Patch 24 Hour 6 MG/24HR, Magnesium Oxide Tablet 400 MG, Heparin Sodium (Porcine) Solution 5000 UNIT/ML,Aspirin EC Tablet Delaye
Current Illness: Parkinson''s disease, S/P GT Placement, HTN, Allergic Rhinitis, Protein Calorie Malnutrition, Herpes Viral Infection, Dysphagia, S/P Pacemaker Insertion
Preexisting Conditions: End Stage Parkinson''s Disease
Allergies: Flomax
Diagnostic Lab Data: 01/31/21 Rapid Test (-) COVID 02/02/21 Rapid Test (-) COVID 02/04/21 Rapid Test (-) COVID 02/02/21- WBC 20.92, Na 142, BUN 59- MD was notified
CDC Split Type:

Write-up: Resident getting rehab therapy in the facility and has a long history of Parkinson''s Disease. On 01/29/21, he received the COVID vaccine on left deltoid, resident was recently hospitalized due to Pneumonia and was on antibiotic IV and was recently placed on GT feeding due to severe dysphagia from his Parkinson''s disease. On 01/31/21, started having increased congestion. On 02/02/21, started having increased temperature and WBC went up $g20,000 on 02/03/21, started on Vancomycin IV on 02/04/21 but was transferred to the hospital. Facility was notified today (02/18/21) that resident expired in the hospital.


VAERS ID: 1040005 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: New York  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 LA / IM

Administered by: Pharmacy       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: 2021-02-17
   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: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive and had passed away.


VAERS ID: 1040170 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-06
Onset:2021-02-13
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Agonal rhythm, Alanine aminotransferase increased, Analgesic drug level therapeutic, Aspartate aminotransferase increased, Blood creatinine increased, Blood glucose decreased, Blood lactic acid increased, Blood magnesium increased, Blood potassium increased, Cardiac arrest, Cyanosis, Endotracheal intubation, Erythema, Pain, Peripheral coldness, Pyrexia, Respiration abnormal, Resuscitation, Troponin increased, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, calcium citrate, antifungal cream to stoma, Bisacodyl suppository as needed, calcium citrate, tube feeds, lansoprazole, reglan, centrum multivitamin, polyethylene glycol every other day, norgestimate-estradiol daily, trazodone, tiz
Current Illness: none. she had been very stable on her medication regimen and in her living arrangement for years. No issues whatsoever. Caregivers had been caring for her for as long as 19 years.
Preexisting Conditions: cerebral palsy, spastic quadriplegia, dysphagia with g-tube in place, developmental delay - minimally verbal, tube feed dependency, intrathecal baclofen pump, osteoporosis, white coat hypertension, candidiasis of skin..
Allergies: reclast - caused fever in 2014, leading to hospitalization, seizure from the fever.. tegretol (no reaction noted)
Diagnostic Lab Data: labs from ER on 2/13/2021 - trop 2.49; WBC 55, lactate 21.5, creat 1.29, postassium 6.2, mag 3.4, glucose 57, AST 3024, ALT 3088, acetaminophen < 10, salicylate < 1.
CDC Split Type:

Write-up: Received vaccine on 2/6/2021. was a bit off all week per caregivers - low grade temp and reporting pain which they treated with Tylenol. She was pretty much herself on morning of 2/13/2021 - got up, had shower. caregivers noted her extremities were cool and face was red. temp was 97.4. She was placed in wheelchair with book in the living room. caregivers noted she was not turning pages of the book as she usually would. She was tracking, so they don''t think she had a seizure. Caregiver moved her back to bed with blanket and noted that her lips were blue and at that point called 911. She was found with agonal breathing, CPR started, intubated by EMS, taken to the ER and diagnosed with cardiac arrest upon arrival. CPR was continued until family could be reached and decision was made to stop resuscitation.


VAERS ID: 1040574 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-08
Onset:2021-01-16
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, 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: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient collapsed and could not be revived. There was no prior warning. She was otherwise in good condition for her age. The death was listed as probable cardiac arrest but no autopsy was performed. Since it occurred so close to the vaccine shot I thought someone may want to know.


VAERS ID: 1040633 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-30
Onset:2021-02-06
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M2OA / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Levothyroxine 100mcg, one tablet daily
Current Illness:
Preexisting Conditions: Hypothyroidism, recent hypertension
Allergies:
Diagnostic Lab Data: CAT scan (2/6/2021)
CDC Split Type:

Write-up: Death due to hemorrhagic stroke.


VAERS ID: 1040802 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Death, Diarrhoea, Injection site pain, Vomiting
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Toileting and had expired while doing so; Severe abdominal pain; Diarrhea; Vomiting; Mild injection site pain; A spontaneous report was received from a healthcare professional concerning an 88-year-old , female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced the events, toileting and had expired while doing so (death), mild injection site pain, severe abdominal pain, diarrhea, and vomiting. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 20 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Lot number: 029L20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. On 20 Jan 2021, the patient felt mild pain at the injection site after receiving the vaccine. On 21 Jan 2021, the patient reported severe abdominal pain, diarrhea and vomiting. These symptoms were intermittent for a week and no other adverse events were noted. On 27 Jan 2021, the patient passed away while toileting. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 27 Jan 2021. The cause of death was unknown. An autopsy was not performed.; Reporter''s Comments: The gastrointestinal events were consistent with increased risk associate with elderly age of patient. The cause of death was unknown. Autopsy was not performed. Very limited information regarding the events is available at this time. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1040877 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-02-18
Onset:2021-02-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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: 2021-02-18
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: wellbutrin, crestor, albuterol, deltasone, cozaar, spiriva, coreg
Current Illness: chest pain, COPD, Bipolar, dyslipidemia, stage 3 chronic kidney disease
Preexisting Conditions: as above
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown if related to vaccine. patient received 2nd vaccine at 0830, observed 15 minutes, discharged, arrested at 0915 upon entering her home. vaccine was administered by DOH at their community location. patient was pronounced lifeless in the ED.


VAERS ID: 1040927 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-16
Onset:2021-01-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Dizziness, Fall, Feeling abnormal, Resuscitation, SARS-CoV-2 test negative
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Accidents and injuries (narrow), Vestibular disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nisidipine 90 MG once day, Ramipril 20 MG once a day, Synthroid 137 MCG once a day, Aricept 10 MG once a day
Current Illness:
Preexisting Conditions: Hypertension, Hypothyroidism, early dementia, Vertigo
Allergies:
Diagnostic Lab Data: COVUD test on the 7th and 8th (once deceased by hospital) both were negative
CDC Split Type:

Write-up: Patient previously had dizzy spills, but about a week after receiving the vaccine her dizzy spills began to get worse. The whole prior she kept saying I am just not right. On the 2/7/21 she a COVID test done, a nurse came to her house and preformed. On the morning of the 8th patient was on the phone with someone else and patient asked this person to call me and go check on her. Within 5 minutes I was over at her house, and I found her on the floor, she on her belly facedown. It looked like she was on the toilet, and it looked like she fall getting her off, she was still wet, she still felt warm. I called the ambulance and immediately began CPR. When EMS arrived they took over the CPR and transported her to the Hospital. The EMS was there for about 40 minutes and used an machine to preform the compressions. She was pronounced deceased at the hospital. No autopsy was done.


VAERS ID: 1041064 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-02-04
Onset:2021-02-11
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / N/A LA / IM

Administered by: Public       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:
Current Illness:
Preexisting Conditions:
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: CLIENT EXPIRED 1 WEEK FOLLOWING THE VACCINE.


VAERS ID: 1041200 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, COVID-19, Death, Fall, Muscular weakness, Nervousness, SARS-CoV-2 test positive, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 9
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Was tested for COVID-19 on January 30th, 2021.
CDC Split Type:

Write-up: Patient described feeling nervous, anxious the next morning (Wednesday) after the vaccine. He later fell in the bathroom after using the restroom, his legs gave out (his words) and consequently was on the ground for 23 hours before being transported to the hospital. That was Thursday afternoon. He was diagnosed with COVID-19 on Saturday night and died the following Friday morning.


VAERS ID: 1041276 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-12
Onset:2021-02-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dehydration, Foaming at mouth, Hypercalcaemia, Respiratory tract congestion
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Generalised convulsive seizures following immunisation (broad), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Namenda, Mirtazapine, Multi-vitamin, Loratidine, Effexor XR
Current Illness: Hypertension, dementia, arthritis
Preexisting Conditions: Hypertension. Recent decline in weight and appetite, 8 pound weight loss in 30 days.
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: on 2/13 at 7:30am resident was observed congested, foaming at the mouth. transferred to the hospital, verbal report from hospital nurse stated the resident was admitted for hypercalcemia and dehydration. The resident expired on 2/14/21 at 9:30am. Died on 2/14/2021


VAERS ID: 1041333 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-05
Onset:2021-02-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bedridden, Dysphagia, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Lorazepam, Seroquel, Trileptal, Senna Plus, Acetaminophen, Aspirin, Buspar, Sinemet, Cyanocobalamin, Depakote, Aricept, Pepcid, Hydrochlorothiazide, Provera, Melatonin, Namenda, Dolophine, Milk of Magnesia, Morphine, Omeprazole, Sorbitol, F
Current Illness: End stage Dementia, End stage Parkinson''s Disease, on Hospice care. Dependent in all cares, non-verbal.
Preexisting Conditions: End stage Dementia, End stage Parkinson''s Disease, on Hospice care
Allergies: Penicillin, Vicodin
Diagnostic Lab Data:
CDC Split Type:

Write-up: He developed a fever on 1/8, become unable to swallow and bedbound. He was already end of life and Hospice care at the time of the vaccine.


VAERS ID: 1041719 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-02-17
Onset:2021-02-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arthralgia, Death, Fall, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Hypersensitivity (broad), Arthritis (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Depakote, lasix, memantine, metoprolol, senna s, vit D3, miralax, xarelto, remeron
Current Illness: Resident slid out of recliner at 430pm on the date of vaccine and death. Denied pain and ROM was without issues. At 630pm she complained of right hip pain. Mobile xray was ordered. Resident passed in her bed after sleeping for 30 mins. Xray did not make it on time, therefore, unsure of fracture.
Preexisting Conditions: Dementia, PVD, Vit D deficiency, anxiety, HTN, Afib, postrial kyphosis, CHF, UTIs, Debility, sundowning, skin neoplasm left side of nose
Allergies: Fosomax
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received moderna vaccine #2 at 1:30pm. No s/s of adverse reactions. Ate dinner at 4pm. She was in her room at 430pm and she slid out of her chair and was laying on her Right side. She reported she slid out of her chair because she needed to go urinate per staff. She denied pain. At 630p complained of right hip pain. mobile xray was ordered. At 825pm resident was sleeping x 30 mins in her bed when she was found to have no pulse or respirations. She ceased to breathe. Mobile xray did not make it on time.


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