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

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



Case Details

This is page 6 out of 43

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VAERS ID: 1042351 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-11
Onset:2021-02-16
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: synthroid
Current Illness: mild liver disease
Preexisting Conditions:
Allergies: none
Diagnostic Lab Data: none not sure if this is a vaccine reaction but thought I should report it just in case you wanted to investigate farther like an autopsy.
CDC Split Type:

Write-up: death


VAERS ID: 1042967 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-13
Onset:2021-02-18
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Loss of consciousness, Medical induction of coma
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), 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), 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: 2021-02-19
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol
Current Illness: Sinus infection
Preexisting Conditions: Hypertension, Diabetes
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient called son around 6:30am on 2/18/21. When son tried to contact patient around 8:30am, he was not able to get a hold of patient. Son sent someone over to check on patient. They found patient on the floor. He was coherent at first but then lost consciousness. It believed he experienced a stroke sometime around 8:30-9:00am of 2/18/21. Patient was taken to hospital and then transferred to another hospital. He was put in a medically induced coma. He passed between 4:00 and 4:30 pm on 02/19/21.


VAERS ID: 1043123 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-01-28
Onset:2021-02-06
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-20
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: 2021-02-06
   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: Unknown
Current Illness: Positive COVID-19 PCR collected postmortem
Preexisting Conditions: Hypertension, COPD, T2DM, Obesity
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1043482 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M2OA / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Drainage, Erythema, Haemangioma of skin, Purulent discharge, Rash, Rash macular, Scab
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lisinopril,
Current Illness: none
Preexisting Conditions: HTN and cardiac disease
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Noted red blotchy areas 2 days post vaccination on bilateral inner thighs. Patient states he has yellow drainage if he expresses the areas. Has a photo of the rash. They are circular individual areas about 1 cm circumference. Each individual area is bright red with a open pinpoint area in the center. Some have a crusty area. He denies itching, burning. Denies rash in any additional areas post vaccination. Referred to see physician.


VAERS ID: 1043880 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Death, Insomnia, Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: atorvastatin, Vit D3, Vit B12, Plavix, duloxetine, Gabapentin, glipizide, levothyroxine, tolterodine, verapamil, atropine, Flonase, Symbicort, Invega, loperamide, Tylenol, albuterol sulfate
Current Illness: urinary tract infection
Preexisting Conditions: diabetes mellitus with polyneuropathy, schizoaffective disorder, chronic obstructive pulmonary disease, essential hypertension, bipolar disorder, hypothyroidism, history of cerebral infarction, diabetic retinopathy, overactive bladder, Vitamin D deficiency, encephalopathy, chronic kidney disease, seizures
Allergies: iodine, shellfish
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received second Moderna COVID-19 vaccination administered in left arm at her assisted living facility by Pharmacist at 1153 on 2/19/2021. Pt was monitored for vaccine reaction with no known adverse reaction. Approximately 18 hours post-vaccine, she was found deceased in her sleep at 0540 on 2/20/21. Per circumstances/pt history, it is presumed that the patient aspirated while sleeping, perhaps secondary to a seizure. Coroner was notified and declined as coroner''s case. VAERS notification being made due to pt death within 24 hours of receiving a vaccine.


VAERS ID: 1044247 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-21
Onset:2021-01-26
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna COVID 19 Vaccine: Patient started with symptoms of covid 5 days after first vaccine. She was hospitalized and passed due to COVID 19 on 2/6/21. Patients family informed us when she was due for the second dose.


VAERS ID: 1044352 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-08
Onset:2021-02-14
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 AR / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal discomfort, Cardiac failure, Death
SMQs:, Cardiac failure (narrow), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (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: Synthroid; Cosentix; Multivitamin; Vitamin C; Omeprazole; Loratadine
Current Illness: None
Preexisting Conditions: Psoriatic Arthritis; Hypothyroidism
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stomach upset, sudden heart failure, death


VAERS ID: 1045894 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2020-12-31
Onset:2021-01-27
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 11
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID infection, death


VAERS ID: 1045895 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-21
Onset:2021-02-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Heart meds recently changed by cardiologist . Inhalers for asthma. Other unknown
Current Illness: None know
Preexisting Conditions: Heart arrhythmia, enlarged prostate, low blood pressure, CAD, asthma, season allergies/hay fever, spinal stenosis, with neuropathy
Allergies: Unknown
Diagnostic Lab Data: None at this time
CDC Split Type:

Write-up: He was found deceased in his home by Sheriff and paramedics evening of 2/21/21.


VAERS ID: 1046230 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-04
Onset:2021-02-20
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes
Preexisting Conditions: Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death. My father-in-law was found unexpectedly deceased in his home Saturday morning. He worked the previous day.


VAERS ID: 1046347 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-20
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 - / IM

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

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

Write-up: When family members came to receive the second dose of their COVID vaccine, they informed us that the above patient had passed away.


VAERS ID: 1046542 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-02
Onset:2021-02-15
   Days after vaccination:44
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / -

Administered by: Senior Living       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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away with in 60 days of receiving a COVID vaccine


VAERS ID: 1046613 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-02-22
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1046698 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-02-20
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1046752 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Chest pain, Death, Fall, Hypothermia, Pain, Refusal of treatment by patient, Rhabdomyolysis, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 21 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: apixaban, aspirin, Ativan, baclofen, carbidopa - levodopa
Current Illness: Rhabdomyolysis, dementia d/t Parkinsons disease w/ behavioral disorder
Preexisting Conditions: Atypical Parkinsonism, HTN, diplopia, Neurological gait disorder, osteoarthritis
Allergies: No known allergies
Diagnostic Lab Data: 2/8/21 1642 BP 134/78 - 84
CDC Split Type:

Write-up: Pt was hospitalized Jan 18, 2021 after he had fallen outside overnight and lay there approximately 12 hours until he was found. Hypothermic & rhabdomyolis diagnosis. Gradually improved w/ strength & mental status - was in swing bed @ hospital. He got his first Covid 19 shot on 2-8-21. Was fine @ 0300 on 2-9-21 and @ 0430 he was found unresponsive. Dx: probable arrythmia & pronounced dead @ 0454. Noted on pain scale @ 2/8/21 @ 21:11, clients pain was a 7/10 They offered pain med & he refused They repositioned & distracted him @ 2047 on 2/8/21 Pain had decreased to 3/10 and nothing given. Then @ 0300 check he was sleeping and @ 0430 unresponsive.


VAERS ID: 1046795 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-12
Onset:2021-02-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Blood gases, Blood lactic acid, Chest X-ray, Death, Dyspnoea, Full blood count, Hypotension, Metabolic acidosis, Metabolic function test, Oxygen therapy, Pulse absent, Resuscitation, SARS-CoV-2 test, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Flagyl 500 mg TID, Tramadol 50 mg q4h PRN, Gabapentin 400 mg q 8h, lisinopril 10 mg daily, duloxetine 30 mg daily
Current Illness: Recurrent IVb uterine carcinosarcoma, open ventral abdominal wall
Preexisting Conditions: uterine cancer, PE, CHF
Allergies: Sulfa medications
Diagnostic Lab Data: CBC, BMP, COVID, lactic acid, ABG''s, cxray all drawn and completed on 2/21/2021
CDC Split Type:

Write-up: Per ED note: Brought in ED by EMS at 1945 for acute shortness of breath and hypotension. Patient was placed on supplemental oxygen and covid test completed. Patient was placed on BiPAP to maintain oxygen greater than 90%. Found to be in metabolic acidosis. Patient became unresponsive and pulse could not be palpated. Chest compressions were initiated. ACLS medications given and pulses regained. Patient lost pulse 30 mins later and never regained pulse. Per ED noted; likely developed a PE. Passed away at 2127


VAERS ID: 1046845 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

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

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

Write-up: Deceased 02/18/2021 with an unknown cause of death


VAERS ID: 1046881 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / 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: 2021-02-20
   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: Carvedilol, Gemfibrozil, Ferrous Sulfate, Folic acid, metoclopramide, mvi, pravastatin, digoxin, clonazepam, Senna, bisacodyl, docusate, memantine, rivastigmine, linaclotide, lansoprazole, fish oil, clonidine, amlodipine, losartan,
Current Illness: UTI
Preexisting Conditions: CHF, CKD, MI, Encephalopathy, Aortic stenosis
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Code blue called at 11:00pm. Patient had code status of Do Not Resuscitate.


VAERS ID: 1047169 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-06
Onset:2021-02-13
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Haemoglobin decreased, Haemolytic anaemia, Haemorrhagic stroke, Intensive care, Jaundice, Multiple organ dysfunction syndrome, Platelet count decreased, Shock haemorrhagic
SMQs:, Cholestasis and jaundice of hepatic origin (narrow), Haemolytic disorders (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Biliary system related investigations, signs and symptoms (narrow), Biliary tract disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 7
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: risedronate 35 mg po q week levothyroxine 25 mcg po daily lipitor 10 mg po daily azelastine nasal spray 2 sprays nasally as needed
Current Illness: none
Preexisting Conditions: mild anemia hypothyroid "prediabetic" dyslipidemia macular degeneration
Allergies: NKA
Diagnostic Lab Data: Hgb=3.4 on admit 2/16 platelet ct 2/20= 40 have many more lab results, vital signs, too numerous to input here
CDC Split Type:

Write-up: jaundice-$ghemolytic anemia-$g hemorrhagic shock-$gmulti organ failure-$gdeath pt admitted to ICU 2/16 with Hgb=3.4, treated with steroids, supportive care , pressors, pt died 2/20/21


VAERS ID: 1047183 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-14
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

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

Write-up: Pt had expired before second dose was delivered.


VAERS ID: 1047197 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-12
Onset:2021-02-20
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Morphine concentrate, Lorazepam Intensol, Clopidogrel, Vitamin D2, Tamsulosin, Amlodipine, Atovastatin
Current Illness: Pt on hospice
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1047282 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Blister, Chills, Death, Dizziness, Fatigue
SMQs:, Severe cutaneous adverse reactions (broad), Anticholinergic syndrome (broad), Vestibular disorders (broad), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: duloxetine 20 mg daily cyclobenzaprilne 10 mg as needed for pain meclizine 25 mg as needed for nausea
Current Illness: none
Preexisting Conditions: none, other than back pain
Allergies: Benadryl Diazepam Valium
Diagnostic Lab Data: County Medical Examiner performed an autoposy on Wednesday, February 10, 2021. Results are still pending.
CDC Split Type:

Write-up: Patient felt fine on Friday afternoon and evening after shot. Felt fine on Saturday until the afternoon when she started feeling fatigued and chilled. Decided to take a warm bath at about 6pm. Was found dead in bathtub at approximately 7pm with blisters on arms, legs, and face.


VAERS ID: 1047326 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-25
Onset:2021-01-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pyrexia, Rash macular
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Namenda, Aricept, Multivitamin, Glucophage, Creon
Current Illness: Decubitis Ulcer
Preexisting Conditions: Diabetes Mellitus Type 2, TIA (never diagnosed per Caregiver)
Allergies: Penicillin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: According to patient''s caregiver, patient presented with symptoms of fever (101.6 F) and purple blotches all over the body within an hour. Since patient was in hospice , caregiver called Hospice and a pharmacy and was told to give patient Benadryl and Tylenol. Patient was given both medications and the fever subsided in a few days but the purple blotches never went away. Patient passed away at the facility a week later.


VAERS ID: 1047634 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia, SARS-CoV-2 test positive, Urinary tract infection
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to hospital on 2-9-21 for urinary tract infection and tested positive for Covid. Developed pneumonia and expired on 2-12-21.


VAERS ID: 1048786 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Electrocardiogram, Fall, Full blood count, Metabolic function test, Pulseless electrical activity, 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), Accidents and injuries (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? Yes
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: unknown
Current Illness: ? sepsis, CAD, HTN, increased lipids
Preexisting Conditions: hypertension, constipation, hyperlipidemia, CAD, BPH
Allergies: Orudis, Statins (intolerance)
Diagnostic Lab Data: ECG, 2/11 -2/12/21 PEA then asystole CBC with auto diff, CMP
CDC Split Type:

Write-up: Was given vaccine around 1:30Pm on 2-11-2021. He and his wife waited in the building for 15 minutes and then left. he denied complaint. (He was waiting to have both Covid shots before he went to cardiologist Re: CAD.) He had an alarm going off in his house, was going to basement to check it out. Police officer heard alarm, came into house, & heard a thud when Doc fell. He was in PEA (Pulseless Electrical Activity) when brought into ER. Given 5 "rounds of Epinephrine with no response.


VAERS ID: 1048665 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: New York  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

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

Write-up: Died; Internal bleeding and died; A spontaneous report was received from a nurse concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced internal bleeding and died. The patient''s medical history was not provided. No concomitant product use was reported. On unknown date, the patient received their first of two planned doses of mRNA-1273 (Lot number: not provided) intramuscularly for prophylaxis of COVID-19 infection. On unknown date, a nurse reported she read about a doctor who received the COVID-19 vaccine and died 3 days later. She stated she read that the doctor had internal bleeding. It started with bleeding in his hands and feet, then went to his brain and died 3 days later. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not provided. The outcome of the events, internal bleeding and died, was considered fatal.; Reporter''s Comments: Very limited information regarding the events has been provided at this time and is insufficient for causality assessment. Further information has been requested.; Reported Cause(s) of Death: Internal bleeding


VAERS ID: 1048672 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-29
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: No adverse event, Continue: [UNK], Comment: No reported medical history.
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Pass away; Got COVID; A spontaneous report was received on from a consumer, concerning an 87-year-old male patient, who received Moderna''s COVID-19 (mRNA 1273) vaccine and experienced pass away (death) and COVID (COVID-19). The patient''s medical history was not provided. No relevant concomitant medications were reported. On 29 Dec 2020, the patient received their first of two planned doses of mRNA-1273 injection for the prophylaxis of COVID-19 infection. Two days after mRNA-1273 injection, the patient''s daughter was diagnosed with COVID-19 infection. The daughter states that her mother also got infected with COVID. On an unknown date, the patient got COVID. It was reported that he passed away. Treatment for the event was not provided. The cause of death was not provided. The plans for an autopsy were not provided. .; Reporter''s Comments: Although the onset date of COVID-19 and the fatal outcome is lacking, Based on the natural history of COVID-19, the reported event, it is assessed as unlikely related with mRNA-1273. The actual cause of death cannot be ascertained but assessed as not related and most likely due to the COVID-19 infection.


VAERS ID: 1048882 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-02-01
Onset:2021-02-12
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

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

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:
Current Illness:
Preexisting Conditions: diabetes
Allergies: Augmentin (hives)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine was administered 2/1/2021 at approximately 9am. Due to self reporting of allergic reaction (hives) to Augmentin, patient was monitored on site for 30 minutes. After the monitoring period, she was cleared to go with no issues reported at the time. We were later informed that the patient passed away from a pulmonary embolism on 2/12/2021.


VAERS ID: 1048917 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram normal, Death, Fall, Laboratory test, White blood cell count increased, X-ray normal
SMQs:, Neuroleptic malignant syndrome (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   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: Aspirin 81 MG EC tablet 1 daily, Latanoprost 0.005% Ophth Soln, Incruse Ellip 62.5MCG/ACT Inh, , Losartan 25 MG tablet, Ompeprazole 20 mg, Potassium CL 20 MEQ ER tablet, Preservision Areds Tablet, Simvastatin 40 MG tablet,
Current Illness: No acute illness
Preexisting Conditions: Diagnosis Codes obtained upon admission in 11.17.2015 I45.10, J30.9, J44.9, E78.0, i10, K21.9, H40.9, D69.6, G93.40, K59.0, Z96.641, sm869, sm859
Allergies: Morphine, Shellfish
Diagnostic Lab Data: Tests ran at Hospital. Unsure of full tests and results. Only received updated from resident representative.
CDC Split Type:

Write-up: Resident yelling for assistance in apartment. Nursing personnel found resident on floor at 6:10 AM on 2/18/2021. Resident was transported to Hospital on 2/18/2021. Status update on 2/18/2021 from son, resident CT & X-rays were done all normal. Labs done and WBC count was elevated and awaiting results. Resident stable and admitted to hospital for observation. Resident passed away on 2.21.2021.


VAERS ID: 1048947 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Endotracheal intubation, Gastrointestinal tube insertion, Hypotension, Hypoxia, Loss of consciousness, Small intestinal obstruction, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (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: Oxybutinin Carvedilol Eliquis allopurinol atorvastatin losartan amiodaron furosemide ezetimibe zofran
Current Illness:
Preexisting Conditions: End stage renal failure on dialysis Hospitalization on 2/5/21 for ESRD and initiation of hemodialysis Anemia of chronic disease Chronic atrial fibrillation on anticoagulation Congestive Heart failure Recurrent abdominal wall hernia
Allergies: keppra decadron
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient experienced an episode of emesis and loss of consciousness several hours after vaccine on 2/16/21. He was taken by EMS to the hospital and was noted to be hypoxic and hypotensive. He was admitted to the hospital and subsequently intubated. He was also found to have a small bowel obstruction and a nasogastric tube was placed to decompress the bowel. He required pressor support as well. He expired on 2/17/21.


VAERS ID: 1049012 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-02-12
Onset:2021-02-19
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 RA / IM

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

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

Write-up: Patient was given vaccine on friday, one week later she passed away. The family called the pharmacy to inform us on Saturday, Feb 20, 2021. After the phone call was over, we saw in her pharmacy profile that she had received the vaccine one week prior


VAERS ID: 1049284 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Virginia  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: Died; A spontaneous report was received from a consumer concerning a 58-year-old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and patient was died. The patient''s medical history was reported as underlying health issue. Concomitant product use was not provided by the reporter. On an unknown date, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: if reported or unknown) intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, patient with underlying health issue died after getting the Moderna COVID-19 vaccine. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on an unknown date. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 58-year-old female who died on unknown date after first dose of mRNA-1273, lot # unknown. Very limited information regarding this event has been provided at this time, therefore it is difficult to assess a cause and effect relationship. No further information will be available. Of note, patient''s medical history included unknown underlying health issues.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1049389 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Idaho  
Vaccinated:2021-02-09
Onset:2021-02-20
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

Administered by: Private       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: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Spironolactone, Atorvastatin, Gabapentin, Trelegy Ellipta, Januvia, Xarelto, Losartan, Metoprolol Succinate.
Current Illness: No
Preexisting Conditions: Type 2 DM, HTN, COPD, Hyperlipidemia unspecified, A-fib unspecified, Chronic pain, Morbid Obesity
Allergies: No
Diagnostic Lab Data: Nothing wife opted out for any test to be performed.
CDC Split Type:

Write-up: Patient passed away Saturday at 14:04pm. Patient''s wife reports his death was sudden, he passed away sitting in his chair his heart just stopped she said. They tried to perform CPR, 911 was called and paramedics arrived at the scene and he was given medication but never had any return of vital signs and so his death was called at the scene. Wife reports he was not ill, did not have any symptoms prior to the event. They are not going to be doing a autopsy. She wanted us to know based on timing that there may be some possible correlation with his COVID19 vaccine. He obtained the vaccine on 02/09/2021 - wife reports he had no symptoms, not even arm soreness after the vaccine. Had no fever, shortness of breath. Did not complain of chest pain. We can update chart to reflect the patient is deceased and lets make a card for the family.


VAERS ID: 1049406 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-02-21
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: COVID-19, Death, Exposure to SARS-CoV-2, 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: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none listed
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient rcvd 1st covid 19 vaccine on 1/26/2021. Patient had house guests on 1/30/21. Those house guests tested positive for covid on 2/1/2021. Patient started getting symptoms on 02/2/2021. Patient tested postivie on 2/4/2021. Patient was hospitalized 2/7/2021. Patient passed away on 2/21/21.


VAERS ID: 1049648 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-02
Onset:2021-02-20
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: I was notified on 2/22/21 that this patient passed away over the weekend. I do not know the details, nor can I confirm anything beyond what I was told. I believe the death occurred on 2/20/21 due to a massive stroke.


VAERS ID: 1049773 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-12
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none listed on consent form
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient died on 02/20/2021. Cause of death was pulmonary embolism.


VAERS ID: 1049787 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), 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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: High Cholastrol
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Without showing any side effect symtoms, patient suddenly fell unconscious and passed away within an hour. Though 911 was called and Paramedic was trying to revive the patient.


VAERS ID: 1049852 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: vitamin d 1.25 mg 1 per week
Current Illness:
Preexisting Conditions: cvd
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: When calling to get billing information we were notified that patient had passed away. Patient''s daughter said patient was having cvd a/s on 2.1.2021 got vaccine 2.2.2021 and passed away 2.5.2021. Cardiologist said not related


VAERS ID: 1049963 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-12
Onset:2021-01-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Myocardial infarction, Pulse absent, Respiratory arrest, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: chlorpromazine 800mg QHS amantadine 100mg BID divalproex 1000mg QAM, 1500mg QHS haloperidol decanoate 225mg Q2weeks amlodipine 5mg QHS carvediol6.25mg BID docusate sodium 250mg BID fluticasone propionate 1 spray each nostril BID lisinopril
Current Illness:
Preexisting Conditions: obese, pre-diabetic, hypertension, atherosclerotic disease, coronary artery blockage, schizoaffective disorder Tested COVID-19 positive on 1/21/2021, asymptomatic, 1-1/2 weeks after first COVID-19 vaccination
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found lying face down without respiration or pulse, believed to be within 5 minutes of event. ACLS procedures unsuccessful. Unable to get autopsy. Believed to be heart attack secondary to COVID infection, but unconfirmed. Relative contribution of recent vaccination unknown.


VAERS ID: 1049997 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Other       Purchased by: ?
Symptoms: Aphasia, Death, Hypotension, Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: Pliavis, tramadol, aspirin, statin, remeron, protonix
Current Illness: none identified
Preexisting Conditions: Heart Rhythm Irregularity, High Cholesterol, Arthritis, Hypertension, CVA/TIA/Stroke, GERD/Reflux, Sleep Apnea, Heart Disease
Allergies: Ace inhibitors, solifenacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine was administered at Nursing Facility. Patient is an 89-year-old female with prior medical history of CVA with dysphagia, history of possible dementia, GERD, hyperlipidemia, and a pacemaker. She is a resident from town. She was sent for hypotension with a blood pressure of 90/52, tachypnea respirations of 54, possible aspiration pneumonia. Status post Covid vaccine earlier today. History is limited as patient is nonverbal on my exam. Death within 24 hours of vaccination


VAERS ID: 1050137 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-21
Onset:2021-02-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Agonal death struggle, Back pain, Blood chloride decreased, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood potassium increased, Blood sodium normal, Blood urea increased, Brain natriuretic peptide increased, C-reactive protein increased, C-reactive protein normal, Chest X-ray abnormal, Contusion, Death, Electrocardiogram, Electrocardiogram abnormal, Haematocrit increased, Haemoglobin increased, Headache, Hyperglycaemia, Hypotension, Lung opacity, Pacemaker generated rhythm, Petechiae, Troponin, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), 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: 2021-02-23
   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: Entresto, Metoprolol, Spironolactone, Vit D, Lasix, Flomax, Digoxin, Eliquis, Tradjenta, ASA, Novolog Flex pen, Levothyroxine, Vit B12, Lipitor, Aricept, Temazepam, Lorazepam, Glucose prn.
Current Illness: Fall on 2/15/21 pm resulting in skin tear requiring dressing. Pt Seen on 2/16 for skin tear repair secondary to fall the pm prior. Vital signs WNL. Pt returned on 2/20/21 for dressing change. Vital signs WNL. Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes Home Health nurse sent secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization)
Preexisting Conditions: Hypertension, MI, CHF, DM, CRF, Thyroid, High Cholesterol, Prostate
Allergies: Shrimp, Red Man Syndrome, Cleocin, Clindamycin
Diagnostic Lab Data: 2/22/21: CBC WBC 11.74, H/H: 8.6/26.8. Glu $g625mg/dl, BUN 70, Creatnine $g4.10, Sodium <114, Potassium $g6.8, Cl 81, Troponin 0.583, CRP 1.5 BNP 26900, Lactate 8.4 CXR: Subtle inter stitial opacities could represent atelectasis, superimposed mild bronchitis or edema suspected.EKG: Ventricular Paced rhythm. Unsure if death applicable as adverse event secondary to vaccination. Physician noted Vascular Collapse post covid vaccine.
CDC Split Type:

Write-up: Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes states that Home Health nurse sent patient to ER secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization). Patient was treated with IVF bolus in addition to initiating Dopamine for hypotension, patient became agonal and daughter at bedside presented Adv. Directive, pt was DNR. Pt pronounced time of death was 2110pm. (Pt only reported a sore shoulder secondary to vaccine).


VAERS ID: 1050172 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Diarrhoea, Musculoskeletal discomfort, Nausea, Pain, Pyrexia, Unresponsive to stimuli, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Inpatient admission to Medical Center 12/26/2020 - 01/07/2021 for Congestive Heart Failure
Preexisting Conditions: Pulmonary Hypertension, Congestive Heart Failure, Insulin Dependent Diabetes, Oxygen dependant
Allergies: Unknown
Diagnostic Lab Data: None. Family requested an autopsy and the medical examiner declined.
CDC Split Type:

Write-up: Individual developed severe body aches, severe shoulder discomfort, high fevers (documented max temp. 103.7 F). Daughter reported that she became non-responsive with high fevers, and when the fevers decreased she was more lucid. Her condition rapidly progressed to nausea vomiting, diarrhea and patient died on 2/9/2021.


VAERS ID: 1050201 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-02-02
Onset:2021-02-09
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M2QA / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: multiple
Current Illness: Metastatic Lung Cancer
Preexisting Conditions: see above
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Died 7 days after receiving 2nd dose of Moderna vaccine. Had underlying hx Lung CA w/mets.


VAERS ID: 1050281 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-09
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cardiac arrest, Death, Malaise, X-ray abnormal
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), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 14
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 Tablet Delayed Release, 1 Tablet Orally once a day Norvasc 10 MGTtablet, 1 Tablet orally once a day Lisinopril 20 MG Tablet, 1 Tablet orally once a day Terazosin HCl 10 MG tablet, 1 tablet orally once a day Metformin HCl 1000
Current Illness:
Preexisting Conditions: Z86.39 History of vitamin D deficiency Z99.89 Uses continuous positive airway pressure (CAPAP) ventilation at home E11.40 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin I10 HTN (hypertension) N40.0 BPH (benign prostatic hyperplasia E11.29 Microalbuminuria due to type 2 diabetes mellitus Z87.09 Hx of emphysema G47.33 Severe obstructive sleep apnea G47.30 Sleep apnea H25.13 Age-related nuclear cataract, bilateral Z68.36 BMI 36.0-36.9, adult I83.813 Varicose veins of both lower extremities with pain E00.36 Type 2 diabetes mellitus with diabetic cataract, without long-term current use of insulin
Allergies:
Diagnostic Lab Data: X-rays were taken at Medical Center, Patient was diagnosed with Cardio arrest secondary to COVID-19 pneumonia.
CDC Split Type:

Write-up: Per family, patient has been feeling sick since he was vaccinated, patient went to ER on 02/15/2021, and after few hours at ER patient passed away.


VAERS ID: 1050431 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-02-02
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Bradykinesia, Fall, Pulse absent, Resuscitation, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (narrow), Accidents and injuries (narrow), Cardiomyopathy (broad)

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: To the best of my knowledge these are the drugs he took that morning. Furosemide 20 mg; Isosorbide Mononitrate-ER 60 mg; Calcitrol .25 mcg; Levothyroxine - .15 mg; Folic Acid 800 mcg; MultiVits; Metamucil 525 mg capsule; Metroprolol ER -
Current Illness: None
Preexisting Conditions: Heart disease, diabetes in the past but not for the past 4 years; had 3 toe amputations; poor circulation in his legs.
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Since I was not with my husband I can only tell you what was told to me. He walked out of the store toward our car. Someone watched him, concerned, because he was walking very slowly (normally has a slow gait because of leg braces and toe amputations so I don''t know if it was unusually slow). The woman saw him fall and she ran to help-administered CPR immediately-and told me he died instantly. Medics tried to resuscitate and failed to bring a pulse. (My husband left our home around 11:15 to drop a package off at store. The store is one mile from our home. At around 12:30 a deputy came to my door and when I saw him my knees buckled. I knew something horrible happened.


VAERS ID: 1050441 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-20
Onset:2021-02-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Malaise, 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: 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: reported "Zelcor", may have meant Zocor
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccination and observation period successfully completed without adverse event. The patient''s significant other reported neither of them were feeling well on 2/21/2021. Approximately 28 hours after vaccination, the patient was found unresponsive in the bathtub. EMS arrived within 5 minutes, resuscitation attempt was unsuccessful, CPR terminated at 1503 and the patient pronounced dead. The Medical examiner refused the case on the basis of lack of jurisdiction, and the remains were moved to a local funeral home. No autopsy was performed. This event is not thought to be related to the vaccination event or the vaccine, the death is thought to be from natural causes.


VAERS ID: 1051263 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Brain hypoxia, Coma, Death, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: PHENOBARBITAL; LAMICTAL; KEPPRA
Current Illness: Seizures
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Found unconscious; Coma; Lack of oxygen to the brain; A spontaneous report was received from a consumer, concerning his mother, a 71-year-old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away, prior to death, patient experienced lack of oxygen to the brain and was found unconscious and went to coma. The patient''s medical history reported included seizures. Concomitant medications included phenobarbital, lamotrigine and levetiracetam. On 27 Jan 2021, approximately six days prior to the onset of events, the patient received their first of two planned doses of mRNA-1273 (lot number: 030L20A) intramuscularly for prophylaxis of COVID-19 infection. On 01 Feb 2021 at 4 am, the patient was found to be unconscious on the couch, hence she was rushed to the hospital with lack of oxygen to the brain. Later, she went into a coma, hence she was in hospital for 30 hours and then was transferred to a different hospital for a second opinion on 06-Feb-2021, where she was passed away at 02:20 PM. Treatment information was not provided Action taken with mRNA-1273 in response to the events were not applicable. The outcome of events, lack of oxygen to the brain, found unconscious and coma were considered unknown. The outcome of event passed away was fatal as she died on 06 Feb 2021 at 2:20 pm. The cause of death was not provided. Plans for an autopsy were unknown.; Reporter''s Comments: This is a case of 71-year-old female subject with a history of seizures who died 6 days after receiving first dose of vaccine. Very limited information has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Passed away


VAERS ID: 1051267 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031I20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Injection site pain
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cardiovascular disease, unspecified; Depression; Diabetes mellitus; Hypercholesterolemia; Hypertension; Stroke (Previous stroke.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Slight soreness in arm; A regulatory report was received from a pharmacist concerning a 72-year-old male patient who received Moderna covid-19 vaccine and death occurred 4 days after the vaccine and also experienced soreness in his arm after the vaccine administration. The patient''s medical history includes diabetes mellitus, Hypertension, Hypercholesterolemia, CVD, previous stroke and Depression. No relevant concomitant medications were reported. No information on allergies. On 4-FEB-2021 at 10:43 am, prior to the onset of events, the patient received his first of two planned doses of covid-19 vaccine for the prophylaxis of covid-19 infection. He had soreness in his arm the day following the shot, but he had no other symptoms. He passed away on 08-FEB-2021 at 10 am. As per his wife, they never made it to the hospital, and he had poor health prior to vaccination. Action taken with 2nd dose of Moderna Covid-19 vaccine was not applicable. The outcome of the event death is fatal.; Reporter''s Comments: This is a 72 year old male with hx of diabetes mellitus, hypertension, hypercholesterolemia, and CVD who died 4 days after the vaccine was administered. No autopsy report provided. No further information is expected in this regulatory report case.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1051651 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-23
Onset:2021-02-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Abdominal pain, Acidosis, Activated partial thromboplastin time prolonged, Alanine aminotransferase increased, Angiogram pulmonary abnormal, Angiogram pulmonary normal, Anion gap, Ascites, Aspartate aminotransferase increased, Atelectasis, Atypical mycobacterial infection, Bilirubin conjugated, Blood albumin, Blood alkaline phosphatase increased, Blood bicarbonate decreased, Blood bilirubin, Blood creatinine increased, Blood glucose decreased, Blood lactic acid, Blood lactic acid normal, Blood pH decreased, Blood pH increased, Blood potassium decreased, Blood urea increased, Cholelithiasis, Computerised tomogram abdomen abnormal, Computerised tomogram pelvis abnormal, Death, Dyspnoea, Enteritis, Fibrin D dimer, Hypoglycaemia, Ileus, International normalised ratio increased, N-terminal prohormone brain natriuretic peptide increased, Nausea, PCO2 increased, Pericardial effusion, Platelet count decreased, Pleural effusion, Proctitis, Retching, Troponin, Varices oesophageal, Vomiting, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (narrow), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Gallbladder related disorders (narrow), Gallstone related disorders (narrow), Pulmonary hypertension (broad), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Noninfectious diarrhoea (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (narrow), Infective pneumonia (broad), Hypokalaemia (narrow), Opportunistic infections (narrow), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Lisinopril, metoprolol, simvastatin, acetaminophen, ibuprofen, calcium carbonate, furosemide, diphenoxylate/atropine, magnesium chloride, omeprazole, Carafate, testosterone, vitamin D3, levothyroxine
Current Illness: None
Preexisting Conditions: Colon Cancer Hypothyroidism Hyperlipidemia GERD Hypertension
Allergies: NKDA
Diagnostic Lab Data: 2/23/21: White count is 2.1, platelet 26, INR 1.7, PTT 107.5, D-dimer greater than 5000 pH is 7.03 with PCO2 of 50, potassium 3.3, bicarb of 16, anion gap of 21, BUN of 26, creatinine 2.5, glucose of 39, lactic acid of 14.6, total bilirubin of 4.58, direct bilirubin of 3.87, AST 134, ALT of 43, alk phos of 194. Troponin is negative. proBNP of 4229. Albumin 1.9. CT scan of the abdomen pelvis shows complex fluid attenuation the posterior right hepatic lobe, possibly metastasis, nonspecific hepatic morphology, possibly cirrhosis. Small volume ascites, punctate calcified gallstone with pericholecystic fluid related to ascites. Infiltration of the submucosal fat of the ascending colon. Possible wall thickening of a short segment of jejunum possibly infectious or inflammatory process such as enteritis. Distention of a few loops of jejunum which may represent localized ileus. Fluid within the distal thoracic esophagus which can be seen in reflux. Mild wall thickening of the GE junction with intraluminal nodularity which may represent esophageal varices. Limited evaluation of bladder due to incomplete distention with possible mucosal hyperenhancement. CT angiogram of the chest demonstrates no evidence of pulmonary thromboembolic disease. Small segmental and subsegmental pulmonary emboli cannot be excluded. Distention of the entirety of thoracic esophagus with simple fluid. Trace bilateral pleural effusions. Overlying compressive atelectasis. Small pericardial effusion. Small focal atelectasis or atypical infection in the inferior lingula.
CDC Split Type:

Write-up: Abdominal pain, nausea and vomiting, shortness of breath, acidosis, hypoglycemia, death. Onset of abdominal pain was 30 minutes after administration of the vaccine followed by 20+ episodes of vomiting and dry heaving.


VAERS ID: 1051803 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-08
Onset:2021-01-15
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown- not the facility that administered the vaccine
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown- not the facility that administered the vaccine
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown, was informed by Health Director that person had passed away


VAERS ID: 1051923 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-31
Onset:2021-02-21
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1051942 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-11
Onset:2021-02-18
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Casodex, Sinemet CR, Plavix, Namenda, Midodrine, Protonix, Crestor, Zoloft, Trazadone,
Current Illness: Acute Hepatitis,
Preexisting Conditions: CAD, MI, RLS, Peripheral Neuropathy, PD, hyperlipidemia, orthostatic hypotension, Shy-Drager
Allergies: Intolerance to Morphine, Propoxyphene, Statins, Bisphosphonates, Tramadol, Methadone, and Meperidine
Diagnostic Lab Data: Partial autopsy. Results not complete
CDC Split Type:

Write-up: Hepatorenal syndrome- Death


VAERS ID: 1051975 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-19
Onset:2021-02-23
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1052045 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-12
Onset:2021-02-22
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M02A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away with in 60 days of receiving the COVID vaccine series


VAERS ID: 1052106 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-11
Onset:2021-02-17
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood cholesterol increased, Blood creatinine normal, Blood glucose increased, Blood potassium normal, Blood triglycerides increased, Blood urea increased, Cardiac arrest, Death, Low density lipoprotein normal, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Lipodystrophy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Metformin 500 2 tablets bid glipizide 10 mg bid Alopliptan 25 mg daily Prescribed statin, ASA and ace inhibitor but she was not taking them
Current Illness: DM with proteinuria and foot complications hyperlipidemia
Preexisting Conditions: DM with proteinuria and foot complications Renal insufficiency hyperlipidemia alcohol abuse
Allergies: Augmentin and NSAID
Diagnostic Lab Data: none Last hgbA1c was Jan 19 when if was 9.6%. BUN on that date was 36 and creatinine was 1.27. Potassium was 4.6. Random glucose was 185. LDL was 127 and total cholesterol was 211. Triglycerides were 232.
CDC Split Type:

Write-up: While at counseling appointment on February 17 patient had witnessed sudden cardiac arrest and was not able to be resuscitated. She was pronounced dead at 12:09. At the time of death her glucose was about 500.


VAERS ID: 1052108 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-02-19
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 2 - / -

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

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

Write-up: Patient passed away within 60 days of receiving the COVID vaccine series


VAERS ID: 1052138 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-29
Onset:2021-01-17
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arteriovenous fistula operation, Haemodialysis, Hypotension
SMQs:, Acute renal failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received Moderna 1st dose on 12/29/2020. Was in the hospital on 1/17/21-1/21/21 for severe hypotension and removal and replacement of hemodialysis shunt.


VAERS ID: 1052164 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / UNK AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Cardio-respiratory arrest, Death, Dyspnoea
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Stage 4 Kidney Disease Hypertension Ischemic Bowel Hyperlipidemia GERD CAD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 911 called to patients house for trouble breathing and abdominal pain. Patient coded, wife presented DNR paperwork. Patient presented to Hospital DOA at 0958.


VAERS ID: 1052172 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-18
Onset:2021-02-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Death, 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: 2021-02-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: statins- stated no allergic reaction but can''t take
Diagnostic Lab Data: Autopsy completed 2/20/2021 at medical school by MD
CDC Split Type: na

Write-up: Agency contacted 2/19 In evening by employer representative- client Died Suddenly after work"


VAERS ID: 1052179 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-25
Onset:2021-02-21
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1052226 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-02-11
Onset:2021-02-13
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cyanosis, Death, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (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: 2021-02-13
   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: Alveso, Xopenex, Aspirin, Atorvastatin, Cetirizine, Fiber, Hydralazine, Hydrochlorothiazide, Levothyroxine, Lisinopril, Meloxicam, Metformin, Metoprolol, Novolin,
Current Illness:
Preexisting Conditions: Arthritis, Diabetes Mellitus, Diabetic Neuropathy, Venous Insufficiency in Lower Extremity, Hypothyroidism, Chronic Obstructive Pulmonary Disease, Hypothyroidism, Obesity
Allergies: Bactrim
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient discovered unresponsive in cell, blue coloration to skin, vital signs, undetectable. CPR initiated, Ambulance summoned. Following EMS arrival with additional unsuccessful attempts to revive patient, patient was determined to have expired.


VAERS ID: 1052273 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted to the hospital the day after receiving a COVID vaccine x 5 days. Patient passed away on 2/23/2021.


VAERS ID: 1052700 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Senior Living       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: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: COPD, Essential hypertension
Preexisting Conditions: COPD, Essential hypertension
Allergies: Aspirin, Bee Stings, Bupropion
Diagnostic Lab Data:
CDC Split Type:

Write-up: 71 year old male patient recived the Moderna vaccine on 12/28/2020 and 1/27/2021. Tested positive for Covd-19 on 2/1/2021 (aysmptomatic). Passed away on 2/23/2021. Report came from facility.


VAERS ID: 1052738 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pyrexia, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: he takes prescriptions
Current Illness: no
Preexisting Conditions: CHF
Allergies: no
Diagnostic Lab Data: no
CDC Split Type:

Write-up: He vaccine on 2/5/2021 I went to see my husband the next day he was shaking and his mouth was open shaking, and he had fever of 105, they gave him Tylenol suppositories and he passed away 2 hours later. They should not have given him should not have given him the vaccine that is on hospice, it was not the right decision. I am worried about the elderly and those very sick.


VAERS ID: 1052809 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / UNK LA / IM

Administered by: Private       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: Neurontin, Proscar, Glucophage XR, Norvasc, Glucotrol, Lasix, Lipitor, Cozaar, Hygroton, Protonix, Hytrin
Current Illness: Pressure ulcers
Preexisting Conditions: BPF, CAD, Essential HTN, Diverticulosis of colon, Hyperlipidemia, Osteoarthritis, chronic respiratory failure, DM2 with peripheral vascular disease, peripheral edema, GERD, obstructive sleep apnea, osteoarthritis of knees,
Allergies: Lisinopril
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient passed away


VAERS ID: 1052820 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Hip fracture, Hip surgery, Pneumonia bacterial, Poor peripheral circulation, Stent placement, Surgery
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Infective pneumonia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 18 days
   Extended hospital stay? No
Previous Vaccinations: Breathing issues ~2 weeks after first dose of mRNA vaccine in the series but were not nearly as acute or severe as they were fol
Other Medications: A variety of medications for diabetes, blood circulation, hypertension
Current Illness: Diabetes, hypertension, cancer (lung)
Preexisting Conditions: cancer for many years.
Allergies: none
Diagnostic Lab Data: Bacterial pneumonia
CDC Split Type:

Write-up: Approximately 2 weeks after the first COVID vaccine she developed shortness of breath that was much more significant than she had previously. This was the first time she had expressed this symptom to me as being something she was concerned about and difficult for her to manage (we have spoken almost daily for many years). Within 24 hours of the second dose of the mRNA vaccine, they called an ambulance to get her and she was taken to the hospital and diagnosed with bacterial pneumonia. The doctors said it was unrelated, but I found a study with a different vaccine (LAIV) that also seemed to increase the incidence of bacterial pneumonia. They hypothesized through diverting the immune system. So while I don''t think the vaccine gave her the bacteria, I do think it may have caused her immune system to be temporarily compromised allowing the bacteria to grow out of control. I feel this is important to report to look for these types of patterns as perhaps it can help others avoid the death spiral that happened to my mother. There were also intervening events between her hospitalization and her death including two successful surgeries (one for a broken hip and another to put in stents in her leg). So to summarize, the first vaccine was within about 2 weeks of the onset of her breathing problems. Within 24 hours of the second vaccine she was hospitalized and diagnosed with bacterial pneumonia. As she was battling bacterial pneumonia in the hospital she broke her hip and was found to have reduced peripheral circulation and had 2 surgeries to correct those. They were successful according to the surgeons, however she died within a week or so of the surgeries. She had other comorbidities as well which I''m sure predisposed her such as diabetes, hypertension and cancer for many years.


VAERS ID: 1052972 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-23
Onset:2021-02-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / SC

Administered by: Senior Living       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: NO
Current Illness: NO
Preexisting Conditions: ACUTE KIDNEY DISEASE, DIABETES, HYPERTENSIVE HEART
Allergies: NO
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: RESIDENT EXPIRED


VAERS ID: 1053191 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-02-08
Onset:2021-02-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Communication disorder, Contusion, Death, Thrombocytopenia, Thrombosis
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine administered 02/08/2021 , by Thursday 02/11/2021 patient almost nonverbal, by Monday 02/15/2021 patient went to the hospital with bruising, sores on her stomach and clots reported as thrombocytopenia, deceased by Friday 02/19/2021.


VAERS ID: 1053322 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Missouri  
Vaccinated:2020-12-29
Onset:2021-01-31
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / UNK LA / IM

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

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

Write-up: Pt had passed away before second dose


VAERS ID: 1053694 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-08
Onset:2021-02-17
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Tamsulin, Xarelto, Lasix
Current Illness: A-FIB, DM2,
Preexisting Conditions: DM2, A-FIB
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden Death on 2/17/2021


VAERS ID: 1053788 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-02
Onset:2021-02-15
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

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

Write-up: Received call that patient is now deceased


VAERS ID: 1053978 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Death, Pain, Pyrexia, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Albuterol sulfate inhaler, atenolol, ipatropium-albuterol nebulizer, Sensipar, lisinopril, Incruse Ellipta, lovastatin, pantoprazole, furosemide, trazodone, diclofenac gel, triamcinolone cream, fluticasone nasal spray
Current Illness: none
Preexisting Conditions: CKD Stage 3, COPD, hyperlipidemia, secondary hyperparathyroidism
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt woke up at 0400 with fever, chills, and body aches progressing over 4 hours to the point when she became unresponsive. husband called 911, pt was declared dead at the time of EMS arrival around 1200


VAERS ID: 1054080 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-18
Onset:2021-02-21
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine, centrum silver, vitamin C, Vitamin D, vitamin E, zinc, Lexapro, Seroquel, trazodone.
Current Illness: none
Preexisting Conditions: hypertension, COPD, schizophrenia
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest, death: 2/21/21


VAERS ID: 1054160 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Back pain, Death, Headache, Nausea, Pain in extremity, Seizure
SMQs:, Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Generalised convulsive seizures following immunisation (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

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? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: not applicable
Preexisting Conditions: Right VP shunt at birth.
Allergies: Latex and Ceclor
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/12/2021 woke up with sore arm and back. 2/13/2021 woke up with headache around 1am. Headache and nausea all morning. Mid-late afternoon started having seizures. Admitted to Hospital 2/15/2021 expired. Reported per wife on 2/25/2021.


VAERS ID: 1054192 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-16
Onset:2021-02-23
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unk
Current Illness: None listed
Preexisting Conditions: None listed
Allergies: NKA
Diagnostic Lab Data: Unk
CDC Split Type:

Write-up: Pt''s wife reports death 2/23/2021


VAERS ID: 1054337 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: several including METOPROLOL ER SUCCINATE 50 MG TABS
Current Illness: NONE
Preexisting Conditions: HEART CONDITION
Allergies: UNKNOWN
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: FOUND DEAD IN HIS OWN BED


VAERS ID: 1054435 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 RA / IM

Administered by: Public       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: Low dose oral Chemo
Current Illness: Patient has CLL
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed on 01/28/2021 per family member.


VAERS ID: 1054699 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, tamsulosin, M vit. clopidogrel; aspirin; sertraline, melatonin, losartan, myrbetriq, senna, vit. D
Current Illness:
Preexisting Conditions: PRimaRy hypertension, HypeRlipidemia, BRadycaRdia
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found at 6 AM on 01/21/2021 - he passed away during his sleep


VAERS ID: 1054813 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-29
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Urinary tract infection
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 17
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: Chest clear - Hospitalized for a UTI


VAERS ID: 1054859 (history)  
Form: Version 2.0  
Age: 102.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-15
Onset:2021-01-22
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013120A / UNK RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not reported
Current Illness:
Preexisting Conditions: COPD, chronic kidney disease, heart disease
Allergies: not reported
Diagnostic Lab Data: none reported
CDC Split Type:

Write-up: No details - patient died on 1/22/2021


VAERS ID: 1054966 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-12
Onset:2021-02-16
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Angiogram pulmonary normal, Apnoeic attack, Blood creatine, Blood creatine phosphokinase increased, Blood potassium normal, Blood urea increased, CSF glucose increased, CSF protein increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram head normal, Decreased appetite, Dehydration, Fibrin D dimer increased, Glomerular filtration rate decreased, Hypophagia, Protein total increased, SARS-CoV-2 test negative, Tenderness
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Acute pancreatitis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol inhaler Allopurinol Aspirin Carvedilol Cyanocobalamin Escitalopram Fanny Cream Fluticasone nasal spray Furosemide Glipizide Insulin detemir Ipratropium/albuterol nebs Losartan Melatonin Metformin Olanzapine Fish oil Pravastatin Ps
Current Illness: None. Recently in hospital for a fall.
Preexisting Conditions: Dementia, atrial fibrillation, type 2 diabetes, heart failure with reduced ejection fraction, gout, hyperlipidemia
Allergies: None
Diagnostic Lab Data: 2/16/2021: Chest X-ray - boarderline CHF 2/16/2021: Head CT - no intracranial abnormality. stable severe chronic changes 2/16/2021: Chest CTA - no pneumothorax COVID-19 tests all negative CSF glucose: 137 CSF total protein: 176 D-dimer: $g5250 BUN: 41-111 eGFR: 54.2-11.9 Potassium: 4.1-7.3 SCr: 1.28-4.75
CDC Split Type:

Write-up: Mentation has declined since hospital discharger for fall on 2/6/20201. Patient has also had significant poor oral intake. Brought in due to apneic episodes. Abdominal pain - diffuse tenderness (right sided) Elevated liver enzymes - likely secondary to dehydration Increased serum creatine kinase - likely due to dehydration


VAERS ID: 1055070 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-02-19
Onset:2021-02-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cetirizine, ferrous gluconate, atorvastatin, acetaminophen, aspirin EC, sertraline, clozapine, risperidone, clozapine, polyethylene glycol, sennosides, glipizide, levothyroxine,
Current Illness: Morbid obesity, hypothyroidism, Diabetes, Iron deficiency anemia, QT prolongation, hyperlipidemia, chronic hypoxia, psychosis, luteal phase dysphoria, anxiety, early onset schizophrenia, moderate intellectual disability, left ankle ORIF.
Preexisting Conditions: Same as item 11, remove left ankle ORIF
Allergies: No known allergies
Diagnostic Lab Data: Post pending
CDC Split Type:

Write-up: Client died on 02/21/2021 and had received the second dose of the vaccine series on 02/19/2021.


VAERS ID: 1055149 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027LZOA / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Respiratory distress, Use of accessory respiratory muscles, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: Amlodipine, lasix, toprol XL, PRN: lorazipam and morphine
Current Illness: MEDICAL HISTORY; CHF (EF=20%), CAD, AAA (NO REPAIR) 5.3CM, ANEMIA (HISTORY TRANSFUSIONS ARANESP/PROCRIT), CKD STAGE 5 (BUN=110/CREATININE=6.09), HTN, ISCHEMIC CARDIOMYOPATHY, GLAUCOMA, HOH, COVID-19 PNEUMONIA 11-27-2020 THROUGH 12-12-2020, SEVERE NONRHEUMATIC MITRAL VALVE REGURGITATION, NSTEMI 03-27-2019, CAROTID ARTERY STENOSIS, CABG 2009, CARDIAC STENT PLACEMENT, FORMER SMOKER.
Preexisting Conditions: see above
Allergies: ace inhibitors, codeine, lysynopril
Diagnostic Lab Data: none
CDC Split Type:

Write-up: This is a hospice patient under the care of Hospice at an affiliated nursing home. Pt received the vaccination around noon on 2-16-21 by a representative from Pharmacy. The following afternoon 2-17-21 at 14:45 the pt started to experience severe SOB resp rate 36, audible wheezing and use of respiratory accessory muscles. BP180/80, 113 pulse temp 98. Pt was given morphine and ativan. The respiratory distress was eased however pt never returned to baseline and died 2-22-21 around 4am.


VAERS ID: 1055290 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-02-08
Onset:2021-02-11
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M208 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: not known at this time. I can research if needed
Current Illness: unknown
Preexisting Conditions: elderly
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death occurred 02/14/2021


VAERS ID: 1055418 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-15
Onset:2021-02-24
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Lisinopril/HCTZ, Prasugrel, Rosuvastatin
Current Illness:
Preexisting Conditions:
Allergies: Codeine, Morphine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient suffered a stroke and passed away


VAERS ID: 1055563 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-18
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living       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: 2021-02-18
   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: Pt tested positive for COVID-19 on 2/10/2021 and died from illness related to COVID-19 on hospice at home on 2/18/2021, per care facility.


VAERS ID: 1055588 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-15
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living       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: 2021-02-18
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021 and was hospitalized on 2/15/2021 and deceased on 2/18/2021 at the hospital of admission, per caregiver.


VAERS ID: 1055613 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-10
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021 and was deceased on 2/16/2021 per the caregiver.


VAERS ID: 1055618 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-16
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living       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: 2021-02-16
   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: Pt tested positive for COVID-19 on 2/10/2021, and was deceased on 2/16/2021 at.


VAERS ID: 1055629 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-05
Onset:2021-02-12
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Senior Living       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: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt tested positive for COVID-19 on 2/10/2021, and deceased on 2/12/2021, per caregiver at.


VAERS ID: 1055691 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-19
Onset:2021-01-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 - / SC

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aspiration, Death, Ischaemic stroke, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), 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: 2021-01-24
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zoloft, ASA, Lipitor
Current Illness: dyslipidemia, mild dementia, lumbar stenosis with indwelling suprapubic catheter - no known infection/symptoms of infection
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Massive ischemic stroke with aspiration, unable to arouse on the morning of 1/21/2021 and placed on Hospice with death 1/24/2021


VAERS ID: 1055791 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-11
Onset:2021-01-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 UN / SYR

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Hives
Other Medications: Yes
Current Illness: Yes Dementia
Preexisting Conditions: Yes
Allergies: Yes
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Was given without consent from POA patient got severely sick and never recovered later passed away only live 1 month POA did not allow second vaccine to be given just wanted to report this vaccine was given illegal without POA knowledge


VAERS ID: 1055819 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Dyspnoea, Gait inability, Laboratory test normal, Mechanical ventilation, Pyrexia, Sudden death, Vaccination complication
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dystonia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 39 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Taking various meds/antibiotics for UTI, CDIF, high sodium, high blood pressure, diabetes
Current Illness: Treated for COVID pneumonia. Tested positive on Jan 2, 2021. This caused other infections (UTI, CDIF), required oxygen.
Preexisting Conditions: Treated underlying conditions for diabetes, high sodium, high blood pressure, kidney disease.
Allergies: NA
Diagnostic Lab Data: See above
CDC Split Type:

Write-up: On January 1, 2021, patient was admitted to Medical Center with COVID. Tested positive on January 2, 2021. Spent 10 days in hospital. Once recovered from pneumonia and fever gone, on January 10, 2021, she was transferred to Rehabilitation Center for continued treatment. She spent 16 days there. She developed UTI and CDIF infections and was on/off oxygen. She started physical therapy. She was scheduled to be released to go home on January 27, 2021. On January 26, 2021, the day before going home, Rehabilitation Center gave her the Moderna vaccine. On January 27, the day she went home, she started feeling very weak and couldn''t walk. My dad tried lifting her and they both fell to the ground. My dad called 911 and she was taken to Medical Center, with high fever and possible stroke symptoms (which later was negative). Two days later, she had difficulty breathing and was put on a ventilator. She was on a ventilator for about three days. They took it off and she slowly started recovering. The doctors did all kinds of tests (blood clot in lung, heart, etc.) and all was negative. The only thing they could trace it to was an adverse reaction to the vaccine. After spending 11 days at hospital and treating her for various infections, her heart stopped and she passed away suddenly.


VAERS ID: 1056011 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-07
Onset:2021-02-10
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiovascular disorder, Cerebrovascular accident, Death, Dyspnoea, Endotracheal intubation, Feeling abnormal, Hemiparesis, Sedation, Thrombosis
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Blood pressure medication, cholesterol medication, some other vitamins and supplements.
Current Illness: Kidney disease
Preexisting Conditions: Kidney disease
Allergies: None.
Diagnostic Lab Data:
CDC Split Type:

Write-up: My grandpa had a stroke on the 15th of February. He claimed he had been feeling "off" for a few days, but didn''t say anything. A blood clot had formed in his brain. He was doing better and about to go to rehab to strength his right side of his body. On the 22nd he took a turn for the worst. He was having trouble breathing and they sedated and partially paralyzed him to put a tube in his mouth. I believe another blood clot had formed and oxygen wasn''t properly going through his body. They could not stabilize him, and he passed away the same day.


VAERS ID: 1056518 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-01-18
Onset:2021-02-13
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: 2021-02-13
   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: VITAMINS NOS
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Bypass surgery
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: The coroner said it was some type of heart attack; A spontaneous Report Received from a Health care professional concerning a 84 year old male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and who experienced a heart attack / myocardial infarction. The patient''s had undergone triple bypass surgery years ago. Concomitant medications were vitamins. On 18-Jan-2021 prior to onset of events the patient received his first of first two planned doses of (mRNA-1273) COVID-19 vaccine of unknown batch no, unknown route and unknown site of administration for prophylaxis of COVID-19 infection. On 13-Feb-2021 the patient experienced death 27 days after the first dose of the vaccine. The coroner said it was some type of heart attack and think he expired sometime Saturday 13-Feb-2021. On 16-Feb-2021 the patient was supposed to have his second dose of (mRNA-1273) COVID-19 vaccine. The event, heart attack, was fatal.; Reporter''s Comments: This is a case of death to heart attack in a 84-year-old female subject with a hx of triple bypass surgery, who died 27 days after receiving first dose of vaccine. Very limited information has been provided at this time. No death certificate provided. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of Death


VAERS ID: 1056842 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-11
Onset:2021-02-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The medical facility did not treat patient as her primary care, but were informed that she passed away on 15 February 2021 of a stroke. I do not have further information on the medical aspect of this as we were not her treating provider but did administer the vaccine on 12 February.


VAERS ID: 1056972 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-01-29
Onset:2021-02-04
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Biliary dilatation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Gastrointestinal oedema, Hepatic cirrhosis, Imaging procedure, Intestinal angioedema, Intestinal mass, Intracranial mass, Laboratory test, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Peritonitis bacterial, Supraventricular tachycardia, Thrombosis
SMQs:, Torsade de pointes/QT prolongation (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Angioedema (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Torsade de pointes, shock-associated conditions (narrow), Pseudomembranous colitis (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Gastrointestinal perforation (narrow), Gastrointestinal haemorrhage (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (broad), Biliary tract disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Gastrointestinal nonspecific inflammation (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Pregnancy, labour and delivery complications and risk factors (excl abortions and stillbirth) (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 23
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction Prolonged Q-T interval on ECG Leukocytosis A-fib Common bile duct dilation Duodenal mass Cirrhosis Small bowel edema Stroke Bleeding esophageal varices SBP (spontaneous bacterial peritonitis) Catastrophic antiphospholipid syndrome
CDC Split Type:

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center. She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.


VAERS ID: 1057281 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-05
Onset:2021-02-19
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: per husband, stage 4 pancreatic cancer
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient''s husband reported her death that happened after first COVID-19 vaccine


VAERS ID: 1057363 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-13
Onset:2021-02-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L28A / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dementia
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient with severe dementia in Hospice Care


VAERS ID: 1057547 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Texas  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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 medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: 86 year old manager received the two doses of the Moderna vaccine and died; A spontaneous report was received from a consumer, concerning an 86-year-old, male 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 unspecified date, the patient received their doses of mRNA-1273 (Lot number: unknown) through an unknown route in an unknown arm for prophylaxis of COVID-19 infection. On an unspecified date, it was reported that the patient passed away after receiving both doses. The cause of death was unknown. It was unknown if an autopsy was performed. The patient received both scheduled doses of mRNA-1273 prior to the event; therefore, action taken with the drug in response to the events is not applicable. The outcome of event "86 year old manager received the two doses of the Moderna vaccine and died" was fatal.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. No autopsy report provided. Further information has been requested.; Reported Cause(s) of Death: 86 year old manager received the two doses of the Moderna vaccine and died


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