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From the 9/17/2021 release of VAERS data:

Found 15,386 cases where Vaccine targets COVID-19 (COVID19) and Patient Died



Case Details

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VAERS ID: 992238 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Michigan  
Vaccinated:2020-12-16
Onset:2021-01-05
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 24 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol sitagliptin/metformin glipizide pioglitazone folic acid rivaroxaban tadalafil aspirin atorvastatin lisinopril nephrocaps omeprazole
Current Illness:
Preexisting Conditions: ischemic heart disease hypertension diabetes mellitus type 2 gastroesophageal reflux disease hyperlipidemia obstructive sleep apnea obesity
Allergies: Plavix
Diagnostic Lab Data:
CDC Split Type:

Write-up: Tested positive for COVID19 on 12-30-2020, Admitted to Hospital on 1/5/2021 with active COVID, Patient died 1/29/2021.


VAERS ID: 992342 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Dyspnoea, Hypertension, Oxygen saturation decreased, Pneumonia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Baby Aspirin
Current Illness: none
Preexisting Conditions: Diabetes Type 2
Allergies: NKDA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Shortness of Breath, decreased oxygen saturation, irregular heart rhythm, hypertension, Positive for COVID, bilateral pneumonia


VAERS ID: 992347 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: hydrocodone, fentanyl, albuterol
Current Illness: none known
Preexisting Conditions: degenerative disc disease, chronic back pain, hypothyroidism, hypertension, GERD, COPD, tobacco dependence
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 992372 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011I20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Atrophy, Cerebral haemorrhage, Cerebral small vessel ischaemic disease, Chest X-ray normal, Computerised tomogram head normal, Death, Embolic cerebellar infarction, Embolic cerebral infarction, Erythema, Laboratory test normal, Magnetic resonance imaging brain, Magnetic resonance imaging brain abnormal, Mental status changes, SARS-CoV-2 test negative, Troponin increased, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), 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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: (1) Acetaminophen 500mg PO Q4H PRN pain (2) Albuterol inhaler 1 puff Q4H PRN (3) Cyanocobalamin 1000mg PO daily (4) Diazepam 5mg PO daily PRN anxiety (5) Ergocalciferol 48,000 units PO daily (6) Fluoxetine 20mg PO daily (7) Arnicare cream 1
Current Illness:
Preexisting Conditions: (1) Advanced dementia (2) Hypothyroidism (3) Anxiety (4) Hx falls
Allergies: (1) Etodolac (rxn = n/v, diarrhea, SOB) (2) Bee Pollen (3) Escitalopram (rxn = ''intolerance'') (4) Paroxetine (rxn = ''ineffective'') (5) Venlafaxine (rxn = ''ineffective'')
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is a 73 year old female that received her 1st dose with Moderna vaccine on 1/8/21 at approximately 1600. Within one hour, the patient developed altered mental status and increasing weakness. She was transported to the hospital by the staff at her Assisted Living Facility for concern of a vaccine reaction. On admission, oxygen saturation was found to be 89% on room air, BP=137/86, HR=94. Labs were normal, with the exception of WBC=15 (leukocytes normal, chest xray clear, COVID test negative), and a detectable troponin=63. Head CT negative. Physical exam was only notable for ''slight superficial erythema over distal right forearm and dorsal hand. No significant edema.'' The patient was treated for a possible allergic reaction to vaccine with NS bolus, methylprednisolone 125mg, famotidine 20mg, and aspirin 300mg PR. She was admitted for monitoring given continued altered mental status/weakness. The next day, she continued to show no improvement, so a head MRI was ordered. MRI showed " 1. Numerous acute cerebral and cerebellar infarcts involving both anterior and posterior circulations consistent with a central embolic source. 2. Minimal right parietal petechial hemorrhage. 3. Moderate atrophy and moderate nonspecific white matter signal abnormalities compatible with chronic microvascular ischemia " Neurology was consulted, who approved the start of aspirin and to continue DVT prophylaxis. The patient''s advanced dementia and timeline preclude other intervention. The patient''s status was DNR/DNI. The patient was discharged on hospice to her assisted living facility on 1/11/21 (with reports of continued somnolence). It was reported that date of death was 1/24/21.


VAERS ID: 992571 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Dyspnoea, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: He stated he was experiencing some shortness of breath with cold and walking up the steps. The patient did report that they had some bloody stool early in the week but that had resolved.
Preexisting Conditions: PMH: DM, HTN, Obesity, hyperlipidemia, Chronic kidney Disease, polyp?s removal. History of Angioedema secondary Ace Inhibitor
Allergies: ACE inhibitor
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient''s wife called the physician''s office with increasing SOB. MD advised that the patient go to the ED. While dressing, the patient became unresponsive, 911 called. Patient expired in ED.


VAERS ID: 992599 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: California  
Vaccinated:2020-12-31
Onset:2021-01-03
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lactobacillus Capsule MULTIVITAMINS TABLET CRANBERRY TABLET
Current Illness: COVID-19 POSITIVE 12/14/20
Preexisting Conditions: COPD, DM TYPE 2, CHF, GERD, HYPERTENSION, HYPERLIPIDEMIA
Allergies: Ciprofloxacin, Codeine, Bactrim, Lactose Intolerant
Diagnostic Lab Data:
CDC Split Type:

Write-up: right arm redness


VAERS ID: 992677 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041620A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Body temperature increased, Vomiting projectile
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Clonazepam, Mirtazapine, Seroquel, Austedo, Risperdal, Senna, Omeprazole
Current Illness:
Preexisting Conditions: Huntington''s Anxiety, Depression, Constipation.
Allergies: Paroxetine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Low Grade Temp, Persistent low back pain, Projectile Vomiting.


VAERS ID: 992734 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-07
Onset:2021-01-24
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: alendronate sodium 70 mg 1 time a day every sunday for arthritis aspirin 81 mg q day Buspirone HCL 5 mg 3 times daily Calcitonin solution 200 units 1 spray via nostril Calcium capsule 250 mg 2 times per day Cardedilol 6.25 tab 2 times per
Current Illness: Rheumatoid Arthritis, overactive bladder, glaucoma, major depressive disorder, Alzheimers Disease, polyneuropathy,
Preexisting Conditions: Rheumatoid Arthritis, overactive bladder, glaucoma, major depressive disorder, Alzheimers Disease, polyneuropathy,
Allergies: codeine, penicillin, enbrel, septra, sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1st COVID immunization 1/7/2021, COIVD positive results on 1/16/21, 1/24/21 O2 sats decreased to 78%, 1/24/21 reveived the Bamlanivimab infusion 50 ml/hr. 1/24/20 chest x ray 1/24/21 She was sent to hospital and admitted. 1/27/2021 Expired


VAERS ID: 992846 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Coreg 12.5 mg tablet: 12.5 mg PO BID; Hytrin 10 mg capsule po daily; Lasix 20 mg tablet po daily; Lipitor 40 mg tablet daily; Phenobarbital 30 mg tablet po BID; Levothyroxine 100 mcg tablet daily; lisinopril 2.5 mg tablet po daily; pantopra
Current Illness: CRT-P upgrade on 1/7/2021 Pacemaker 0107 on 1/7/2021
Preexisting Conditions: Acute MI; arthritis; atrial fibrillation; bleeding; bronchitis; bypass; cholecystitis; chronic anemia; COPD; CKD; CAD; Heart block Hypercholesteremia; HTN; hypothyroidism; MI
Allergies: CeleBREX-GI Bleed Morphine-urticaria
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient complained to wife of not feeling well in evening after the vaccination and expired at home during the night.


VAERS ID: 992884 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-01-16
Onset:2021-01-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Fatigue, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Sulfa Allergy
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: The next morning after vaccine, patient ran a fever, vomited, and was very tired. Mom laid her down to sleep and when she checked later, patient had passed away.


VAERS ID: 992977 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-20
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 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: 2021-01-25
   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: pantoprazole, tramadol, duloxetine, vesicare
Current Illness: unsure
Preexisting Conditions: unsure
Allergies: cephalosporins, sulfa, penicillins, opiods,
Diagnostic Lab Data: unsure
CDC Split Type:

Write-up: spoke with patient husband on Saturday 1/23 and he said that she had been in the hospital. that she had had a stroke, the MD''s at the hospital told him that it was not contributed to the vaccine and that they were unsure even if the stroke had occurred prior to the vaccine or after. spoke with him again on 1-29 and he stated that she had passed away on 1/25/21


VAERS ID: 993028 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-06
Onset:2021-01-09
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Hyperhidrosis, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 2
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: see attached med list
Current Illness: C-diff
Preexisting Conditions: COPD, HTN, DM II, CAD, Acute kidney failure, CHF, GERD, Adult failure to thrive,
Allergies: metoprolol, demerol
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/9/21-Diaphoresis, O2 90%, respirations 22, increased weakness, wheezing bilaterally. Send to ER for evaluation and treatment. She was sent to ER, where she was admitted for 2 days, then expired there on 1/11/21


VAERS ID: 993072 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-01-27
Onset:2021-01-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / SYR

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain, Ascites, Blood alkaline phosphatase increased, Blood chloride decreased, Blood creatinine increased, Blood culture positive, Blood lactic acid increased, Blood potassium decreased, Blood sodium decreased, C-reactive protein increased, Carbon dioxide decreased, Death, Malaise, Omental necrosis, Ovarian necrosis, Peritoneal lavage, Platelet count decreased, Septic shock, Streptococcus test positive, Surgery, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Toxic-septic shock conditions (narrow), Biliary system related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 4
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: Metoprolol, Lipitor, Lisinopril, Asa,Demedex, Levimir, Jardiance, Metformin
Current Illness: None reported
Preexisting Conditions: Type 2 DM, MGUS, Cardiomyopathy with implanted Defib, Chronic heart failure
Allergies: Environmental and Magnesium succinate
Diagnostic Lab Data: WBC 1.2 with lactic acid 9.3, Plt. 113, Na 128, K 3.3, Cl 92, CO2 16, Cr 2.25, Alk phos 150, CRP 160.6. Blood cultures grew out strep A, Pt. taken to emergent surgery with no intra abdominal pathology. for sepsis found. Had massive ascites. Subsequently had a repeat wash out with necrotic ovaries/omentum noted. Never recovered and subsequently died from her illness.
CDC Split Type:

Write-up: Pt. presented to the ER with abd pain and septic shock. Pt. reported to feel ill shortly after receiving the vaccine.


VAERS ID: 993112 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: California  
Vaccinated:2020-12-01
Onset:2021-01-01
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Cardiac arrest, Death, Decreased appetite, Dependence on respirator, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin ec 81mg, xarelto 20 mg, propranolol 40 mg, Vita-B1 100mg Trazodone 50mg, Clonidine HCL 0.1 mg tablet, Divalproex 80D DR 25mg, CHLORPROMAZINE 10mg, folic acid 1 mg ,Benztropine mes 1mg, cetirizine HCL 10mg, SPIriva 18 MCG CP-handihal
Current Illness: Broken ankle
Preexisting Conditions: Mid intellectual Disabilities, Schizoaffective Disorders, Obesity, Unspecified Heart Disease, Unspecified Hypothyroidism, unspecified Allergic rhinitis
Allergies: PCN,Lactose Intol
Diagnostic Lab Data: Hospital would not share any information at all
CDC Split Type:

Write-up: she was injected, sh stopped eating and talking, the doctor watched her for 2 days. had her transported to the hospital. i was told she had tested positive for COVID 2 times once at the home and once at the hospital. with in 2 DAYS at the hospital she wa on a ventilator 2 days later she died. i talked with the rehab center and confirmed she tested negative for COVID on Dec 27th 2020 and was given the Vaccine on the 29th Dec 202 was in the hospital 4 day later, was on a ventilator 4 days after that then died a few day later as her heart stopped beating. all the while i had POA and was not contacted by Hospital staff until after they had made the next step.


VAERS ID: 995147 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-23
Onset:2021-01-20
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chills, Death, Erythema, Fatigue, General physical health deterioration, Injection site pain, Laboratory test normal, Pain in extremity, Pyrexia, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Lab tests after MODERNA COVID-19 vaccine: ALL NEGATIVE Orders for date: 01/19/2021 Test Urgency Status Lab NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/19/2021 12:43 Orders for date: 01/14/2021 Test Urgency Status Order NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/14/2021 15:59 Orders for date: 01/11/2021 Test Urgency Status Lab NASAL SWAB NASOPHARYNGEAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test complete 01/11/2021 12:27 Orders for date: 01/07/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/11/2021 17:01 Orders for date: 01/04/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/08/2021 07:34 Orders for date: 12/28/2020 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX COVID-19 DIAGNOSTIC PANEL (BIOFIRE) ROUTINE Test Complete 12/28/2020 13:58 PCR 20 1403 Most recent med list prior to patient''s death: INPT ACETAMINOPHEN 650 MG RTL SUPP (Status=Active) 650MG RCT FOUR TIMES A DAY AS NEEDED Fever. Give PR if unable to take PO ORDER LAST ACTION: 12/29/20 16:37 GIVEN ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3 ML INHALE 1 VIAL IN NEBULIZER BY ORAL INHALATION FOUR TIMES DAILY AS NEEDED COPD, MED HAS LARGE SUPPLY INPT BISADODYL 10MG RTL SUPP (Status=Active) 10MG RCT EVERY 72 HOURS AS NEEDED Constipation. Give if MOM ineffective ORDER LAST ACTION: 02/26/20 18:11 GIVEN INPT LORAZEPAM 2MG/ML INJ. 1 ML (Status=Active) 0.5MG(0.25 ML) SUBCUTANEOUSLY EVERY FOUR HOURS AS NEEDED End of life agitation or anxiety INPT MILK OF MAGNESIA 30 ML UD (Status=Active) 30ML BY MOUTH DAILY AS NEEDED CONSTIPATION ORDER LAST ACTION: 01/07/21 15:09 GIVEN INPT MORPHINE SO4 4MG/ML INJ PFS (Status=ACTIVE) 4MG/ML IV EVERY ONE HOUR AS NEEDED if needed for end of life restlessness, air hunger, pain. ORDER LAST ACTION: 01/19/21 11:15 GIVEN POLYETHYLENE GLYCOL 3350 ORAL PWDR TAKE 17 GM (ONE CAPFUL) BY MOUTH DAILY AS NEEDED constipation. MED HAS LARGE SUPPLY
CDC Split Type:

Write-up: Death Narrative: Patient received the first COVID-19 dose on 12/23. Afterwards, patient complained of localized pain on L deltoid area where the vaccine was administered; his temperature was 98.1 F. On 12/26-27, staff reported that patient appeared more fatigued than usual and was shivering on 12/27, which seized after blanket was given. On 12/28, patient presented with fever (Tmax 100.2 F) and acetaminophen was administered for alleviation of fever. ADR was reported for the fever on 12/29. Patient continued to decline and was placed back on hospice care on 12/29; on 12/30. the symptoms reported on nursing note include erythema and pain on whole L arm. Lidocaine was applied. Patient''s family and provider mutually agreed not to administer the second dose of vaccine. He continued to decline and was started on end-of-life care around 1/4 and passed on 1/20 1417.


VAERS ID: 995165 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-27
Onset:2021-01-30
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

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

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

Write-up: Died in sleep


VAERS ID: 993822 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021075824

Write-up: he got both doses then a few days later he died; This is a spontaneous report from a contactable consumer reporting for a friend''s father. A male patient of an unspecified age received the second dose of bnt162b2 (BNT162B2) vaccine , via an unspecified route of administration on an unspecified date at single dose for Covid-19 immunisation . The patient medical history and concomitant medications were not reported. The patient received the first dose on an unknown date. The patient died few days after receiving the second dose of the vaccine on an unspecified date. It was not reported if an autopsy was performed. Information about lot/batch number has been requested.; Reported Cause(s) of Death: he got both doses then a few days later he died


VAERS ID: 993823 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021077709

Write-up: died due to heart attack; This is a spontaneous report from a contactable consumer (reporting for her son-in-law) from the Pfizer-sponsored program Pfizer First Connect. A male patient of an unspecified age received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on an unspecified date at a single dose for COVID-19 immunization. The patients medical history and concomitant medications were not reported. The patient died due to heart attack on an unspecified date. The patient died on an unspecified date. It was unknown if an autopsy was performed. Follow-up (28Jan2021): This follow-up is being submitted to notify that the lot/batch number is not available despite the follow-up attempts made. Follow-up attempts completed. No further information is expected.; Reported Cause(s) of Death: died due to heart attack


VAERS ID: 993828 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Blood glucose normal, Cardiac arrest, Death, Dysphagia, Fall, Glycosylated haemoglobin increased, Pulse absent, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NOVOLOG
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure abnormal (Verbatim: Blood pressure); Diabetes; Neuropathy; Walker user; Weight abnormal
Allergies:
Diagnostic Lab Data: Test Date: 20210124; Test Name: blood sugar; Result Unstructured Data: Test Result:91; Test Name: blood pressure; Result Unstructured Data: Test Result:fine; Test Name: heart test; Result Unstructured Data: Test Result:perfect; Test Name: A1C; Result Unstructured Data: Test Result:was always high
CDC Split Type: USPFIZER INC2021079922

Write-up: Heart stopped; Could not swallow; This is a spontaneous report from a contactable nurse (patient''s wife). An 85-year-old male patient received the first dose of the bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on 21Jan2021 at a single dose for COVID-19 immunization. Medical history included blood pressure abnormal (verbatim: blood pressure) from an unknown date and unknown if ongoing, neuropathy from an unknown date and unknown if ongoing, weight issue from an unknown date and unknown if ongoing, diabetes from an unknown date and unknown if ongoing, walker user from an unknown date and unknown if ongoing. Concomitant medications included insulin aspart (NOVOLOG) taken for diabetes from an unspecified date to an unspecified date; and he was taking a long acting one as well. The patient previously received the influenza vaccine (MANUFACTURER UNKNOWN) for immunization on unknown dates ("had flu shots before with no reactions and everything, nothing before"). On 24Jan2021, the patient''s heart stopped (death, medically significant), and could not swallow (medically significant). The clinical course was reported as follows: The patient''s wife stated the patient was taking insulin aspart (NOVOLOG) and he was taking a long acting one as well. The reporter, the patient''s wife and a retired registered nurse (RN) stated, her husband (patient) just died and she thought he died from the COVID vaccine (later clarified the reason of death was-heart stopped). The patient had the vaccine on 21Jan2021, which was on a Thursday, and he was fine. On the following Sunday around 1:30 (on 24Jan2021), the patient was feeling a little weak, however, the patient''s wife thought maybe his blood sugar was low. The patient''s wife checked, and the patient''s blood sugar was 91. The patient''s wife went to get some yogurt to feed him in order to get his blood sugar up a little; "which was a normal thing for him, it was not that low for him." Then, suddenly, the patient fell, and the patient''s wife could not get a pulse or anything. The patient''s wife called an unspecified number and she started compressions; however, he was dead. The patient''s wife stated the patient just had his heart test, a three hour long one, and it was "perfect three weeks ago." The patient had just gone to the doctor the other day and his blood pressure was "fine and everything." The patient''s wife stated that other than his diabetes, "which he had for (sentence incomplete)." Regarding lab tests, the patient''s wife stated, "No, he had it before but not in the last two weeks. He was going for one because we just went to the doctor last week and he was going to call yesterday to make the appointment request to get his blood work done. Blood work has been good except his A1C was always high, but other than that everything was good" (as reported). Regarding causality, the patient''s wife stated, "I do, because he was fine until about half an hour before he died. He said to me, I feel a little weak today and then I was talking to him that your upper body strength is really good and then I said, we just have to work on your weight a little more because he did have neuropathy. And then, I went out of the room and all of a sudden I just heard him fall and that is when I just went in to check his blood sugar and it was 91 and I got him yogurt and he started eating that and then that was it, he started spitting it out and he said, I could not swallow and that was it, he just died." The patient''s wife further added, "I just wanted other people to know that things like this happen and I am sure it was from that because he was healthy as could be. He was walking with his walker, the day before outside and he felt fine." The clinical outcome of the event, heart stopped, was fatal. The clinical outcome of the event, could not swallow, was unknown. The patient died on 24Jan2021 due to "heart stopped." An autopsy was not performed. The batch/lot numbers for the vaccine, PFIZER-BIONTECH COVID-19 MRNA VACCINE, were not provided and will be requested during follow up.; Reported Cause(s) of Death: Heart stopped


VAERS ID: 993832 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Maine  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021081901

Write-up: At the end of the conversation, caller stated that recently saw in (place name) that someone passed away 3 hours after receiving the injection.; This is a spontaneous report from a contactable nurse. A patient of unspecified age and gender received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on unspecified date at single dose for COVID-19 immunization. Medical history and concomitant medication were not reported. Caller, calling on behalf of her sister who has pseudocholinesterase imbalance, would like to know if the Covid vaccine has any contraindication or interaction with succinylcholine. Caller stated that her and her sister are scheduled to receive the first dose of the vaccine this weekend. Caller stated that her sister had a severe reaction to succinylcholine and did not wake up for four days. Caller stated that her sister has to wear a medical bracelet because of this condition. Caller reported that her sister''s son has the same severe reaction to succinylcholine. Caller also stated that when she was a director in the lab, she heard of a person passing away in the OR due to the same reaction with succinylcholine. At the end of the conversation, caller stated that recently saw in (state name) that someone passed away 3 hours after receiving the injection. It was unknow if autopsy was done. Information on the lot/Batch number has been requested.; Sender''s Comments: The information currently available does not allow a medically meaningful assessment for the event "passed away" with unknown cause of death. The case will be reassessed should additional information become available. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics committees and Investigators, as appropriate.; Reported Cause(s) of Death: At the end of the conversation, caller stated that recently saw in (place name) that someone passed away 3 hours after receiving the injection.


VAERS ID: 993998 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Death, Posture abnormal
SMQs:, Anaphylactic reaction (broad), Dystonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hospice care (prior to vaccination); Living in nursing home; Oxygen supplementation (few days before vaccine was given oxygen level was low and started on oxygen)
Preexisting Conditions: Medical History/Concurrent Conditions: Congestive heart failure; Sulfonamide allergy
Allergies:
Diagnostic Lab Data: Test Date: 202101; Test Name: oxygen level; Result Unstructured Data: Test Result:gone down; Test Name: Covid-19 test; Test Result: Negative
CDC Split Type: USPFIZER INC2021063617

Write-up: passed away; cough; This is a spontaneous report from a contactable consumer, the patient''s daughter. A 92-year-old female patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Lot Number: UNKNOWN), via an unspecified route of administration in the left arm on 13Jan2021 at 11:00 (at the age of 92-years-old) as a single dose for COVID-19 immunization. Ongoing medical history included nursing home resident, admitted to hospice on 13Jan2021 (prior to vaccination), and oxygen supplementation (due to low oxygen levels) from a few days prior to the vaccine (Jan2021). Other relevant medical history included congestive heart failure from Dec2020 and sulfa allergy. Prior to the vaccination, the patient was tested numerous times (as reported) for COVID-19 and was negative. There were no concomitant medications. The patient did not receive any other vaccines within four weeks prior to the vaccination. A few days before the vaccination, her oxygen level had gone down, and she had been placed on oxygen. Prior to receiving the vaccine, the patient was reported as being ''fine''. On 13Jan2021, the patient received the vaccine at 11:00. The patient coughed maybe 5 or 6 times and then dropped her head. Resuscitation was not performed as patient had a do not resuscitate (DNR) order. The patient passed away on 13Jan2021 at 13:05. The cause of death was not reported. An autopsy was not performed. The clinical outcome of the cough was unknown at the time of death. The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.; Reported Cause(s) of Death: passed away


VAERS ID: 994309 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-15
Onset:2021-01-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine, 5 mg; Metformin, 500mg (twice a day); Simvastatin, 20mg; Omeprazol Dr, 40mg.
Current Illness:
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Got vaccine on 1/15/21. He was tired right away, bedridden the next 3 days. He couldn''t breathe so he was taken by ambulance on 1/18/21. He was in hospital for several days. put on remdesivir cocktail for 10 days. Slowly getting worse and died in hospital on 1/30/21.


VAERS ID: 994544 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-31
Onset:2021-01-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cyanosis, Death, Dental discomfort, Diarrhoea haemorrhagic, Dizziness, Nausea, Resuscitation, Toothache, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient went home around 11 am on 1-31-21 after her vaccine and 15 minute observation period. She was eating breakfast after at home and complained to a neighbor that her teeth hurt and she was nauseated after eating. In the afternoon, she felt dizzy and had diarrhea accompanied with blood. Close to 9 PM, her son went to check on her. The patient was found on the floor--she was unresponsive and had purple lips. Her son called an ambulance and started chest compressions. The patient passed away at the hospital. The doctor has ordered an autopsy, and the results are pending.


VAERS ID: 994678 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Kentucky  
Vaccinated:0000-00-00
Onset:2021-01-04
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

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: 2021-01-12
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Diabetes; Heart disorder; Obesity
Allergies:
Diagnostic Lab Data: Test Date: 20201224; Test Name: Nasal Swab; Test Result: Negative ; Test Date: 20201228; Test Name: Nasal Swab; Test Result: Negative ; Test Date: 20201231; Test Name: Nasal Swab; Test Result: Negative ; Test Date: 20210104; Test Name: Nasal Swab; Test Result: Positive
CDC Split Type: USPFIZER INC2021076918

Write-up: patient contracted COVID; patient contracted COVID; This is a spontaneous report from a contactable consumer. A non-pregnant 80-year-old female patient received two doses of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, the first dose in 2020 and the second dose on 22Dec2020 11:00, both at a single dose for covid-19 immunization. Medical history included heart, diabetes, obesity. There were no concomitant medications. The patient did not have covid prior to vaccination. The patient contracted COVID on 04Jan2021 11:00. The patient was hospitalized for COVID-19 for 8 days. The patient underwent lab tests and procedures which included: Nasal Swab: negative on 24Dec2020, negative on 28Dec2020, negative on 31Dec2020, positive on 04Jan2021. Unspecified therapeutic measures were taken as a result of the event. The outcome of patient contracted COVID was fatal. The patient died on 12Jan2021. It was unknown if an autopsy was performed. The batch/lot number for the vaccine, BNT162B2, was not provided and will be requested during follow-up.; Reported Cause(s) of Death: patient contracted COVID


VAERS ID: 994778 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-01-22
Onset:2021-01-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, COVID-19, Condition aggravated, Death, Decreased appetite, SARS-CoV-2 test positive
SMQs:, Guillain-Barre syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Pepcid, Aspirin, DOK Plus, Miralax, Potassium Chloride ER, Vitamin C, Ensure Clear, Metoprolol Tartrate, Tramadol, Artificial Tears,
Current Illness:
Preexisting Conditions: OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION, Macular Degeneration, Anorexia, Peripheral Vascular Disease, Cardiac Arrhythmia,
Allergies: No known allergies
Diagnostic Lab Data: COVID-19 PCR test positive on 1-28-21
CDC Split Type:

Write-up: Resident received the vaccine on 1-22-21 and she was diagnosed with COVID-19 during routine testing on 1-28-21. She didn''t have any symptoms except feeling weak and she had a decrease in her appetite. She already had a poor appetite prior. She died on 2-2-21.


VAERS ID: 994788 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-25
Onset:2021-02-01
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient was a nursing home resident, please contact the facility for further scheduled medications.
Current Illness: Patient was a nursing home resident, please contact the facility for further diagnosis.
Preexisting Conditions: Patient was a nursing home resident, please contact the facility for further diagnosis.
Allergies: Ativan, Buspar, Cymbalta, Levaquin, Lyrica, Mirapex, Pristiq, Symbicort
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death on 2/1/2021 at 4:55am at hospital.


VAERS ID: 994790 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-31
Onset:2021-02-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (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: Prevacid, Hydrocodone, Famotidine, Combivent Respimat, Boniva, Zinc Oxide, Spiriva, Loratadine, Risperdal, Albuterol, Sertraline, Cyanocobalamin, Levothyroxine, Advair, Omega-3 fatty acids, Atorvastatin, Aspirin, Sennoside, Ergocalciferol,
Current Illness: none
Preexisting Conditions: COPD, cad, morbid obesity, depression, bipolar, hypothyroidism, hypertension and gerd.
Allergies: Ibuprofen, ketorolac, morphine,tramadol.
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident found unresponsive in room this am at approx. 9:30 am. Resident was observed eating breakfast around 8:45 am. Housekeeper reported seeing resident between breakfast and time found unresponsive. Resident had voiced no complaints. Code was initiated until EMS arrived and transported resident to hospital. Resident expired.


VAERS ID: 994913 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Death, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (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: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away 2 days after vaccine. patient had temperature, nausea, and vomiting after vaccine.


VAERS ID: 994989 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-10
Onset:2021-01-19
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: unsure
Current Illness: unsure
Preexisting Conditions: unsure
Allergies: unsure
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Employee was found unresponsive in floor at her home. EMS arrived and person had expired.


VAERS ID: 995146 (history)  
Form: Version 1.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-15
Onset:2021-01-24
   Days after vaccination:9
Submitted: 2021-01-29
   Days after onset:5
Entered: 2021-02-02
   Days after submission:4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Arthralgia, Cardiac arrest, Decreased appetite, Dyspepsia, Dyspnoea, Fatigue, Feeling abnormal, Hypophagia, Palpitations, Pulseless electrical activity, Respiratory depression, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Gastrointestinal nonspecific dysfunction (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Narrative: Patient experienced cardiac arrest with PEA and a witnessed collapse upon arrival to the emergency department on 1/24/21. Patient received his first dose of the COVID vaccine on 01/15/2021and felt poorly thereafter. He was describing shortness of breath to his wife and requiring 5L of O2 at home to maintain saturations in 80s, while he usually was on 3L to maintain saturations in the mid 90s. He had been oriented but more fatigued than normal and described bilateral shoulder pain (which was not new for him) as well as indigestion. Took Tylenol with some relief. He had decreased PO intake and less appetite. The patient''s wife encouraged him to come to the hospital daily for a week prior to admission, but the patient did not want to because he felt his side effects were secondary to the vaccine. Symptoms:RespDepression, Palpitations, Syncope & cardiac arrest Treatment: EPINEPHRINE 1 MG ONCE 3 rounds given ,CALCIUM CHLORIDE 1000 MG ONCE


VAERS ID: 995224 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-14
Onset:2021-01-19
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain lower, Axillary pain, Cardiac arrest, Chest pain, Death, Myalgia
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Cardiac arrest; Pain on her upper right chest; Lot of pain in lower abdomen; Pain underneath arm; Thought it was muscle aches; A spontaneous report was received from a nurse concerning a 92-year-old, female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed upper right chest pain and underneath the arm, severe abdominal pain, muscle aches and cardiac arrest. The patient''s medical history was not provided Concomitant product use was not provided by the reporter. On 14 Jan 2021, approximately five days prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly in the arm for prophylaxis of COVID-19 infection. On 19 Jan 2021, the patient developed upper right chest pain and pain underneath the arm. They thought it was muscle aches. Sometime later, the patient developed a lot of pain in the lower abdomen. The called emergency services and an ambulance arrived but the patient then suffered cardiac arrest. Treatment for the event included tramadol. Action taken with mRNA-1273 in response to the events was not applicable due to the patient was died. The patient died on 19 Jan 2021. The cause of death was reported as cardiac arrest. Autopsy were not provided.; Reporter''s Comments: Company Comment: This case concerns a 92-year-old female patient who experienced unexpected serious events of cardiac arrest, upper right chest pain and underneath the arm, severe abdominal pain, muscle aches. The event occurred 5 days after the administration of the first dose of the vaccine mRNA-1273 vaccine (Lot #: unknown, expiration date-unknown). Although a temporal association exist between the events and the administration of the vaccine, in the absence of critical details such as the patient''s medical history, any diagnostic test or autopsy result, adequate evaluation and assessment cannot be established. Main field defaults to ?possibly related'' for all events.; Reported Cause(s) of Death: Cardiac arrest


VAERS ID: 995441 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-25
Onset:2021-01-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysstasia, Mobility decreased, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Atorvastatin, Eliquis, Donepezil HCL, Aspirin EC, Fluticasone Prop, Losartan Potas, Desonide, Levothyroxine, Melatonin, Potassium Cl, Cerovite Senior, Vitamin B-12, Vitamin D3 5,000 Unit, Docusate Sodium, Latanoprost OS, Torsemide
Current Illness: None
Preexisting Conditions: Mild Cognitive Impairment, Hypothyroidism, Coronary Artery Disease, Hyperlipidemia, Hypertension, Neuropathy, Vertigo, Vitamin B deficiency
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The vaccine was given on Monday. Tuesday afternoon he developed weakness in both legs and could not stand up. This was a new development; he had neuropathy in one leg but he had been able to stand up and walk three hours before. He was helped to the bathroom. He said he felt better and might want to stand up again. He was helped to bed. He was found dead around 5:30 Wednesday morning. He was 94 years old and had a lot of medical conditions. No one has indicated his death had anything to do with the vaccine. I''m sure it''s just a coincidence that he died so soon after receiving the vaccine


VAERS ID: 995460 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-01-07
Onset:2021-01-16
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Levothyroxine Sodium Tablet 50 MCG daily Cholecalciferol Tablet 2000 UNIT daily Metoclopramide HCl Tablet 5 MG 4 times a day Tylenol Tablet 325 MG as needed Q4hrs Senokot S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) 2 tabs daily Atorv
Current Illness: N/A Covid positive on 1/10 Hospitalized 1/16 Deceased 1/25
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE AFFECTING RIGHT DOMINANT SIDE (I69.951) WEAKNESS (R53.1) UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE (F03.90) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9) UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY (R26.9) HEART FAILURE, UNSPECIFIED (I50.9) CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (J44.9) ENCOUNTER FOR SURGICAL AFTERCARE FOLLOWING SURGERY ON THE DIGESTIVE SYSTEM (Z48.815) ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) ESSENTIAL (PRIMARY) HYPERTENSION (I10) ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF RIGHT UPPER EXTREMITY (I82.621) APHASIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE (I69.920) DYSPHAGIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE (I69.991) FLUID OVERLOAD, UNSPECIFIED (E87.70) DYSPHAGIA, OROPHARYNGEAL PHASE (R13.12) COVID-19 (U07.1) SPONDYLOLYSIS, CERVICAL REGION (M43.02) HYPERLIPIDEMIA, UNSPECIFIED (E78.5) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9) VITAMIN D DEFICIENCY, UNSPECIFIED (E55.9) CELLULITIS OF RIGHT UPPER LIMB (L03.113) ENCOUNTER FOR ATTENTION TO COLOSTOMY (Z43.3) INCONTINENCE WITHOUT SENSORY AWARENESS (N39.42) OTHER PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (I26.99) OTHER SPECIFIED SOFT TISSUE DISORDERS (M79.89) OTHER SPECIFIED SYMPTOMS AND SIGNS INVOLVING THE DIGESTIVE SYSTEM AND ABDOMEN (R19.8) VASCULAR DISORDER OF INTESTINE, UNSPECIFIED (K55.9) DYSPHAGIA, UNSPECIFIED (R13.10) HYPOKALEMIA (E87.6) GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9) OTHER DYSPHAGIA (R13.19) VERTEBRO-BASILAR ARTERY SYNDROME (G45.0) ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOTIONS AND CONDUCT (F43.25) BENIGN NEOPLASM OF COLON, UNSPECIFIED (D12.6) CEREBROVASCULAR DISEASE, UNSPECIFIED (I67.9) DISORDER OF KIDNEY AND URETER, UNSPECIFIED (N28.9) HEMATEMESIS (K92.0) HYPOTHYROIDISM, UNSPECIFIED (E03.9) LONG TERM (CURRENT) USE OF ANTICOAGULANTS (Z79.01) METABOLIC ENCEPHALOPATHY (G93.41) OTHER HYPERLIPIDEMIA (E78.4) OTHER SPECIFIED MENTAL DISORDERS DUE TO KNOWN PHYSIOLOGICAL CONDITION (F06.8) PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM (Z86.718) PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS (Z86.73) RESPIRATORY FAILURE, UNSPECIFIED, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA (J96.90) DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED (R26.2) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9)
Allergies: Vancomycin
Diagnostic Lab Data: Positive Covid swab on 1/10
CDC Split Type:

Write-up: Vaccine-1/7 Covid positive-1/10 Hospitalized-1/17 Deceased-1/25


VAERS ID: 995520 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-07
Onset:2021-01-22
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Angina pectoris, Back pain, Blood pH increased, Blood pressure increased, Confusional state, Discomfort, Insomnia, Pollakiuria, Urine analysis, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Other ischaemic heart disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel 75 mg daily, Depakote 125 mg Twice daily, Imdur, Lexapro20 mg daily, lisinopril 10 mg daily, metoprolol succinate 25 mg daily, proscar 5mg daily, seroquel 50 mg daily, seroquel XR 150 mg daily, trazadone 50 mg daily, flomax 0.4
Current Illness: No illness at time of vaccination or one month prior.
Preexisting Conditions: Atherosclerotic heart disease, Hypertension, Borderline personality disorder, Dysthymic, Chronic ischemic heart
Allergies: NKA
Diagnostic Lab Data: Urinalysis Dipstick: Symptoms Confusion,Frequency,urgency, back pain Leukocytes 3+ Lg Ph 8.5
CDC Split Type:

Write-up: 1-12-21 Resident is complaining of heart pain. Resident blood pressure is 228/105. 1-22-21 Dx UTI 1-13-21 His nurse called MD at approximately 0645, reported to him that it was reported to this nurse that resident has not slept in 2 days and night, has an increased blood pressure, reports severe pain in lower back, and appears to be uncomfortable Resident is able to verbalize his pain and where it is at, but is unable to explain the quality of the pain or give a number on the 0/10 pain scale.


VAERS ID: 995641 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
Vaccinated:2021-01-06
Onset:2021-01-31
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute myocardial infarction, Asthenia, Blood test, Computerised tomogram, Condition aggravated, Confusional state, Death, Hypotension, Urinary tract infection
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor 40mg po QD, Baclofen 10mg po BID, Tylenol ES 500mg po BID, Senna-S 50/8.6mg po BID, Vitamin D3 5000 IU po QD, Multivitamin tablet po QD, Garlic Oil 1000mg po QD, Lasix 40mg po QD, Aspirin EC 81mg po QD, Metformin 500mg po QD, Lisino
Current Illness: No active illnesses at time of vaccination or 1 month prior to vaccination; was diagnosed with UTI between vaccination and date of death.
Preexisting Conditions: Malignant neoplasm of prostate, Hypothyroidism, Type 2 Diabetes Mellitus, Hyperlipidemia, Multiple Sclerosis, Neuropathy, Essential primary hypertension, Atrial Fibrillation, Heart Failure, Peripheral Vascular Disease, Constipation, Weakness, Dry mouth, Personal history of Urinary Tract Infections
Allergies: NKA
Diagnostic Lab Data: Non contrast CT Multiple different laboratory blood tests
CDC Split Type:

Write-up: Resident was hospitalized for confusion, and hypotension and increased weakness; resident proceeded to have a NSTEMI and died on 5th day in hospital on 1/31/2021.


VAERS ID: 995649 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-25
Onset:2021-01-29
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: Thyroid disorder, HTN, Peripheral neuropathy, anxiety
Allergies: Augmentin, sulfa
Diagnostic Lab Data: Hospitalization, EMS reports
CDC Split Type:

Write-up: Cardiac arrest; Patient transported by EMS to hospital 11:00pm on 01/29/2021. Patient received vaccine on 01/25/2021. Patient expired 01/30/2021 within the hour into the new day after midnight on 01/30/2021. Patient was feeling well prior to and any chronic health conditions were well controlled. Sudden cardiac arrest 4 days after receiving the vaccine. Details given by patients husband/POA.


VAERS ID: 995789 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-28
Onset:2021-01-31
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 1 LA / IM

Administered by: Other       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: Unknown
Current Illness: Unknown
Preexisting Conditions: Diabetes Heart Condition
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The patient received the vaccine on the afternoon of Thursday, 1/28/21. He was observed for at least 30 minutes following administration of the vaccine with no reactions noted. He was found dead in his car on Sunday, 1/31/21. It is unknown if the vaccine contributed to his death.


VAERS ID: 995825 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-06
Onset:2021-01-13
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Delirium, Gastrointestinal haemorrhage, Sudden cardiac death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Calcium carbonate Cholecalciferol Ezetimibe Insulin (Lantus) Levothyroxine Olanzapine melatonin pantoprazole Senokot-S Sitagliptin Preservision AREDS
Current Illness: Acute lower GI bleed (diverticular bleed) occurred in 12/21/2020 and hospitalization from 12/21-12/31/20 complicated by delirium
Preexisting Conditions: Type 2 DM HLD Macular degeneration Hearing loss HTN Hypothyroidism Osteopenia
Allergies: Statins, ace inhibitors, hydrocodone, metformin, codeine, metoprolol XL
Diagnostic Lab Data: N/A. Client had a DNR order and therefore resuscitation was not attempted.
CDC Split Type:

Write-up: Client unexpectedly collapsed and passed away on 1/13/21 from suspected sudden cardiac death. Prior to her death, she was in skilled care for rehabilitation following hospitalization from 12/21-12/31/20 for an acute lower GI bleed. Her hospitalization and skilled care stay were complicated by delirium and she was being treated for delirium with olanzapine (Zyprexa) at time of death.


VAERS ID: 995977 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-19
Onset:2021-01-25
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Altered state of consciousness, Hypercapnia, Imaging procedure, Laboratory test, Lethargy, SARS-CoV-2 test negative, Sinusitis
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Latest medication list available to us 12/18/19, due to record being deleted after death: CORN STARCH POWDER RED AREA BETWEEN 3RD AND 4TH FINGER RIGHT HAND - APPLY CORN STARCH FOUR TIMES DAILY - FACILITY TO SUPPLY ACYCLOVIR 200MG CAPSULE 1
Current Illness: N/A
Preexisting Conditions: 0 Profound intellectual disability (F73) secondary to Angelman''s Syndrome with microcephaly (Q38.2); Macroglossia (750.15), rumination (307.53) and aerophagia, S|P aspiration pneumonia 9/98(507.0), history of coagulopathy (286.9); finger clubbing probably secondary to chronic pulmonary disorder; surgery 12/70 for undescended testes; Nissen fundoplication w/pyloroplasty 5/2/88; H/o Acne Vulgaris (L70.0) 31 Inability to monitor own health care needs. Frequent urinary tract infections. 39 Gastroesophageal reflux (K21.9) 56 Megacolon and tendency to fecal impaction (K59.3, K56.4) 57 Hand mouthing secondary to Angelman''s syndrome 59 Chronic recurrent herpes simplex (B00.9) 60 Recurrent cyanosis (R23.0), secondary to mucus plugging 61 Maintain optimal nutritional status altered by severe dysphagia (R13.10) 62 Osteoporosis probably secondary to immobility (M81.0) 63 Needs to maintain optimal musculoskeletal status 64 Optic atrophy(H47.20)secondary to Angelman?s syndrome, myopia(H52.10) 77 Prone to dehydration 83 Hiatal hernia (K44.9) 84 Peripheral vascular disease, poor circulation of bilateral ankles and feet. ?? Frequent UTIs. Small bilateral renal stones.
Allergies: Aspirin, NSAIDs.
Diagnostic Lab Data: Multiple imaging studies and lab tests while hospitalized. Covid negative 1/25/21.
CDC Split Type:

Write-up: Lethargy/altered level of consciousness lead to hospital admission. Multiple interventions during hospitalization. Final hospital diagnoses: Acute respiratory failure with hypercapnia, acute pansinusitis.


VAERS ID: 996086 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-07
Onset:2021-01-19
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory distress syndrome, COVID-19 pneumonia, Cardiac failure acute, Cough, Death, Intensive care, Myalgia, Oropharyngeal pain, Pyrexia, Renal replacement therapy, Rhabdomyolysis, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (narrow), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: h.o HTN, elevated BMI
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt received vaccine on 7 jan. 2021 Twelve days later, on 19 January 2021, Pt developed symptoms of COVID (cough, sore throat, fever, myalgias), on 20 Jan, pt admitted to hospital for worsening symptoms. Pt tested positive for COVID 19. Pt admitted to ICU where pt had complicated hospital course to include ARDS secondary to COVID pneumonia, nonSTEMI, with biventricular heart failure, on multiple pressor, rhabdomyolysis with acute kidney injury, requiring CRRT. Pt was in hospital for 10 days; he passed away on 31 Jan 2021.


VAERS ID: 996105 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-23
Onset:2021-01-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, senna, multivitamins, aspirin and possible hospice medications
Current Illness: Dementia, hypothyroidism, coronary artery disease, patient was already on hospice, so unclear if vaccine related . Pt was at her baseline until she passed away
Preexisting Conditions: Dementia, hypothyroidism, coronary artery disease, HTN, multiple other medical issues
Allergies: Egg, co-trimoxazole, Sulfa
Diagnostic Lab Data: None
CDC Split Type:

Write-up: patient received vaccine on Jan 23, 2021 passed away on Jan 24, she was already on hospice, so unclear if due to vaccine or other issues. Was at her baseline before and after vaccine per facility, had b''fast and passed away at noon on Jan 24


VAERS ID: 996156 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arthralgia, Death, Impaired work ability, Injection site pain, Malaise, Pain
SMQs:, Extravasation events (injections, infusions and implants) (broad), Arthritis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Hypertension
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client came to nursing station about 2pm to report she "was not feeling well". Nurses took vital signs, then referred her to the vaccination clinic that was onsite. She was observed by vaccination team for a period of time. She reported shoulder pain radiating into shoulder blade in arm vaccine was received. Vaccination team offered ice pack to her, observed for a period of time, and released back to work. About 10pm that evening, she sent a text to another coworker that her pain was "off the charts" and that she had pain covering her whole left side of her body. She did not come to work in the morning and did not contact work. Well being check was performed at approximately 9am on 2/2/2021 and she was found dead in her home. 911 was immediately called and authorities took over the scene.


VAERS ID: 996259 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-19
Onset:2021-01-25
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluoxetine HCL, 20 mg, Magnesium Oxide, 400 mg, Atrovastatin/Calcium, 10 mg, Omprazole, 20 mg, Lisinoprilm 2.5.mg, Lyrica, 200mg, Metoprolol Tartrate, 25 mg , Potassium Chloride 20 meq,
Current Illness: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation, OSA on CPAP
Preexisting Conditions: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation,
Allergies: Wellbutrin, Niaspan
Diagnostic Lab Data: Reported by hospital patient was COVID negative. Dr. office did not receive any additional lab information or treatment to her office.
CDC Split Type:

Write-up: Unknown. Was informed that the patient went to E/R on 1/25/21 (6 days after receiving vaccine. Died 1/29/21 ( 10 days after receiving vaccine).


VAERS ID: 996291 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Alaska  
Vaccinated:2021-01-07
Onset:2021-01-29
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Haloperidol, Morphine, Lorazepam
Current Illness: HTN, Cerebral Infarction, Anxiety, Hx breast neoplasm
Preexisting Conditions: HTN, Cerebral Infarction, Anxiety, Hx breast neoplasm
Allergies: Codeine, Tramadol, Valsartan, Keflex, Penicillins
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death


VAERS ID: 996423 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: West Virginia  
Vaccinated:2021-01-04
Onset:2021-01-10
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cerebrovascular accident, Sudden death
SMQs:, Torsade de pointes/QT prolongation (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), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Wife reported patient had diabetes and high blood pressure.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had a CVA and passed away suddenly 1/10/21


VAERS ID: 996591 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-23
Onset:2021-01-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Hypotension, Hypoxia, Mental status changes
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: citalopram, Wellbutrin, docusate, Seroquel, acetaminophen, senna, may have received hospice medications
Current Illness: Dementia, depression, arthritis, IBS, atherosclerosis of aorta, hyperlipidemia, osteoporosis
Preexisting Conditions: Dementia, depression, arthritis, IBS, atherosclerosis of aorta, hyperlipidemia, osteoporosis
Allergies: Codeine Penicillin simvastatin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: patient received vaccine on Jan 23, 2021. developed weakness on Jan 25, 2021. Sent to ED on Jan 27, 2021 with hypoxia requiring 6 L O2, low Bp, declining mental status. Per family request transitioned to hospice and passed away on Jan 30, 2021


VAERS ID: 996959 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-01
Onset:2021-02-01
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 59267-1000-01 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lasix, Morphine, Ernesto, Oxycodone, omeprazole Gabapentin
Current Illness: CHF. COPD Chronic Pain
Preexisting Conditions: CHF, COPD, Polio as a child
Allergies: None
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Vaccine was administered Thursday and my father Died early Monday morning unexpectedly


VAERS ID: 997145 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-21
Onset:2021-02-01
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cerebral infarction, Computerised tomogram abnormal, Death, Pulseless electrical activity
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: diabetes, cancer, COPD, hypertension
Allergies:
Diagnostic Lab Data: CT 1/29/21 showed brain infarcts
CDC Split Type:

Write-up: 85 year old patient with multiple medical problems. PEA/asystolic arrest 5 days after receiving vaccine, hospitalized. Patient died on 2/1/2021. It is not clear whether the vaccine administration led to the patient''s death or not. "...healthcare professionals are encouraged to report any clinically significant or unexpected events (even if not certain the vaccine caused the event)"


VAERS ID: 997297 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-01-04
Onset:2021-01-17
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chronic kidney disease, Death, Pneumonia, Septic shock, Urinary tract infection
SMQs:, Rhabdomyolysis/myopathy (broad), Toxic-septic shock conditions (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 1/17/21. Death certificate reports: Septic Shock, UTI, Pneumonia, Chronic Renal Failure


VAERS ID: 997553 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-26
Onset:2021-02-01
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: nexium, isosorbide, metoprolol, norvasc, lipitor, trospium; baby asa, paracalcitrol, vitamin b, mutli vitamin, sodium bicarbonate, tums prn, vit d3, mealatonin prn, pepcid, nitrostat prn, ativan prn
Current Illness: none
Preexisting Conditions: hypertension, CAD, CRF, hyperlipidemia
Allergies: isoniazid, diltiazem,versed
Diagnostic Lab Data:
CDC Split Type:

Write-up: fatigue x 5 days, including day of vaccination, death the night of day 5/early morning of day 6


VAERS ID: 997571 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebral haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: BRAIN BLEED


VAERS ID: 997642 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-01-19
Onset:2021-02-02
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: possible blood clots, not disclosed at time of vaccination
Preexisting Conditions: chronic back pain
Allergies: vibramyacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: We were notified 02/02/2021 of patient''s death. Unknown cause at this time.


VAERS ID: 997677 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure increased, Cerebrovascular accident, Coma scale abnormal, Death, General physical health deterioration, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism
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), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC Split Type:

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21


VAERS ID: 997783 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-01
Onset:2021-02-03
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: pt lived in long term care facility, unknown health conditions
Allergies: none known
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away subsequent to receiving dose on 02/01. Staff does not have reason to believe vaccine was involved.


VAERS ID: 998108 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-31
Onset:2021-02-01
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute left ventricular failure, Acute myocardial infarction, Atrial fibrillation, Cardiac failure congestive, Chronic left ventricular failure, Essential hypertension, Hyperlipidaemia
SMQs:, Cardiac failure (narrow), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Myocardial infarction (narrow), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Hypertension (narrow), Cardiomyopathy (broad), Lipodystrophy (broad)

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

Write-up: Acute on chronic systolic heart failure; Atrial fibrillation with RVR; CHF (congestive heart failure); Essential hypertension; Hyperlipidemia, unspecified hyperlipidemia type; NSTEMI (non-ST elevated myocardial infarction); New onset a-fib


VAERS ID: 998138 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-22
Onset:2021-01-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arthralgia, Back pain, Chills, Headache, Neck pain, Pain, Pain in extremity
SMQs:, Retroperitoneal fibrosis (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Daughter unaware of prescriptions
Current Illness: Was hospitalized in December for testing positive for COVID 12/18/2020 - hospitalized for 4 days then released back to nursing home facility.
Preexisting Conditions: Type 2 diabetes; high blood pressure
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Same day as vaccination given, developed pain went from arm up to shoulder, to back, to neck to head - right side of body; chills/body aches


VAERS ID: 998175 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-07
Onset:2021-01-16
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol succinate ER tab ER 24hr 100mg PO daily Milk of Magnesia Suspension 400mg/5l 30ml PRN Mirtazapine 45mg tab at bedtime Clonazepam tab 0.5mg BID D-Mannose Capsule 500 MG 1 capsule daily Cranberry Tablet 450 MG 1 tablet twice daily
Current Illness: No
Preexisting Conditions: MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION MILD COGNITIVE IMPAIRMENT, SO STATED GENERALIZED ANXIETY DISORDER ESSENTIAL (PRIMARY) HYPERTENSION TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OTHER ALLERGIC RHINITIS OTHER IRRITABLE BOWEL SYNDROME PNEUMONIA DUE TO CORONAVIRUS DISEASE 2019 COVID-19 BACTERIAL INTESTINAL INFECTION, UNSPECIFIED HYPOKALEMIA UNSPECIFIED SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND AWARENESS OTHER SEBORRHEIC KERATOSIS HYPERLIPIDEMIA, UNSPECIFIED AGORAPHOBIA WITH PANIC DISORDER PRESENCE OF RIGHT ARTIFICIAL HIP JOINT ACQUIRED ABSENCE OF BOTH CERVIX AND UTERUS ACQUIRED ABSENCE OF OTHER ORGANS CYST OF KIDNEY, ACQUIRED NEOPLASM OF UNCERTAIN BEHAVIOR OF LIVER, GALLBLADDER AND BILE DUCTS OTHER SLEEP DISORDERS PURE HYPERGLYCERIDEMIA SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY, SITE UNSPECIFIED
Allergies: Penicillin, Pravastatin
Diagnostic Lab Data: See Above-please contact for any further questions
CDC Split Type:

Write-up: Resident vaccinated-1/7/21 Resident covid positive 1/11/21 Resident covid PNA-1/12/21 Resident hospitalized 1/16/21 Resident deceased 1/20/21


VAERS ID: 998228 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-29
Onset:2021-02-03
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ALBUTEROL HFA (8.5GM) 90 MCG INHA TAKE 1-2 PUFFS INHALATION EVERY 4 TO 6 HOURS AS NEEDED APAP 325MG TABS one (1) to two (2) tabs By Mouth two times daily as needed CALCIUM CARB (150) 500 MG CHEW TAKE 1-2 TABS BY MOUTH THREE TIMES DAILY AS
Current Illness: COPD Gastro-espohageal reflux Osteoarthritis Essential Hypertension Dermatitis COVID-19
Preexisting Conditions:
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found unresponsive


VAERS ID: 998419 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-08
Onset:2021-01-16
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

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: Artificial Tears Solution 0.4 % (Hypromellose) Instill 1 drop in both eyes as needed for dry eyes QID Aspirin Tablet 81 MG Give 1 tablet by mouth one time a day Lasix Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for CHF T
Current Illness: See below
Preexisting Conditions: HEART FAILURE, UNSPECIFIED TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED NTA (2 pts) ANXIETY DISORDER, UNSPECIFIED BORDERLINE PERSONALITY DISORDER ESSENTIAL (PRIMARY) HYPERTENSION LEGAL BLINDNESS, AS DEFINED IN USA MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE PERSONAL HISTORY OF COVID-19 DYSPHAGIA, OROPHARYNGEAL PHASE PNEUMONIA, UNSPECIFIED ORGANISM TINEA UNGUIUM ONYCHOGRYPHOSIS UNSPECIFIED OPEN-ANGLE GLAUCOMA, INDETERMINATE STAGE UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION CHONDROCOSTAL JUNCTION SYNDROME [TIETZE] DEPENDENCE ON SUPPLEMENTAL OXYGEN UNSPECIFIED SEQUELAE OF UNSPECIFIED CEREBROVASCULAR DISEASE SLP OTHER SYMBOLIC DYSFUNCTIONS EDEMA, UNSPECIFIED HYPERLIPIDEMIA, UNSPECIFIED IRON DEFICIENCY ANEMIA, UNSPECIFIED ANEMIA, UNSPECIFIED PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED
Allergies: Brimonidine, Metformin, Bactrim, tape
Diagnostic Lab Data: N/A-contact facility for any questions or concerns
CDC Split Type:

Write-up: Resident vaccinated-1/8 Resident deceased-1/16


VAERS ID: 998421 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-06
Onset:2021-01-27
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen aspirin- 81mg calcium carbonate carbidopa-levodopa cholecalciferol fenofibrate fluorouracil cream fluticasone nasal spray folic acid nitroglycerin PRN miralax
Current Illness: Basal cell carcinoma of right ear
Preexisting Conditions: Parkinson''s CAD Labile HTN Renal artery stenosis HLD Basal cell carcinoma Squamous cell carcinoma BPH Prostate CA Urge incontinence Mild cognitive impairment
Allergies: Verapamil Amlodipine Morphine Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away unexpectedly on 1/27/21 from presumed sudden cardiac death.


VAERS ID: 998422 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-30
Onset:2021-01-31
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase normal, Blood albumin, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium, Blood chloride normal, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase normal, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood lactic acid normal, Blood potassium normal, Blood sodium decreased, Blood urea increased, Blood urine absent, Brain natriuretic peptide normal, Carbon dioxide decreased, Cerebral atrophy, Chest X-ray normal, Computerised tomogram head normal, Dehydration, Full blood count normal, Haematocrit normal, Haemoglobin decreased, Hypophagia, Hyporesponsive to stimuli, Immunology test, Mental status changes, Metabolic function test, Muscular weakness, Platelet count normal, Procalcitonin normal, Protein urine, Pyrexia, SARS-CoV-2 test negative, Somnolence, Specific gravity urine normal, Troponin I normal, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic erythropenia (broad), Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Proteinuria (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg daily; cimetidine 300 mg 4 times a day; donepezil 10 mg daily; fluticasone nasal spray daily; gabapentin 600 mg 3 times a day; glipizide 2.5 mg daily; losartan 100 mg daily; memantine10 mg twice a day; metformin 500 mg twice
Current Illness: None
Preexisting Conditions: Type II diabetes, hypertension, hypothyroidism, GERD, hyperlipidemia, early dementia.
Allergies: None
Diagnostic Lab Data: 2/2: WBC 8.7, H/H 13.6/40.5; Plt 185,000; Glucose 173, BUN 23, creatinine 1.5, Na 135, K 4.7, Cl 102, CO2 22, Ca 8.3, Tot protein 6.1, albumin 3.5, ALP 71, AST, 20, ALT 12, Tot bili 0.30, BNP 24, CPK 131, CKMB 1.8, troponin i <0.06. SARS FIA negative. UA: sp gr 1.025, pH 7.0 1+ protein, neg blood o/w normal. 2/3: WBC 8.4, H/H 12.4/36; BUN 18, creat1.1 CT head normal for age; CXR no evidence of infection.
CDC Split Type:

Write-up: patient developed progressive diffuse muscle weakness, altered mental status including excessive drowsiness, decreased oral intake starting on 1/31/2021. Symptoms continued to worsen overnight and he was evaluated in the emergency room on 2/2/2021 and admitted with dehydration and altered mental status. He was aggressively hydrated overnight, but showed persistent diffuse muscle weakness, altered mental status with decreased responsiveness progressing, but no focal neurological findings noted. CT scan of the head on 3/3/2021 showed no findings other than age-related diffuse cerebral atrophy. The patient did spike a fever to 103 on the morning of 2/3/2021. CBC, CMP, procalcitonin and lactic acid levels remained normal. He remains hospitalized in stable condition as of 2/3/2021 @1300.


VAERS ID: 998463 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-06
Onset:2021-01-19
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute coronary syndrome, Death, Endotracheal intubation, Laboratory test, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: acetaminophen amlodipine calcium carbonate + vitamin D3 Celebrex (PRN) Irbesartan lidocaine patch loratadine polyethylene glycol pravastatin
Current Illness: pneumonia, acute hypoxic respiratory failure
Preexisting Conditions: HTN HLD Osteoarthritis osteoporosis impaired mobility secondary to avascular necrosis or right humeral head, and s/p ankle fusions, bilateral knee replacements Sciatica open angle glaucoma
Allergies: horse chesnut seed extract
Diagnostic Lab Data: Tests/ results were performed in hospital, outside of our setting (nursing home).
CDC Split Type:

Write-up: Resident passed away unexpectedly on 01/19/21 after developing acute hypoxic respiratory failure on morning of 01/19/21. She was transferred to hospital via EMS where she was intubated, coded, and ultimately expired with uncertain underlying cause, potentially ACS.


VAERS ID: 998544 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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 medication
Current Illness: diabetes, heart trouble, dementia
Preexisting Conditions: as above
Allergies: Morphine and iodine
Diagnostic Lab Data: Stents placed.
CDC Split Type:

Write-up: Patient had heart attack. Spoke with spouse on 2/3/2021 stated had multiple health issues including heart and lung issues.


VAERS ID: 998576 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-27
Onset:2021-01-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Blood creatinine increased, Blood culture negative, Blood potassium increased, Blood urine present, Brain natriuretic peptide increased, Cardiac telemetry, Chest X-ray abnormal, Electrocardiogram abnormal, Full blood count normal, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Metabolic function test, Pleural effusion, Protein urine present, Pulmonary oedema, Pyrexia, Respiratory distress, SARS-CoV-2 test negative, Sinus tachycardia, Troponin increased, Urine analysis
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Med List @ time vaccine # 2: PRN acetaminophen Bisacodyl PRN TUMS Clotrimazole Flonase Loratadine Lorazepam Melatonin Bengay Nitrostat Zofran oxycodone Miralax Scheduled: acetaminophen 500 md QID amlodipine 5mg BID Metoprolol 50 mg BID Pra
Current Illness: NSTEMI after COVID vaccine #1
Preexisting Conditions: CAD, CKD4, Hypertension, Anemia, dementia
Allergies: DIPYRIDAMOLE, ERYTHROMYCIN, TERAZOSIN
Diagnostic Lab Data: 1/1/2021 CMP remarkable for Potassium 5.8, creatinine 3.20, HS troponin 2.2, 310 BNP 12.7, CBC unremarkable, UA++ protein 1+ blood, Blood Cx No growth x5 days, COVID RNA rapid (-), 1/2/21 COVID PCR (-), Influenza A+B (-), No EKG, Partial CXR no acute cardio pulmonary process, no pneumonia, Telemetry Strip (12/31 22:00 atrial fib normal rate. 1/27/21 CMP remarkable for potassium 6.1, Serum Creatinine 4.46, BNP 1080, HS troponin 13.2, CBC with diff unremarkable, COVID PCR (-), EKG sinus tachycardia, QRS algorithm, left axis deviation rate 107 borderline criteria arterial infarct, CXR Bilateral + alveolar opacities compatible with pulmonary edema, small (L) pleural effusion, (L) basilar air space likely atelectasis
CDC Split Type:

Write-up: Had acute respiratory failure, dysuria NSTEMI after Dose #1 Lot # 025L20A (Moderna) hospitalized same day 12/31/20 administered @ 1040 back to baseline. 2nd Dose on 1/27/21 0950 Lot as above. Unknown exact onset same day, ED by EMS @ 1745, respiratory distress, febrile 39.4 degrees C BP 150/105 RR 29


VAERS ID: 998579 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-25
Onset:2021-02-02
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / IM

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: Patient is a nursing home resident please notify facility.
Current Illness: Patient is a nursing home resident please notify facility.
Preexisting Conditions: Patient is a nursing home resident please notify facility.
Allergies: Iodine, ACE Inhibitors
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away 2/2/2021.


VAERS ID: 998637 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-13
Onset:2021-01-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Irregular breathing, Resuscitation, Somnolence
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No known acute illness
Preexisting Conditions: Macular degeneration Dislipidemia
Allergies: None noted
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient noted to have irregular breathing in bed and unable to arouse. Provided life saving measures in the field x 30 minutes and transferred to hospital. Noted to have heart arrhythmia which suspected to cause cardiac arrest.


VAERS ID: 998770 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypopnoea, Palpitations
SMQs:, Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: OTC APAP prn Tradjenta 5mg daily amlodipine 10mg daily naproxen 500mg BID trazodone 100mg HS atorvastatin 20mg daily gabapentin 100mg TID timolol 0.5% eye drops 1 drop each eye BID metformin ER 500mg daily glipizide 10mg BID lisinopril 20m
Current Illness:
Preexisting Conditions: High blood pressure High Cholesterol Diabetes Restless Legs syndrome depression/anxiety
Allergies: NKA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient had no symptoms or adverse events until the next evening after shot (1/29/21) where daughter reported her having heart palpitations. Family told her to rest and did not seek medical attention. Saturday afternoon (1/30/2021), patient started experiencing labored breathing. Daughter called 911 and before the ambulance arrived, the patient''s breathing became more and more shallow. Patient was taken to the local hospital and passed away Saturday evening around 5:30 pm.


VAERS ID: 1002931 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Absence of immediate treatment response, Cardiac arrest, Cardio-respiratory arrest, Death, Electrocardiogram ST segment elevation, Endotracheal intubation, Pulseless electrical activity, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Lack of efficacy/effect (narrow), Myocardial infarction (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), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

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

Write-up: CARDIAC ARREST, DEATH Narrative: The patient presents to the emergency department in cardiopulmonary arrest. CPR was continued upon arrival. The Combi tube was removed and an endotracheal tube was placed without complications. ROSC was obtained multiple times but the patient continued to go into PEA. The patient was seen in the emergency department by both critical care and Cardiology. EKG shows ST elevations, but the patient was unstable to go to catheterization. The patient had 1 episode of asystole. Despite best efforts and multiple attempts we were unable to resuscitate the patient. Time of death 1253 on 1/24/21.


VAERS ID: 1002937 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-01
Onset:2021-02-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / UNK LA / IM

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

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

Write-up: death Narrative: Pt attended arthritis clinic appt 0900; labs shortly after; rec''d vaccine in clinic ~ 1113; seen on surveillance camera walking to parking garage ~ 1145; medical center rec''d call from wife ~ 1900 that pt never returned home; police found vehicle running in parking garage, code called, pt obviously deceased by that time 1930, body sent to medical examiner for autopsy.


VAERS ID: 1000226 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-19
Onset:2021-01-27
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Ischaemia, Surgery, Volvulus
SMQs:, Gastrointestinal obstruction (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021085163

Write-up: volvulus; volvulus and needed surgery followed by further ischemia; This is a spontaneous report from a contactable physician. An 86-year-old female patient received her first single dose of BNT162B2 (Pfizer-BioNTech Covid-19 vaccine) intramuscularly on 19Jan2021 for Covid-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient had no known allergies. The patient developed volvulus and needed surgery followed by further ischemia and at end of life. The events onset date reported as 27Jan2021. Patient had 3days hospitalization and died eventually. It was unknown if an autopsy was performed. Information about lot/batch number has been requested.; Sender''s Comments: Very limited information was provided in this report. No relevant information regarding the clinical course of the events, the patient''s underlying medical conditions were mentioned. Based on the information currently available, lacking any other alternative explanations as so far, the reported volvulus and Intestinal ischaemia are managed as related to COVID-19 vaccine, BNT162B2, for reporting purpose, only. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to RA, IEC, as appropriate.; Reported Cause(s) of Death: volvulus; ischemia


VAERS ID: 1000228 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Nevada  
Vaccinated:2021-01-21
Onset:2021-01-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19; Immunocompromised
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021085790

Write-up: dead; Collapsed; bnt162b2 was given to patient with immunocompromised w/ reportable conditions; bnt162b2 was given to patient with immunocompromised w/ reportable conditions; This is a spontaneous report from a contactable nurse. A 40-year-old male patient receive first dose of bnt162b2 (Lot number: EK9231, Brand: Pfizer), intramuscular in left arm on 21Jan2021 15:15 at single dose for COVID-19 immunization. Medical history included immunocompromised w/ reportable conditions from an unknown date and unknown if ongoing, positive for Covid in September from Sep2020 to an unknown date. The patient''s concomitant medications were not reported. The patient experienced dead, collapsed on 26Jan2021. Therapeutic measures were taken as a result of collapsed. The outcome of collapsed was unknown. The patient died on 26Jan2021. It was not reported if an autopsy was performed. Received Covid vaccine here on 21Jan2021, was at work on 26Jan2021 and collapsed, no known complaints at the time, CPR (cardiopulmonary resuscitation) was initiated immediately, transported to ER (Emergency room) and pronounced dead. Unknown if other vaccine in four weeks. The patient had COVID prior vaccination. Unknown If COVID tested post vaccination.; Sender''s Comments: Based on the information currently provided, the patient was immunocompromised and had prior COVID infection. The death and syncope more likely are associated with the patient underlying medical conditions. More information such medical history, concomitant medications, treatment indication and event term details especially death cause and autopsy results are needed for fully medical assessment. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate.; Reported Cause(s) of Death: Dead


VAERS ID: 1000233 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021098743

Write-up: just died; This is a Spontaneous report from a Pfizer Sponsored Program from a contactable consumer. A male patient of an unspecified age received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient just died on an unspecified date. It was not reported if an autopsy was performed. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: just died


VAERS ID: 1000624 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021064098

Write-up: Pneumonia; This is a spontaneous report from a Pfizer-sponsored program via a contactable consumer (patient). A male patient of unspecified age (Age: 63; Unit: Unknown) received the first dose and second dose of BNT162B2, via unspecified routes of administration on unspecified dates at single dose for COVID-19 immunization. Medical history and concomitant medications were not reported. After receiving both vaccines, patient still got pneumonia and he had seen many elderly died from pneumonia even after receiving the vaccine. Outcome of the event was not resolved. No follow-up attempts are possible; information about lot/batch number cannot be obtained.


VAERS ID: 1000665 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-18
Onset:2021-01-20
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: GLIPIZIDE; WARFARIN; METFORMIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; Macular degeneration; Prostate cancer; Type 2 diabetes mellitus
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021092300

Write-up: Death 2 days later; This is a spontaneous report from a contactable Other HCP. A 97-year-old male patient received the 1st dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL0140) via intramuscular in the left arm on 18Jan2021 12:00 PM at single dose for covid-19 immunisation. Medical history included prostate cancer, macular degeneration, type 2 diabetes, atrial fibrillation. No known allergies. Concomitant medications included glipizide, warfarin and metformin in two weeks. The patient had no other vaccine in four weeks. The patient experienced death on 20Jan2021 at 09:00 PM. Death cause was undetermined. No autopsy was performed. No treatment was received for AE. The patient had no covid prior vaccination, no covid tested post vaccination. Outcome of the event was fatal.; Sender''s Comments: Event unknown cause of death is assessed as Related until sufficient information is available to confirm an unrelated cause of death or if there is sufficient information to allow an unrelated causality assessment. Case will be reassessed when follow-up information is received. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.; Reported Cause(s) of Death: Death 2 days later


VAERS ID: 1000670 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-01-19
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Myocardial infarction, Pain in extremity, SARS-CoV-2 test negative, Stent placement, Thrombosis
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 25
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: Medical History/Concurrent Conditions: Diabetes
Allergies:
Diagnostic Lab Data: Test Name: Covid-19; Test Result: Negative
CDC Split Type: USPFIZER INC2021094694

Write-up: she was hurting at her chest/ Chest pain; on her left arm hurt real bad that''s what the clot on her left arm; on her left arm hurt real bad that''s what the clot on her left arm; She passed away; heart attack; This is a spontaneous report from a contactable consumer. An 87-years-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 19Jan2021 at single dose for COVID-19 immunisation. Medical history included diabetes mellitus, for which she was taking a pill like an hour before she would take her meal. On Monday (Jan2021) the patient experienced was hurting at her chest/ chest pain, her left arm hurt real bad as she had a blockage in her left arm/clot on her left arm, and they wanted to put in a stent and after the surgery it went well and she all go home in two days. The patient was hospitalized in Jan2021 due to the events. She had a heart attack and that the chamber between the dividers had a hole in it and her heart tissue was too thin so much thin she couldn''t repair it. The patient passed away on 26Jan2021. The patient was tested negative for COVID-19 on unknown date. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: She passed away


VAERS ID: 1000709 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-18
Onset:2021-02-01
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH 9899 / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Pleural effusion
SMQs:, Systemic lupus erythematosus (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: amiodarone, ASA, calcitriol, coreg, folvite, apresoline, synth
Current Illness: see below
Preexisting Conditions: see below
Allergies: Heparin, Amoxcillin
Diagnostic Lab Data: Patient was hospitalized related to multiple chronic diagnoses.
CDC Split Type:

Write-up: Patient with past medical history of CAD, CKD, sCHF, LGL Leukemia admitted to Hospital on 1/19 with pleural effusion. Pt expired on 2/1/2021. Hs of essential HTN, complete heart block, T2Diabetes,thyroid issues, stroke, papillary CA of thyroid, dyslipidemia, anemia, hypercalcemia, pulmonary nodule, hypoparathyroidism, pacemaker, bilat carotid stenosis, afib, pleural effusion, pancytopenia, cardiomyopathy, severe aortic stenosis, sick sinus syndrome, Dressler syndrome, empyema, ESRD


VAERS ID: 1000711 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-08
Onset:2021-01-27
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test abnormal, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: rocaltrol, iron, folvite, neurontin, proamatine, zifaxan
Current Illness: chronic liver disease, hypoganadism, alcoholic cirrhosis, cont
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: multiple from prior records not related to vaccine
CDC Split Type:

Write-up: in addition to above, pt had the following diagnosis: portal HTN, abnormal blood chem, essential tremor, depressive disorder, abnormal glucose tolerance test, hyperlipidemia, hypothyroidism, insomnia, localized osteoarthrosis, calculus of kidney, pancytopenia, odule on liver, hepatocellular CA, hyotension, hypovolemia, hepatorenal syndrome additional meds: zoloft, aldactone, thiamine,demadex, ultram, kenalog, vitamins, bactroban ung


VAERS ID: 1000739 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH PK9231 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Dyskinesia, General physical health deterioration, Influenza virus test, Laboratory test, Muscle twitching, Pallor, SARS-CoV-2 test negative, Seizure, Skin discolouration, Staring
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Dyskinesia (narrow), Dystonia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dermaseptin, Eucerin, Listerine, Ophthalmic Care, Periguard, Acetaminophen, Aspirin, Atorvastatin, Bisacodyl, Chlorhexidine, Memantine, MVA, Rivastigmine Patch, Trileptal Suspension, Vitamin B-50, Vitamin C, Vitamin D, zINC
Current Illness: NKA
Preexisting Conditions: Frontotemporal Dementia, Dysphagia, Tinea Unguium, Peripheral Vascular Diseases, Difficulty Walking, Primary Hypertension, Hypercholesterolemia, Hyperlipidemia, Personality Change dur to known physiological condition, History of other mental and Behavioral Disorders, Constipation, Atherosclerotic Heart Disease of Native Coronary Artery, Nail Dystrophy, Dermatitis, Idiopathic Epilepsy and Epileptic Syndromes with Seizures of Localized Onset, Protein Caloria Malnutrition, Muscle Weakness
Allergies: nka
Diagnostic Lab Data: STAT Labs ordered 1/6/21 1/6/21 Rapid Covid completed, Negative 1/15/21 Rapid Flu completed, Negative
CDC Split Type:

Write-up: Approximately 10 minutes after receiving the COVID- 19 vaccine resident displayed seizure activity, staring straight ahead and strong allover muscle jerking of both the up and lower extremities, color became gray, activity lasted approximately 3 minutes, resident then became relaxed, color returned to normal, BP-140/80, 97.8, 60, 16, sleeping the remainder of the shift,. Resident continued to decline until resident CTB on 1/19/21


VAERS ID: 1000752 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-17
Onset:2021-01-31
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Feeling abnormal, Nasopharyngitis, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (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: 2021-02-01
   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: citalopram, atorvastatin, felodipine, avalide, metoprolol, omeprazole
Current Illness: none that I''m aware of
Preexisting Conditions: aortic atherosclerosis, essential hypertension, depression, type 2 diabetes with stage 4 chronic kidney disease
Allergies: penicillin, procain
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt son, reports patient passed away on 2/1/21 in the early hours. Pt wife, told Pt''s son that patient started feeling "bad" with common cold like symptoms on 1/31/21, had a temp of 99.0. Pt''s wife went to take a shower, when she got out patient was unresponsive. She called EMS, they pronounced patient deceased upon arrival. Pt''s son also reports patient and Pt''s wife both had their 1st COVID-19 vaccine 13 days prior. He was told by EMT on sight to notify the facility where they received their vaccines. He did contact them and was told to notify PCP.


VAERS ID: 1000784 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Foaming at mouth, Mechanical ventilation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

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

Write-up: T.C. from sister to communicate the hospitalization of her sister. She reported that on Friday patient collapsed and started foaming at the mouth and was rushed to hospital. She stated that patient is on a ventilator and at 5PM today they are going to take her off. Sister was very upset and I was uncomfortable asking more questions. She will call me with more information at a later time. She did say that the hospital staff was not sure of what caused her collapse.


VAERS ID: 1000856 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-30
Onset:2021-01-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Fall, Myocardial infarction, Pulse absent, Resuscitation
SMQs:, Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Accidents and injuries (narrow)

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

Write-up: Myocardial infarction Narrative: PMH significant for aortic valve stenosis, mitral valve stenosis, CKD, CHF, DM, HTN, obesity, hypothyroidism and dyslipidemia. Per report from primary care - the patients wife reports that the patient went on Saturday (1/30/21 - about 1050) morning to receive his COVID vaccine. He returned home and told her about the experience and denied any side effects. He then proceeded to sit in his easy chair for a while and around 1:30, she asked him if he wanted any lunch. The patient''s wife reports he "grumbled" at her, and then got up to go to the bathroom. She then heard a loud crash and found him lying on the floor of the bathroom, with his head knocking hole in the wall as he fell. She could not detect a pulse. She called 911 and began compressions. First responders to the scene likewise tried to revive him but were not successful in her efforts. Per primary care documentation - Uncertain if related to Pfizer vaccine; vaccine administered on 1/30/21 and approximately 3 hours later suffered fatal MI at home.


VAERS ID: 1001488 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-18
Onset:2021-01-31
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID infection November 2020
Preexisting Conditions: HTN, Afib, atherosclerotic cardiovascular disease;
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died several days after receiving the second dose of the vaccine. See additional information sent. An autopsy has been performed and results are pending.


VAERS ID: 1001567 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ascorbic acid 500 mg, carbidopa-levodopa 25-100 mg, clopidogrel 75 mg, entacapone 200 mg, finasteride 5 mg, multivitamin, pravastatin, Prevident 5000 Plus 1.1%, propranolol 40 mg, rivaroxaban 20 mg, tamsulosin 0.4 mg.
Current Illness:
Preexisting Conditions: Left anterior fascicular block, hyperlipidemia, hypertension, allergic rhinitis, dysphagia, gastroesophageal reflux disease, benign prostatic hyperplasia, equinovarus deformity, toe amputation, stroke, essential tremor, parkinson''s disease, hemiplegia due to old stroke, neuropathy, spasticity.
Allergies: Hay fever
Diagnostic Lab Data: None. Coroner opted against autopsy due to age and significant comorbidities
CDC Split Type:

Write-up: Death


VAERS ID: 1001713 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data: Test Name: temperature; Result Unstructured Data: 98
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; A spontaneous report was received from a consumer concerning a patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unknown date, approximately 2 hours prior to the onset of the event, the patient received a dose of mRNA-1273 intramuscularly in the for prophylaxis of COVID-19 infection. They were not feeling sick or experiencing any adverse events. Vital signs included temperature 98 degrees Fahrenheit. Approximately two hours after receiving the vaccine, the patient passed away. No treatment information was provided. Action taken with the drug in response to the event was not applicable. The patient died on an undisclosed date. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a patient of unknown age and gender. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately two hours after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1002052 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-19
Onset:2021-01-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? 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: Passed away yesterday, found deceased in her apartment; This spontaneous report was received from a consumer which refers to a 91-year-old female patient who received the Moderna COVID-19 vaccine (mRNA-1273) and next day the patient passed away. The patient''s medical history was not provided. Concomitant medications were not reported. On 19 Jan 2021, the patient received her first of two planned doses of mRNA-1273 intramuscularly (Lot number: not provided) for prophylaxis of COVID-19 infection. On 20 Jan 2021, the patient passed away and she was found deceased in her apartment. No treatment medication was provided. Action taken with mRNA-1273 in response to the events was not applicable as the patient passed away. On 20 Jan 2021, the patient died, cause of death was unknown. Autopsy result was unknown. The reporter assessed the causality as related between the event and Moderna COVID-19 vaccine.; Reporter''s Comments: This case concerns a 91-year old female patient. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the onset of the event, a causal relationship cannot be excluded and the event is considered possibly related to the vaccine.; Reported Cause(s) of Death: Unknown Cause of Death


VAERS ID: 1002057 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK 9231 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Percocet 5/325 mg, Vitamin B12, Ventolin HFA, Amiodarone, Apixaban, Atorvastatin, Carvedilol, Iron sulfate, Lasix, Gabapentin, Insulin Glargine, Insulin Lispro, Levothyroxine, Lidocaine patch, Protonix, Sertraline,
Current Illness: 1) Deconditioning 2) Osteoporosis with acute T4 compression fracture from coughing in 12/15/20 3) Chest wall pain 4) Anemia due to GI bleed 5) HTN 6) DM 2 7) HFrEF 8) Hyperlipidemia 9) Paroxysmal atrial fibrillation 10) PVD 11) CAD 12) Aortic stenosis 13) Hypothyroidism 14) Anxiety disorder
Preexisting Conditions: See above
Allergies: Baclofen, Sulfa antibiotic
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Sudden death


VAERS ID: 1002187 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory 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), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT WAS IN CLINIC FOR 1ST CLINIC. WAS DISCHARGED BEFORE OUR 2ND CLINIC. HE CAME BACK TO OBTAIN HIS 2ND SHOT. WE WENT OUT TO THE CAR GAVE SHOT. THE NEXT DAY TO MY KNOWLEDGE, HE STARTED CODING AT HOME. AMBULANCE WAS CALLED AND HE CONTINUED TO CODE. THE AMBULANCE CREW TRIED CPR FOR 30 MINS WITH NO LUCK. PATIENT PASSED 2-3-21.


VAERS ID: 1002229 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-22
Onset:2021-02-03
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known
Preexisting Conditions: CAD with stent placement 2000
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: spontaneous death, found unresponsive in cell after normal morning activities


VAERS ID: 1002255 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-27
Onset:2021-01-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9263 / 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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1002418 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-01-15
Onset:2021-02-04
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 2 LA / IM

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

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

Write-up: Patient death


VAERS ID: 1002453 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-01-26
Onset:2021-01-29
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 549616 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none
Preexisting Conditions: coronary artery disease
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reaction at time of vaccination. Reported by family that pt. died on 1/29/2021. Coroner does not believe this was related to vaccine, but requested to report to VAERs


VAERS ID: 1002535 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Herpes zoster, Malaise, Neuralgia, Pain, Rash
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/29/21 patient began not feeling well and saw her provider. The doctor gave her fluids and tramadol for pain. They noticed increased confusion, but thought that could have been due to the tramadol. They also increased her gabapentin as she was experiencing nerve pain. Patient also developed a rash and was diagnosed with shingles on 2/1/21. Patient died on 2/3/21


VAERS ID: 1002636 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Washington  
Vaccinated:2020-12-28
Onset:2021-01-17
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Angiogram, Angiogram cerebral abnormal, Aphasia, Cerebral artery occlusion, Computerised tomogram abnormal, Computerised tomogram head, Death, Fall, Movement disorder, NIH stroke scale score increased, Nervous system disorder, Thrombectomy
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (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)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 6
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ASA 81 mg, allopurinol, potassium chloride, furosemide, diltiazem, metoprolol, tiotropium, albuterol, diclofenac gel topical
Current Illness: None - had exposure to COVID19 + case on 12/18/2020 but tested negative.
Preexisting Conditions: CHF, HTN, hyperlipidemia, atrial fibrillation, COPD (O2 dependent) , CKD Stage 4, type 2 diabetes (diet controlled).
Allergies: Oxycodone, Percodan, atenolol, PCN VK
Diagnostic Lab Data: CT 1/17/21 (no acute hemorrhage but mild hypodensity of greater than 1/3 of the MCA territory) and CT Angiogram on 1/17/21 ( distal L M1/M2 occulsion).
CDC Split Type:

Write-up: On 1/17/2021 patient woke and began her day as usual, was found down by family member 1 hour later conscious but unable to speak and unable to move her R side. She was admitted to the hospital - Initial NIHSS was 26 and CT imaging showed no acute hemorrhage but mild hypodensity of greater than 1/3 of the MCA territory (TPA not recommended). CTA did show distal L M1/M2 occulsion and she was transferred to larger facility for thrombectomy. Unfortunately the patient had persistent severe neurological deficits after thrombectomy. Was discharged home on hospice care and expired on 1/23/21.


VAERS ID: 1002808 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-01-09
Onset:2021-02-03
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / UNK UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Ageusia, Anosmia, Asthenia, COVID-19 pneumonia, Death, Decreased appetite, Dyspnoea, Nausea, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Taste and smell disorders (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes, hypertension
Preexisting Conditions: IBS, GERD, overweight, scoliosis, Macular degeneration, sciatica, umbilical hernia, RBBB, Others listed
Allergies:
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: According to medical report, Pt presented to the ED on 1/14/21 w/ cc of SOB for 1 day. She received her COVID-19 vaccine on 1/9/21. Pt stated that she developed a dry hacking cough 2 days prior to the vaccine on 1/7/21. Over the last few days prior to admission, she developed generalized weakness, SOB, loss of sense of taste and smell w/ associated decreased appetite and nausea ultimately SOB in the24 hours prior to admission. Final Diagnosis- acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Pt died on 2/3/21. See Medical report for more information.


VAERS ID: 1002813 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062G20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alphagan gtts, aricept, colace, D3-50, Depakote, levetiracetam, metoprolol,senna, tylenol
Current Illness: None
Preexisting Conditions: medical diagnosis chronic conditions Epilepsy, alzehimer''s disease, acute resp. failure, non-st MI,encephalopathy, ETOH use, claucoma, anxiety/depression, HTN, macular degeneration, extropia, presbyopia, hearing loss,
Allergies: no allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was seen at 0710 he was sleeping but at normal cognitive behavior Patient was again assessed at 0720 where he was noted to be unresponsive, BP 180/100s, HR 230s, he was a DNR therefore not CPR was administered. EMS arrived at facility patient was noted to be in full cardiac and respiratory arrest. Time of death 0735


VAERS ID: 1002840 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ZTC540693 / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamulosin HCL, HCTZ, Oxybutynin CL ER, Lisinopril, Zetia, Lexapro, Trulicity,
Current Illness: none
Preexisting Conditions: DM II, HTN, Hyperlipidemia
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Client lives alone and had dinner at his home with family members after the 4:40 appointment. Client stated that in general he did not feel well but did not give any specific symptom. Family states they asked the client to go to the ER and the client refused. Family states they helped the client to his chair in the living room and then left to go home. Family states that the client was found in his bedroom the next morning at 7:54 a.m. deceased.


VAERS ID: 1003106 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Enteric Coated Aspirin 81 mg tablet,delayed release 1 Time Daily Eliquis 2.5 mg tablet 2 Times Daily Dulcolax (bisacodyl) 10 mg rectal suppository PRN Fleet Enema 19 gram-7 gram/118 mL PRN acetaminophen 500 mg ta
Current Illness: CARDIOMEGALY; LOW BACK PAIN; MUSCLE WEAKNESS (GENERALIZED); NEED FOR ASSISTANCE WITH PERSONAL CARE; - OTHER ABNORMALITIES OF GAIT AND MOBILITY; LUMBAGO WITH SCIATICA, UNSPECIFIED SIDE; R26.81 - UNSTEADINESS ON FEET; REPEATED FALLS; CERVICAL SPONDYLOSIS; Other Diagnoses PRESENCE OF CARDIAC PACEMAKER; DYSPHAGIA, OROPHARYNGEAL PHASE; HYPERLIPIDEMIA, UNSPECIFIED; CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED ; ATHSCL HEART DISEASE OF NATIVE CORONARY ARTERY W/O ANG PCTRS; ESSENTIAL (PRIMARY) HYPERTENSION; INSOMNIA, UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE;
Preexisting Conditions: On hospice
Allergies: Diltiazem
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident received vaccination at 9:12 am, she was monitored and checked at the 15 minute interval 9:27 am, reassessed, vitals were fine. Within 20 (9:32 am) minutes of receiving the vaccine she was unresponsive, pupils were fixed at 9:45 am, no vital signs noted; hospice came out and reported her time of death 10:21 am. This person was on hospice.


VAERS ID: 1003329 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-29
Onset:2021-02-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9263 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: Per medical record: alendronate, amlodipine, aspirin, atorvastatin, benazepril, calcium-Vitamin D, diclofenac, ezetimibe, glimeperide, hydrochlorothiazide, latanoprost opthalmic, topical lidocaine, metformin, Artificial Tears, Lacri-Lube, p
Current Illness: No known recent illnesses per medical record
Preexisting Conditions: Per medical record: type 2 diabetes, hypercholesterolemia, hypertension, non-proliferative diabetic retinopathy, borderline glaucoma, osteoarthritis, obesity
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient''s primary care provider received a death certificate to be signed for this patient. He spoke with the patient''s husband and son, who reported that the patient had pain and swelling at the vaccine administration site after receiving the vaccine and was feeling unwell after receiving the vaccine. The patient''s family reported that they found her unresponsive on 2/2/21 and called 9-1-1. The patient was pronounced dead upon arrival of emergency responders.


VAERS ID: 1003382 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bradycardia, Chest pain, Condition aggravated, Death, Diarrhoea, Full blood count, Hypotension, Metabolic function test, Seizure, Urine analysis, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aricept, citalopram,carbamazepine, Atorvastatin, gabapentin, calcium citrate, metoprolol, amlodipine, vitamin D
Current Illness: COVID dx on 1/4/2021
Preexisting Conditions: Dementia, epilepsy, HTN, PVD, osteoporosis,
Allergies: PCN, Sulfa ATB
Diagnostic Lab Data: Did order CBC, carbamazepine level, UA and CMP. Results are pending
CDC Split Type:

Write-up: Began with vomiting and diarrhea. C/O chest pain. Bradycardia. Hypotension. 2 seizures in 45 minutes after not having one in years. We gave fluids. Gave Zofran. Comfort measures. Pt passed at midnight. Was completely fine one day before. Had minimal issues with COVID though did have a pneumonia that was treated w ATB early on and resolved.


VAERS ID: 1003390 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 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: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 2/1/2021, the patients daughter, who claims is a nurse, reported this incident to me. She stated that the evening after the patient received the vaccine, she felt some mild injection site pain. The morning after, the patient reported severe abdominal pain, diarrhea and vomiting. The patients daughter then called her physician to report these symptoms and attributed them as an adverse reaction to the vaccine at that time. These symptoms were intermittent for one week and no other adverse reactions were noted. In the early morning hours of 1/27/2021, the patient was toileting and had expired while doing so. An ambulance was called and cause of death was not found. An autopsy was not performed.


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