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

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

Government Disclaimer on use of this data



Case Details

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

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

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

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


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

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

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

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


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

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

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

Write-up: Patient with severe dementia in Hospice Care


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

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

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

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


VAERS ID: 1057704 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Florida  
Vaccinated:2021-01-16
Onset:2021-01-16
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Biopsy bone marrow, Blood test, Body temperature, Chills, Computerised tomogram, Dyspnoea, Fatigue, Inflammatory marker increased, Interleukin level, Laboratory test, Multiple organ dysfunction syndrome, Myelodysplastic syndrome, Pancytopenia, Pyrexia
SMQs:, Anaphylactic reaction (broad), Agranulocytosis (narrow), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Neuroleptic malignant syndrome (broad), 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), Blood premalignant disorders (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Myelodysplastic syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 27
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: Breast cancer (in the 1990s); Mastectomy
Allergies:
Diagnostic Lab Data: Test Name: bone marrow biopsy; Result Unstructured Data: showed high grade MDS with 19% blasts.; Test Date: 202006; Test Name: blood work; Result Unstructured Data: Normal; Test Name: body temperature; Result Unstructured Data: degrees Fahrenheit; Test Name: CAT scan; Result Unstructured Data: bilateral pleural effusion; Test Name: IL-6; Result Unstructured Data: High; Test Name: lab profile; Result Unstructured Data: elevated d-dimer and ferritin levels; Test Name: Pancytopenia; Result Unstructured Data: abnormal
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: High grade MDS; Multiorgan failure; Pancytopenia; shortness of breath; Inflammatory marker increased; Chills; Fever; Fatigue; A spontaneous report was received from a healthcare provider concerning a 71Years-old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and who experienced chills, fever, fatigue, pancytopenia, shortness of breath (dyspnoea), multi organ failure, and myelodysplastic syndrome (MDS). The patient''s medical history was reported to include Breast Cancer and mastectomy. No relevant concomitant medications were reported. On 16 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch:unkown) intramuscularly for prophylaxis of COVID-19 infection. On 16 Jan 2021, The patient experienced events like chills, fever, and fatigue. On an undisclosed date, the patient was admitted to the hospital for shortness of breath. Laboratory details include Bone Marrow biopsy with abnormal results such as showed high grade MDS with 19% blasts. Blood work done with normal results. Body temperature results came out 103 degrees Fahrenheit. On 30 Jan 2021 the patient experienced worsening shortness of breath and was intubated. Her IL-6 was very high, and she had profound liver failure. She ended up needing pressors and requiring continuous renal replacement therapy. Treatment included steroids. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 12 Feb 2021. The cause of death was reported as high grade MDS. An autopsy was planned.; Reporter''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1057750 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-20
Onset:2021-02-08
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test, COVID-19 pneumonia, Chest pain, Decreased appetite, Diarrhoea, Headache, Influenza virus test negative, Malaise, Myalgia, Viral test negative
SMQs:, Rhabdomyolysis/myopathy (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: PROCARDIA [NIFEDIPINE]; LOFIBRA [FENOFIBRATE]
Current Illness: Blood pressure high
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210206; Test Name: Blood test; Result Unstructured Data: Blood test; Test Date: 20210206; Test Name: Influenza virus test negative; Test Result: Negative ; Result Unstructured Data: influenza virus test; Test Date: 20210206; Test Name: COVID-19 test; Test Result: Negative ; Result Unstructured Data: COVID-19 test
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Started feeling unwell; Headaches; Body aches; Chest pain; Didn''t had wishes to eat; Diarrhea; COVID-19 pneumonia; A spontaneous report was received from a consumer concerning a 69-year-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced COVID-19 pneumonia, feeling unwell, headaches, body aches, chest pain, decreased appetite and diarrhea The patient''s medical history high blood pressure which was controlled with medication. Concomitant product use included nifedipine and fenofibrate. On 20-JAN-2021, approximately a week and a half or two prior to the onset of the symptoms, the patient received their first of two planned doses of mRNA-1273 (Batch number 030L20A) intramuscularly in the right arm for prophylaxis of COVID-19 infection. A week and a half or two later the patient stated feeling unwell, headaches, body aches, chest pain, decreased appetite and diarrhea for which patient was hospitalized on 06-FEB-2021. Since everything seemed to be fine the patient was discharged on an unknown date in FEB-2021 however, patient''s family was not notified that it was a late reaction to the vaccine''s first dose. Later, due to shortness of breath he was hospitalized again on 08-FEB-2021 and was diagnosed for pneumonia and was intubated on the same day. Due to COVID-19 situation patient''s family could not be in the facilities and that there wasn''t any follow up of the patient given to the family, so family did not have much information. During the first hospitalization(06-FEB-2021) the patient had a blood test which showed a normal result and was tested for COVID-19 and Influenza, both were negative. During second hospitalization (08-FEB-2021) the hospital said that the patient was stable. The patient''s family did not know the results of the tests conducted at the time. The action taken with the vaccine in response to the events is not applicable. The outcome of COVID-19 pneumonia was fatal. The patient died on 14 Feb 2021 The cause of death was reported as COVID-19 related pneumonia. The autopsy was not done.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. The cause of death was reported as COVID-19 related pneumonia. Based on the current available information and the mechanism of action of mRNA-1237 vaccine, the events are assessed as unlikely related. Further information has been requested.; Reported Cause(s) of Death: COVID-19 pneumonia


VAERS ID: 1057795 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-02-22
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Public       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: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 02/22/2021.


VAERS ID: 1057802 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-19
Onset:2021-01-31
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0330L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Decreased appetite, Diarrhoea, Dyspnoea, Endotracheal intubation, Fatigue, Hypophagia, Intensive care, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Respiratory failure (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? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was transferred from hospital for further evaluation and care by pulmonologist. He started having symptoms a week before with fatigue, emesis, decreased p.o. intake, shortness of breath, vomiting and diarrhea. The two previous takes before death required increasing oxygen and family wanted everything done including intubation. He was transferred to ICU.


VAERS ID: 1057828 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-02-03
Onset:2021-02-17
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin 1000mg twice daily, Lisinopril 10mg once daily, aspirin 81mg once daily, amlodipine 10mg daily
Current Illness:
Preexisting Conditions: hypertension, type 2 diabetes, prostate cancer, melanoma, lumbar spondylosis, renal stones, GERD
Allergies: empagliflozin 10mg caused dizziness
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient unexpectedly died on 2/17 after 14 days of receiving first dose of COVID-19 vaccine. EMS presumed it could be from possible myocardial infarction.


VAERS ID: 1057853 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-18
Onset:2021-02-21
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Death
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

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

Write-up: on 2/218/2021 the patient was at home and developed chest pain. Patient was transported by family to urgent care then to the ED where the patient later died.


VAERS ID: 1057997 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 UN / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Death, Feeling hot, Hypotension, Pulseless electrical activity, SARS-CoV-2 test, Seizure, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   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: Ibuprofen
Current Illness: None
Preexisting Conditions: Prostate Cancer and High Cholestrol
Allergies: Penicillin
Diagnostic Lab Data: Autopsy to be performed on 02/27/2021 COVID-19 PCR to be performed on 02/27/2021
CDC Split Type:

Write-up: "Feeling Hot" without fever and nausea 10 hours post vaccine and resolved within 1 hour. Seizure, Hypotension, Unresponsive followed shortly by cardiac arrest and pulseless electrical activity 21 hours post vaccine. Pronounced dead 22 hours post vaccine


VAERS ID: 1058160 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-11
Onset:2021-02-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: Acetaminophen, Aspirin, Atorvastatin, Carvedilol, Fiber-lax, Furosemide, Levetiraceta, Levothyroxin, Lorazepam, Quitiapine, Terazosin, VitD, Antidiarrheal tabs PRN,Tramadol PRN
Current Illness: None
Preexisting Conditions: Hypertension, Hypothyroidism, Hyperlipidemia, seizures, Dementia, Edema Legs
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident expired on 2-25-21


VAERS ID: 1058447 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-23
Onset:2021-02-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Accidental overdose, Death, Drug abuse, Drug screen positive, Toxicity to various agents, Urine analysis abnormal
SMQs:, Anticholinergic syndrome (broad), Drug abuse and dependence (narrow), Depression (excl suicide and self injury) (broad), Medication errors (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: Albuterol, abilify, mirtazapine, buprenorphine/naloxone,
Current Illness: None known
Preexisting Conditions: Opioid use disorder, cocaine use disorder, hypertension, asthma, hepatitis C (treated), tobacco use, bipolar
Allergies: Lamotrigine
Diagnostic Lab Data: Urine toxicology on 2/24/21: positive for cocaine and fentanyl
CDC Split Type:

Write-up: Moderna COVID- 19 Vaccine EUA Patient was found deceased in the community near his home address on 2/24/21. The Medical Examiner''s cause of death is currently listed as "Drug Intoxication - Accidental Overdose." Per the MEO, post mortem urine toxicology was positive for cocaine and fentanyl. His death is believed to be related to a cocaine product that was adulterated with fentanyl and is not believed to be related in any way to the Moderna COVID-19 vaccine. This was explicitly stated by the Medical Examiner''s Office.


VAERS ID: 1058569 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-02-25
Onset:2021-02-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   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 DIED IN HIS SLEEP NIGHT AFTER ADMINISTRATION


VAERS ID: 1058976 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-12
Onset:2021-02-26
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 LA / IM

Administered by: Pharmacy       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: Diabetes; HTN
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Unknown the exact event, but patient has passed away.


VAERS ID: 1059048 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chills, Death, Fatigue, Myalgia, Nausea, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   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: Aspirin 81 mg once daily, lorazepam 1 mg two tablets once daily, metoprolol er succinctness 100 mg once daily
Current Illness: None
Preexisting Conditions: Long QT Syndrome Atrial fibrillation
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, chills, fatigue, muscle aches, nausea, death 48 hours after injection


VAERS ID: 1060525 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-19
Onset:2021-01-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O13L20A / 1 LA / IM

Administered by: Other       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? 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: This was reported to VAERS by another entity and records were requested.


VAERS ID: 1060527 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Blood gases abnormal, Blood lactic acid increased, Blood lactic acid normal, Blood urine, Body temperature increased, Cardio-respiratory arrest, Chest X-ray, Chest X-ray abnormal, Computerised tomogram head normal, Death, Differential white blood cell count abnormal, Dyspnoea, Fall, Full blood count, Haematocrit decreased, Haemoglobin decreased, Hypotension, Hypoxia, Intensive care, Musculoskeletal stiffness, Oxygen saturation decreased, Pain, Platelet count normal, Pyrexia, Red blood cells urine, Respiration abnormal, Respiratory failure, SARS-CoV-2 test negative, Unresponsive to stimuli, Urinary occult blood positive, Urinary sediment present, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Haematopoietic leukopenia (broad), Lactic acidosis (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Arthritis (broad), Myelodysplastic syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 4
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: Rapid covid test was negative. Admission labs 2/18/21: CBC with WBC of 10.1, H/H 9.6/31.5, plts 167. Lactate WNL. UA with 3+ blood/$g100 urine RBC/HPF, 4 WBC/HPF, no culture.
CDC Split Type:

Write-up: loss of consciousness;febrile Narrative: Patient received his 2nd vaccine at 10am 2/17. That evening he felt subjectively febrile and then suffered a ground level fall at 0400 on 2/18. He did not lose consciousness or injure his head. EMS was contacted and assisted him into bed. At 0600, wife noted increased work of breathing, which prompted another EMS call, who found him hypoxic with fever of 106. He was transported to a community hospital, where he was found to have temp 102.9 and blood pressure in 70s-80s systolic. He was transferred to hospital at 1300 on 2/18/21, requiring norepinephrine for pressure support after fluid resuscitation. He c/o stiffness and soreness all over but presenting ROS was otherwise negative. Patient was treated with 4L IV fluids and vancomycin and piperacillin/tazobactam at the outside ER. Here at the hospital he was treated with vancomycin, piperacillin/tazobactam and levofloxacin along with IV fluids and norepinephrine. Despite this he had several fevers with Tmax 103.5F the night of 2/18-2/19 and he required norepinephrine plus vasopressin overnight to maintain blood pressure. Piperacillin/Tazobactam was discontinued in favor of meropenem. His last fever was at 6am on 2/19. ID consult was obtained 2/19/21 and vancomycin and levofloxacin were weaned off. Ultimately his blood pressure improved and he was weaned off of all vasopressors the morning of 2/20. Notably, he never developed severe hypoxemia at rest while in the ICU, but did require BiPAP non-invasive ventilation at night instead of his usual CPAP to keep his oxygen levels $g 90% while sleeping and additionally had desaturations into the low 80% range with exertion from which he was slow to recover. His oxygen saturation was $g90% on 30-40% FiO2 via aerosol mask overnight and 3L (his current baseline) NC during the day. He was transferred out of the ICU on 2/21 based on hemodynamic improvement, stable oxygenation, and improved mentation and symptoms. Unfortunately, on the morning of 2/22/21, patient had an abrupt change in status and was found to be unresponsive with hypercarbic respiratory failure and hypotension. ABG during this event was 7.16/121/65. BiPAP was initiated as patient''s code status was DNR/DNI. CXR with no significant change from 2/18/21. CT of head without contrast was negative for acute processes. Based on lack of rapid improvement, the decision was made by wife to transition to comfort care. Patient died at 1446 on 2/22/21. **Of note: patient was admitted for 1 week for covid 19 pneumonia November 2020. During this hospitalization he was found to have chronic R sided PE, no acute PE.


VAERS ID: 1059207 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-22
Onset:2021-02-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

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

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

Write-up: Unknown symptoms overnight. Appears patient passed away sometime after waking up next morning after receiving vaccine.


VAERS ID: 1059360 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-22
Onset:2021-02-05
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia, Death
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions: Coronary artery disease, arrhythmia
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac arrhythmia, EMS on site within minutes, outcome of death.


VAERS ID: 1059825 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016MZOA / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Lethargy, 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: 2021-02-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Donepezil 10mg daily Vitamin D3 5000 IU daily Eliquis 2.5mg twice daily Vitamin B12 1000mcg daily Enalapril 10mg daily Memantine HCL 10mg twice daily Claritin 10mg dai
Current Illness: none while at community- new move in.
Preexisting Conditions: Dementia HTN A-Fib Cancer
Allergies: NKA
Diagnostic Lab Data: 911 was called and resident went to hospital where treatment was provided there in ER dept. and I have been informed passed away.
CDC Split Type:

Write-up: 30 hours after the first Covid vaccination, the resident was lethargic, non responsive with shortness of breathe.


VAERS ID: 1060190 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-27
Onset:2021-02-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cerebrovascular accident, Computerised tomogram abnormal, Death, Pulse absent, Respiratory arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic 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 (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: CT, Code stroke called. stopped breathing and pulseless at 1248. Checked into ED at 1234 arrival.
CDC Split Type:

Write-up: Patient received Covid Vaccine Moderna at 1145, multiple syncopal episodes at pharmacy, sent to ER. Outcome Death


VAERS ID: 1060529 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Faeces discoloured, Fall, Hypoxia, Mental status changes, Myalgia, Pulse absent, Resuscitation, Terminal state, Unresponsive to stimuli, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (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 (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: Hypoxia, Decreased responsiveness, Narrative: 86yo male with PMHx HTN, Afib not on AC after head trauma, CVA, and colon cancer who was brought to the ED by his family on 2/17. Per documentation the pt was in his usual state of health until 2/16. Received Moderna covid vaccine #2 on 2/16/21 at 0900, and was monitored for 15 minutes following immunization no noted issues. Later that night, had myalgias and took Tylenol. Per the family he slipped on the ice and fell on his butt. Overnight, had several dark stools and vomitus. was brought to the ED by his family because he was being less responsive. Pt arrived to the emergency department in extremis. No pulse identified. CPR immediately initiated for several rounds lasting about 25-30 minutes. ROSC unable to be achieved. Patient expired on 2/17 at 1941. Of note, per previous documentation had waxing and waning mental status at baseline. No symptoms noted with 1st dose of Moderna vaccine, which was administered on 1/16/21.


VAERS ID: 1060858 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death, Decreased appetite, Sudden death, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Nifedipine, Klor-con, HCTZ
Current Illness: Hypertension
Preexisting Conditions: Hypertension
Allergies:
Diagnostic Lab Data: autopsu 2/27/2021
CDC Split Type:

Write-up: had lack of appetite before second dose. When received the second dose, he started vomiting on the way home. Was sick on and off for the next few days. Died suddenly on 2/23/2021


VAERS ID: 1061040 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-20
Onset:2021-02-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK OT / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain upper, Malaise
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Well controlled Insulin Diabetic meds
Current Illness: Insulin Dependant Diabetes
Preexisting Conditions: DM
Allergies: not known
Diagnostic Lab Data: not known
CDC Split Type:

Write-up: Text message from patient : 2.37 pm Saturday 02/20/2021 had the vaccine , waiting for 15 minutes & 2nd dose due 3/18/2021 Test message 9.44 am Sunday :feeling little sick with stomach ach No answer to phone calls on Cell/ Landline on Sunday No answer to phone call/ or text message No further communication.


VAERS ID: 1061059 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-29
Onset:2021-01-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Computerised tomogram abdomen, Death, Muscle spasms, Pain
SMQs:, Dystonia (broad)

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? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Not known to reporter
Current Illness: Was undergoing diagnostic testing for gastrointestinal complaints of several weeks duration. Had CT morning of 1/29/2021.
Preexisting Conditions: History of type 2 diabetes Hip replacement had been postponed due to pandemic
Allergies: not known to reporter
Diagnostic Lab Data:
CDC Split Type:

Write-up: Do not know if patient informed her physician that she received vaccine on 1/29/2021. She had appt at 3:15 pm on 1/29 and afterwards stated she received the Moderna vaccine. Reporter is uncertain if this was at a health office or clinic. She drove herself to the ER at about 3am on 1/30/2021 with increased cramping and pain.


VAERS ID: 1061077 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: Oxygen 6L, furosemide, tylenol, gabapentin, aspirin, hydralazine, glucosamine, mirtazapine, Repatha, procrit, multivitamin
Current Illness: None
Preexisting Conditions: pulmonary fibrosis, coronary artery disease, hypertension, hyperlipidemia, CKD
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Day after second dose decedent had fever and tremors, subsided on day three (less than 72 hours) after dose with exterem wekness followed by death less than 72 hours after second dose


VAERS ID: 1061184 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-14
Onset:2021-02-05
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20AMODERNA / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cold sweat, Dizziness, Echocardiogram, Fatigue, Headache, Hyperhidrosis, Myocardial infarction, Pain, Pain in extremity
SMQs:, Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASA Atorvastatin Lisinopril
Current Illness: none
Preexisting Conditions: Hyperlipidimia Hypertension
Allergies: NKDA
Diagnostic Lab Data: Echocardiogram 2/25/21
CDC Split Type:

Write-up: Possible heart attack on 2/5/21. Complaint: " On Feb 5th l believe l experienced a mild hear attack" (Comment: He said he felt "clammy, sweaty, excruciating pain on my left side - including his left arm, and left leg, dizzy, exhausted." This happened after work, and after taking a shower. He said that was the first time he''s experienced it, and that it has not happened since then. He said he has constant headaches, "It just went away yesterday."


VAERS ID: 1061434 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-11
Onset:2021-02-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Computerised tomogram abnormal, Death, Loss of consciousness, Myocardial infarction
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), 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, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: I am the patient''s daughter as well as an RN-BSN. My mother was given the Moderna vaccine on Feb 11, 2021 and on Feb 15, 2021 she had a CVA and MI. She was found on her apt. floor unconscious. She was transferred to the Hospital by ambulance where a CT scan and other tests were done. It was determined she had a stroke and heart attack. My mother was in great health, took no medications, and lived alone in her apt. before this incident. The medical professionals determined she would not recover so she was admitted to hospice and died on Feb. 21, 2021. I believe there is a relationship between the vaccine and the CVA and MI.


VAERS ID: 1061909 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-29
Onset:2021-01-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebrovascular accident
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: 2021-01-31
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Pacemaker insertion (cardiac)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Massive stroke; A spontaneous report was received from a consumer (patient''s daughter), concerning an 85-year-old female patient, who received Moderna COVID-19 vaccine and death occurred in two days. The patient''s medical history was not provided. No relevant concomitant medications were reported. No information on allergies. She states that her mother was physically and mentally healthy before vaccination. On 29-JAN-2021, prior to the onset of events, the patient received her first of two planned doses of covid-19 vaccine for the prophylaxis of Covid-19 infection. There were no complaints on any side effects from the patient for 6 hours after vaccination. Next day, she was found unresponsive on her bed by her neighbor after they were sent to check on her by her daughter. Her heart was beating, and she was breathing at that time, but did not have consciousness. According to her daughter, the patient had a massive stroke in her sleep sometime between 8:pm on 29-JAN-2021 and 9:30 am on 30-JAN-2021. Her life saving measures were taken out at 1:15 am on 31-JAN-2021 and she died approximately at 1:45am. No information available on hospitalization and treatment received with this event. It is not known whether autopsy was done. Action taken with 2nd dose of Moderna Covid-19 vaccine was not applicable. The outcome of the event stroke is fatal.; Reporter''s Comments: Based on the current available information and temporal association between the use of the product and the onset date of the event of stoke, a causal relationship cannot be excluded. Patient''s elderly age is considered a risk factor.; Reported Cause(s) of Death: Massive stroke


VAERS ID: 1061910 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-11
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
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; A spontaneous report was received from a Pharmacist concerning a 65 years-old, male patient who passed away/MedDRA PT: death, days after receiving the second dose of the Moderna COVID-19 vaccine. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. The patient received their first of two planned doses of mRNA-1273 (Lot #012L20A) on 12 Jan 2021. On 11 Feb 2021, the patient received their second of two planned doses of mRNA-1273 (Lot # 030M20A) (route of administration and injection site not provided) for prophylaxis of COVID-19 infection. On an unknown date, days after receiving the second dose of the Moderna COVID-19 vaccine, the patient passed away. The patient did not come to the hospital; therefore the Pharmacist had very little detail of the situation but believed it was due to aspiration based on report received from the patient''s boss. The Pharmacist reported there was no report of any issues from the first vaccine. The patient was found at home by spouse and had yellow stuff on face and chest. Action taken with mRNA-1273 was not applicable as the patient deceased. The patient died on an unknown date. The cause of death was reported as unknown. Plans for autopsy were not provided.; Reporter''s Comments: Very limited information regarding the event of death has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Death days after receiving the second dose of the Moderna Covid-19 Vaccine


VAERS ID: 1061911 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-01-28
Onset:2021-01-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Anxiety depression; Blood pressure high; Thyroid disorder
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died at home; Gasping for air/difficulty breathing; Soreness; A spontaneous report was received from a physician concerning a 45 years-old, female patient who experienced soreness/MedDRA PT: pain, gasping for air/difficulty breathing/MedDRA PT: dyspnoea and subsequently died/MedDRA PT: death. The patient''s medical history included blood pressure (disorder not specified), thyroid disorder, depression and anxiety. Concomitant product use included blood pressure medication, thyroid medication and possibly depression and anxiety medication. On 28 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Lot #007M20A) (route of administration and injection site not provided) for prophylaxis of COVID-19 infection. On 28 Jan 2021, following the vaccination, the patient was fine but had experienced some soreness. Per patient''s coworker, the patient did not take any medication as it made the patient sick. The physician was not aware of any complaints from the vaccine. On 13 Feb 2021 at 3:31am, the patient called 911. Per the 911 call, the patient was gasping for air on the call and having difficulty breathing. The patient subsequently died on 13 Feb 2021 at home. The physician inquired whether Moderna gets involved with the autopsy and logistics of the death of patients and wanted to know the time frame for reporting a death of a patient who received the vaccine. The physician did not know who administered the patient''s vaccine. Action taken with mRNA-1273 in response to the events was not applicable as the patient deceased. The event died was fatal. The outcome for the events soreness and gasping for air/difficulty breathing was unknown. The patient died on 13 Feb 2021. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding the event of dyspnea and death has been provided at this time. Further information has been requested. Patient''s medical history of blood pressure is considered a risk factor. Based on the current available information and temporal association between the use of the product and the onset of the pain, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Died at home


VAERS ID: 1062350 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-23
Onset:2021-01-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013620A / 1 - / OT

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

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

Write-up: Death; A spontaneous was received from a consumer concerning a male patient, who received Moderna''s COVID-19 vaccine and who died. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 23-Jan-2021, prior to the onset of the event, patient received their first of two planned doses of mRNA-1273 (Lot number:013620A) intramuscularly for prophylaxis of COVID-19 infection. On 25-Jan-2021, approximately 2 days after injection, patient Died. On 26-Jan-2021, neighbor Reporter called in to report a potential AE death. She shared that she lives in a condo building with other elderly. She shared that she and 2 other neighbors went to a vaccination site in Miami at a fire department. She shared that she is fine but that her neighbor died two days after shot. She shared that she didn''t know if he had symptoms and that she knows that he had a lot of medical issues and was on about 15 medicines. She shared that she didn''t know his age but guessed 70. She said we can contact his wife, but it must be a Spanish speaking agent because she speaks little English. She is concerned because they all received the vaccine at the same time. She wanted to reiterate that she was fine but believed we should know about the neighbor''s death. No treatment information was provided. Action taken with the second dose of mRNA-1273 in response to the event death is not applicable. The patient died on 26-Jan-2021. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. Further information has been requested. The cause of death was not provided.; Reported Cause(s) of Death: Unknown


VAERS ID: 1062666 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-22
Onset:2021-02-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Catheterisation venous, Cough, Death, Disability, Fall, Fatigue, Respiratory arrest
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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: AMIODARONE, DOXYCYCLINE, LACTULOSE, OCTREOTIDE, POTASSIUM CHLORIDE, TORSEMIDE, WARFARIN
Current Illness: CONGESTIVE HEART FAILURE ON LEFT VENTRICULAR ASSIST DEVICE MALNUTRITION, DEBILITY
Preexisting Conditions: EOSINOPHILIC MYOCARDITIS GI BLEED
Allergies: NO KNOWN DRUG ALLERGIES
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2-24-21 patient with development of cough, fatigue, increasing on chronic disability worsening debility and falls. scheduled for office visit 2-25.21 0900 call from spouse 0210 am patient was not breathing and lvad alarming low flow alarm on arrival of ems confirm asystolic not breathing and dead


VAERS ID: 1062830 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-25
Onset:2021-02-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Death, Endotracheal intubation, Pulseless electrical activity
SMQs:, Angioedema (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: APAP 1 gm po tid ASA 81 po qd Atorvastatin 40 mg po qhs Bisacodyl 10 mg PR qd prn constipation Bisacodyl EC 5 mg po qhs prn constipation Cholecalciferol 2000 units po qd Methocarbamol 500 mg po bid Metoprolol succinate 25 mg po qd Miral
Current Illness: 1/17/21 Spine compression fracture 1/19/21 New diagnosis of atrial flutter and NSTEMI
Preexisting Conditions: HTN Chronic back pain Osteoarthritis
Allergies: Trazodone - tachycardia and numbness of extremities (hands/feet)
Diagnostic Lab Data:
CDC Split Type:

Write-up: 92 yo female who received her first dose of Moderna vaccine on 1/11/2021 with no known adverse effects. Admitted to the hospital on 1/17/21 with a spine compression fracture. Discharged and readmitted on 1/19 /21 with nausea and vomiting. Found to have new atrial flutter and elevated troponin attributed to NSTEMI. Discharge on Aspirin and Plavix. No cath. Second dose of Moderna vaccine 2/25/21. No immediate reaction. One hour later began to feel progressively weak. EMS called shortly after getting home. Intubated in the field. Died at 0658 on 2/26/21 s/p PEA arrest without ROSC.


VAERS ID: 1062895 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-11
Onset:2021-02-28
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1063000 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-25
Onset:2021-02-27
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1063561 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-07
Onset:2021-02-07
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Diet refusal
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Resident had hx of CVA with deficits in speech and extremities. Hx of decreased circulation to BLE''s which resulted in wounds to bilateral feet on and off that needed treatment. Decreased oral Intake. Average meal consumption 25-50% of meals, started refusing more often in December and January. Would consume small amounts 60-120mL of fluids here or there.
Preexisting Conditions: CVA, Decreased circulation to BLE, Decreased oral intake
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was a Resident on our LTC wing. Per the LTC Manager: Resident had hx of CVA with deficits in speech and extremities. Hx of decreased circulation to BLE''s which resulted in wounds to bilateral feet on and off that needed treatment. Average meal consumption 25-50% of meals, started refusing more often in December and January. Would consume small amounts 60-120mL of fluids here or there. Vaccinated on 1/7/21. Stopped eating 1/18/21. Attempted bolus NS fluid 1/25/21. Resident refused all treatment afterwards. Went hospice on 2/3/21 and passed away on 2/7/21.


VAERS ID: 1063681 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Nevada  
Vaccinated:2021-01-27
Onset:2021-02-04
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Triam/HCTZ, Omeprazole
Current Illness: none
Preexisting Conditions: Mild hypertension, GERD
Allergies: none
Diagnostic Lab Data: None. no Autopsy was done
CDC Split Type:

Write-up: Pt got his vaccine 1/27 and was found dead at his residence on 2/7/21. I heard from our county health officer who talked to the coroner who said that they estimated that the patient had been deceased for 2-3 days prior to when they were found. No apparent cause of death was found.


VAERS ID: 1063727 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Montana  
Vaccinated:2021-01-21
Onset:2021-02-23
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 RA / IM

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

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

Write-up: Called pt for Dose 2 appt. Pt had passed away.


VAERS ID: 1063758 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-24
Onset:2021-02-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: unknown
Current Illness: unknown
Preexisting Conditions: Fully treated for TB many years ago
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died on 2/25/21 in the AM after receiving his COVID-19 Moderna vaccine #1 at approximately 2:30P on 2/24/21. I do not have a time of death. I contacted the County Medical Examiner''s office who stated that they received his body after he was determined to be deceased at the shelter. No autopsy was performed and his body was released to a funeral home on 2/26. The ME''s office said that "permit for burial/cremation is pending" and no other information on COD was available. Per staff, he was also tested for COVID as part of shelter protocol on 2/24 and PCR was negative. He arrived to the shelter on 2/19/21.


VAERS ID: 1063812 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-13
Onset:2021-01-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Confusional state, Death, Dementia, Diet refusal, Laboratory test abnormal, Renal failure, Restlessness
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (narrow), Akathisia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. Decreased appetite, more restless, increased confusion with dementia, On 1/25/21 Resident labs showed kidney failure, on 2/5/21 went on comfort care
Preexisting Conditions: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical.
Allergies: Doxycycline
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident had severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. After last surgery, resident did not have a good appetite, more restless, increased confusion with dementia. Significant other passed away on 12/30/20, resident began refusing meals, decreased eating. Vaccinated on 1/13/21. On 1/25/21 Resident labs showed kidney failure. Dr. spoke with family and transitioned to Comfort care, on 2/5/21 went hospice. Patient passed away on 2/13/2021.


VAERS ID: 1063846 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-22
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Decreased appetite, Hyperphagia, Respiration abnormal, Weight increased
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hx dementia, CVA, CAD. 2-3 year history of only consuming 25% of 1-2 meals daily
Preexisting Conditions: Hx dementia, CVA, CAD. 2-3 year history of only consuming 25% of 1-2 meals daily
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hx dementia, CVA, CAD. 2-3 year history of only consuming 25% of 1-2 meals daily. All meds d/c early 2020 because of refusing to eat or drink anything. Suddenly began drinking april/may, gained weight back. Vaccinated on 1/7/21 & 2/4/21. On 2/22/21 had significant changes in respiratory status. Passed away 2/23/21.


VAERS ID: 1063863 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-13
Onset:2021-02-23
   Days after vaccination:41
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hx of DM T2, Hx of prostate CA. Started having swallowing difficulties in November. Increased c/o nausea and decreased appetite. 25% per meal average. Decreased energy to participate in activities and refused getting out of bed or meals.
Preexisting Conditions: Hx of DM T2, Hx of prostate CA. Started having swallowing difficulties in November. Increased c/o nausea and decreased appetite. 25% per meal average.
Allergies: Penicillins- Hives/ Urticaria, Rash
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident had Hx of DM T2, Hx of prostate CA. Started having swallowing difficulties in November. Increased c/o nausea and decreased appetite. 25% per meal average. Decreased energy to participate in activities and refused getting out of bed or meals. Was vaccinated on 1/13/21. Hospice care started on 1/25/21. Resident passed away 2/23/21.


VAERS ID: 1063903 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-09
Onset:2021-02-10
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: METOPROLOL TARTRATE 25MG, AMIODARONE 200MG, FUROSEMIDE 80MG, PARICALCITOL 1MCG, AMLODIPINE 5MG
Current Illness:
Preexisting Conditions: CONGESTIVE HEART FAILURE, KIDNEY FAILURE,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: NO SPECIFIC ADVERSE EVENT DUE TO THE VACCINE BUT THE PATIENT PASSED AWAY 02/10/2021 DUE TO COVID


VAERS ID: 1064265 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 2 - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluoxetin 20mg - 1 every day, Lisinopril/HCTZ 20 - 12.5 mg - 1 every day, Potassium CL ER 20MEQ Micro - 1 twice daily, Pravastatin 40mg - 1 every day, Tamsulosin .4mg - 1 every day Vitamin D 50 mcg - 1 every day, Vitamin E 180 mg - 1 every
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: Coroner requested autopsy but I have been told by the coroner''s office that state medical examiner deemed it unnecessary
CDC Split Type:

Write-up: Death


VAERS ID: 1064294 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-26
Onset:2021-02-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan 50 mg bid, Calcium Carbonate 500 nmg qd, Aspirin 81 mg qd, multivitamins, Macuhealth
Current Illness: none
Preexisting Conditions: Hypertension, Hyperlipidemia, Diverticulosis, Osteopenia, Kyphosis
Allergies: nkda
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Death on 2-28-21. Not felt by this provider to be likely related to vaccination.


VAERS ID: 1064433 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-27
Onset:2021-03-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions:
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac Arrest


VAERS ID: 1065078 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-22
Onset:2021-01-11
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

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

Write-up: Unresponsive; A spontaneous report was received from a Reporter concerning a 25 Years-old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273). The patient''s medical history was not provided. No relevant concomitant medications were reported. On 22-DEC-2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 01-JAN-2021, The patient became unresponsive and died which is serious. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not reported. On 01-JAN-2021, the outcome of the event unresponsive became fatal. patient died.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1065394 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / OT

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

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

Write-up: Died; A spontaneous report was received from a consumer on a social media, concerning a 58-years-old female patient, unknown race and ethnicity, who was administered Moderna''s COVID-19 vaccine (mRNA-1273), and died. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unknown date, prior to the onset of the event, the patient received dose of mRNA-1273 (Lot number: unknown), for the prophylaxis of COVID-19 infection. On 17-Feb-2021, social media interaction was posted concerning a death of a patient on an unknown date after receiving Moderna vaccine. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on an unknown date. The cause of death was not provided. Plans for autopsy were not provided.; Reporter''s Comments: Very limited information regarding the event has been provided at this time and is insufficient for causality assessment. The cause of death was not provided. Plans for autopsy were not provided.; Sender''s Comments: US-MODERNATX, INC.-MOD-2021-018302:Same Reporter; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1065507 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-23
Onset:2021-01-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027C20A / 1 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Fluid intake reduced, Hypophagia, Pain
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: YES
Current Illness: DEMENTIA
Preexisting Conditions: DEMENTIA
Allergies:
Diagnostic Lab Data: NKA
CDC Split Type:

Write-up: EXTREME PAIN, STOPPED EATING/DRINKING -- STARTED MORPHINE


VAERS ID: 1065543 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-01-15
Onset:2021-02-14
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Platelet transfusion, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: NKDA
Diagnostic Lab Data: not available.
CDC Split Type:

Write-up: It was reported to staff that this gentleman suffered thrombocytopenia following his vaccine, a platelet infusion was done and he expired on 2-14-21


VAERS ID: 1065712 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-14
Onset:2021-02-18
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain upper, Asthenia, Confusional state, Death, Dyspnoea, Hypotension, Neck pain
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic 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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Arthritis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes Mellitus, CA Bladder
Allergies:
Diagnostic Lab Data: A copy of the medical record and lab tests from the hospital was requested.
CDC Split Type:

Write-up: Patient started feeling weak, stomach pain, neck pain, respiratory problems, confusion, low blood pressure which led to death on February 21, 2021, 7 days after the vaccine was given.


VAERS ID: 1065719 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-18
Onset:2021-02-22
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Feeling abnormal, Headache, Musculoskeletal stiffness, Nausea, Pyrexia, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Arthritis (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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

Write-up: My grandpa got his second covid vaccine on Thursday. Saturday he complained of stiff neck. Sunday he had low grade fever, nausea and vomiting, chills, and mild headache. He was feeling bad enough to call squad at 3 pm. The paramedics did evaluation and thought he was just experiencing normal side effects from vaccine and felt no need to transport to hospital so my grandpa decided to stay home and just rest. At 2 am that same night he went into cardiac arrest and was not able to be brought back


VAERS ID: 1065979 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Texas  
Vaccinated:2020-12-01
Onset:2021-01-20
   Days after vaccination:50
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / UN

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

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

Write-up: No known side effects; postmortem Covid-19 test negative Date of death: 02/12/2021


VAERS ID: 1066199 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-08
Onset:2021-03-01
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 15M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Anion gap increased, Aspartate aminotransferase increased, Blood albumin decreased, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood calcium increased, Blood chloride normal, Blood creatine phosphokinase MB, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase increased, Blood glucose increased, Blood potassium normal, Blood sodium normal, Blood urea increased, Bradycardia, Carbon dioxide decreased, Death, Epinephrine, Full blood count, Globulins increased, Glomerular filtration rate decreased, Laboratory test, Malaise, Metabolic function test, Mydriasis, Myocardial necrosis marker, Myoglobin blood increased, Protein total normal, Pulse absent, Pupil fixed, Resuscitation, Syncope, Troponin I increased, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (narrow), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (narrow), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Multiple Vitamins(multivitamin) tablet 1 tablet by mouth once a day aspirin(aspirin) 81 mg tablet,delayed release (DR/EC) 1 tablet once a day ibuprofen(ibuprofen) 200 mg capsule 1-2 capsule by mouth at bedtime as needed carvedilol(carvedi
Current Illness: Per EMS report patient had been having diarrhea and vomiting for the last 3 to 4 days.
Preexisting Conditions: Hyperlipidemia (disorder) Generalized osteoarthritis (disorder) Hypothyroidism (disorder) Tinnitus (finding) Benign essential hypertension (disorder)
Allergies: LIPITOR
Diagnostic Lab Data: TROPONIN I 0.478 HH ng/mL 0.000 - 0.056 LG2 03/01/2021 15:47 CKMB 6.7 HH ng/mL 0.0 - 3.6 LG2 03/01/2021 15:47 MYOGLOBIN 4467 H ng/mL 10 - 92 LG2 03/01/2021 15:47 CK (CREATINE KINASE) 470 HH unit(s)/L 39 - 308 LG2 03/01/2021 15:47 SODIUM 142 N mmol/L 136 - 145 CLH 03/01/2021 15:19 POTASSIUM 4.8 N mmol/L 3.5 - 5.1 CLH 03/01/2021 15:19 CHLORIDE 100 N mmol/L 98 - 107 CLH 03/01/2021 15:19 CARBON DIOXIDE 20.0 L mmol/L 21.0 - 32.0 CLH 03/01/2021 15:19 ANION GAP 22 H mmol/L 4 - 15 CLH 03/01/2021 15:19 GLUCOSE 152 H mg/dL 65 - 99 CLH 03/01/2021 15:19 CALCIUM 10.7 H mg/dL 8.5 - 10.1 CLH 03/01/2021 15:19 AST (SGOT) 87 H U/L 0 - 37 LG2 03/01/2021 15:47 ALT (SGPT) 84 H U/L 0 - 65 LG2 03/01/2021 15:47 ALK PHOSPHATASE 105 N U/L 46 - 116 LG2 03/01/2021 15:47 BILIRUBIN, TOTAL 1.8 H mg/dL 0.2 - 1.3 LG2 03/01/2021 15:47 PROTEIN, TOTAL 7.3 N g/dL 6.4 - 8.2 LG2 03/01/2021 15:47 ALBUMIN 3.2 L g/dL 3.4 - 5.0 LG2 03/01/2021 15:47 GLOBULIN 4.1 N g/dL 1.4 - 4.8 LG2 03/01/2021 15:47 BUN (BLOOD UREA NITROGEN) 48 H mg/dL 8 - 23 CLH 03/01/2021 15:19 CREATININE 3.86 H mg/dL 0.70 - 1.30 CLH 03/01/2021 15:19 BUN/CREAT RATIO 12 N RATIO 10 - 20 CLH 03/01/2021 15:19 GFR, FEMALE (CREAT $g0.7) 10 mL/min/1.73m^2 CLH 03/01/2021 15:19 GFR, MALE (CREAT $g0.9) 14 mL/min/1.73m^2 CLH 03/01/2021 15:19 GFR, FEMALE (CREA <=0.7) 47 mL/min/1.73m^2 CLH 03/01/2021 15:19 GFR, MALE (CREAT <=0.9) 44 mL/min/1.73m^2 CLH 03/01/2021 15:19
CDC Split Type:

Write-up: Patient had gotten up to the bathroom and collapsed in the hallway after using the restroom. Patient was unresponsive upon EMS arrival with vomitus coming out of the mouth per the report when they rolled patient over onto his side the emesis was pouring out of his mouth. ER course: Examination. Epinephrine 1 mg IO x4 CBC, CMP, cardiac panel MDM: 1447 patient arrival, per EMS report patient had been sick and vomiting all morning. Bradycardia noted at arrival with rates in the 30s, CPR was initiated patient had received 3 rounds of epi prior to arrival. 1450 CPR continues via the Lucas device, 1 mg epinephrine given IV push 1451 CPR pause rhythm check. CPR resumes 1453 CPR paused for rhythm check. No central pulses, CPR resumed, glucose of 99 per fingerstick 1454 King tube removed. Oral airway placed respirations by BVM. 1 mg epinephrine IV push 1455 CPR pause for both pulse and rhythm check. No central pulses noted. CPR resumes via Lucas 1456 pupils are fixed and dilated bilaterally 1457 CPR pause for pulse and rhythm check. No central pulses noted. CPR resumed via Lucas. 1 mg epinephrine IV push 1459 warm blankets applied. CPR pause for pulse and rhythm check. No central pulses noted. CPR resumed 1501 CPR pause for pulse and rhythm check. No central pulses. CPR resumes 1502 1 mg epinephrine given IV push 1503 CPR pause for pulse and rhythm check. No central pulses noted. CPR resumed via the Lucas device 1506 resuscitation is ceased at this time. Time of death recorded at 1506


VAERS ID: 1066291 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-01-14
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J204 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: nitroglycerin, asa,crestor,lantus,gabapentin,clopidogrel isosorbide, metformin,metoprolol, furosemide, ramipril, pantoprazole, albuterol, ondansetron, methocarbamol, norco, diclofenac Patient was given influenza vaccine by an outside provid
Current Illness: none
Preexisting Conditions: Type 2 diabetes, heart failure, hyperlipidemia, claudication, left hip and knee pain
Allergies: Aspirin, pneumococccal vaccine
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient administered vaccine on 1/14/21 with no reactions noted after 15 minutes. Patient seen for wellness visit on 1/20/21 with no complaints regarding vaccine. Patient died on 1/30/21


VAERS ID: 1066484 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac disorder, Death, Diabetes mellitus, End stage renal disease, Fall, Hypertension, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   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: In-center meds: Doxercalciferol, Cinacalet,Mircera, LiquaCel. Home medication: Amlodipine 5mg 1 daily, ASA 81mg. 1 daily, Atorvastatin 40mg 1 at night, Auryxia 210mg 1 three times a day, Daily Multi-vitamin 1 daily, 6.25mg 2 tablets every
Current Illness: Same as listed in # 12.
Preexisting Conditions: Hypertnesion, Cardiovascular disease, Diabetes Type 2, End Stage Renal Disease, Amputee,
Allergies: Morphine Xarelto
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received vaccination at 14:20 2/26/21. Was observed until discharged at 15:15. Discharged per wheel chair to lobby in alert/stable condition, to wait on bus to take him home. At 18:00 his neighbor heard him fall, could not get patient to answer phone, found him unresponsive. Neighbor called 9-1-1, ambulance personnel could not revive patient. Coroner''s office ruled his death as Natural Causes due to Hypertension, Cardiac disease, Diabetes, ESRD. There were no indication of anaphylactic reaction noted when I questioned the coroner''s office. The Coroner''s office/EMS were aware the patient had received the Moderna COVID 19 vaccination that day.


VAERS ID: 1066715 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-29
Onset:2021-01-21
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Epistaxis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: mvi, albuterol, invanz, macrobid, flomax, metoprolol, enalapril,
Current Illness: copd, prostate ca
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: epistaxis.


VAERS ID: 1066770 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lasix, seroquel, kcl, coreg, eliquis, vasotec,omeprazole, tylenol, rocephin
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: died


VAERS ID: 1066852 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-24
Onset:2021-02-28
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Steroids
Current Illness: None
Preexisting Conditions: Terminal cancer- Hospice care started 1/2021
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: History of terminal cancer, entered hospice care 1/2021, expired 2/28/2021. No reported adverse events from patient or family after receiving vaccine


VAERS ID: 1067036 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen saturation decreased, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   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: Patient was discharged from the hospital to a home on 2/25/21 after a complicated 25 day hospitalization.
Preexisting Conditions: history of hypertension, diabetes mellitus, history of chronic AFib, on anticoagulation, history of MI with a stent, history of BPH, history of dementia, chronic kidney disease, GERD and benign essential tremor, who was at a nursing home
Allergies: lisinopril, metoprolol
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received dose 1 of Moderna Vaccine on 1/14/21 administered by pharmacy. Patient was hospitalized on 1/31/21 due to shortness of breath and diminished O2 sats down to 88%. Patient was in atrial fibrillation. Patient discharged from hospital on 2/25/21 to home. Patient received dose 2 of Moderna Vaccine on 2/25/21 prior to discharge from hospital. Last hospital note stated that patient was pleasant and cooperative with good motivation. Patient passed away after discharge from the hospital on 2/26/21. Patient''s son called the hospital to report his passing.


VAERS ID: 1067125 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   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: was reported to staff at Health Department that client passed away hours after receiving Moderna vaccine, also reported that client had multiple health conditions.


VAERS ID: 1067177 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-02-20
Onset:2021-02-27
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Dizziness, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   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:
Current Illness:
Preexisting Conditions: diabetes, hypertension, hypothyroidism, osteoporosis, chronic kidney disease
Allergies: actonel, aspirin, bextra, celebrex, iodine, novacaine, penicillin, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had sudden death 1 week after 2nd COVID vaccine. Had complained of dizziness throughout the week leading up to it.


VAERS ID: 1067358 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-23
Onset:2021-01-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, COVID-19, COVID-19 pneumonia, Cough, Dyspnoea, Emotional distress, Malaise, Pneumonia, Rales, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Depression (excl suicide and self injury) (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tessalon Perles 100 mg Tivicay 50mg ibuprofen 400mg cimduo 300mg peridex 0.12% mouthwash augmentin 500mg-125mg zyrtec 10mg Flonase allergy relief 50mcg diclofenac 1% topical gel
Current Illness: Mild respiratory symptoms with cough
Preexisting Conditions: HIV Obesity
Allergies: Acetaminophen
Diagnostic Lab Data: 1-29-2021- SARS-CoV02 viral RNA COVID-19 test 2/01/2021- test result positive
CDC Split Type:

Write-up: 1-25-2021- Phone call: pt had cold and cough prior to vaccine. cough worsened 1-28-2021 Phone call: pt requesting provider visit, cough is same and taking tessalon pearls 1-29-2021 Provider in office visit: pt complain of cough and SOB for 6 days. Getting worse. Temp 101.2, pulse ox 87%, BP 128/70. level of distress- leaning forward to breath. appeared ill. diffuse rales throughout both lung fields, more at bases. Diagnosis Pneumonia due to COVID 19 virus. Sent to ER


VAERS ID: 1068882 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-29
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Other       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? 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: Son stated that patient was doing well, still working and driving places. He stated that he called his son and stated that he wasn''t feeling well and died shortly after that.


VAERS ID: 1068885 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-15
Onset:2021-02-17
   Days after vaccination:33
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Decreased appetite, Fatigue, Illness, Incomplete course of vaccination, Insomnia, Lethargy, Malaise, Nocturia, Pollakiuria
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Medication errors (narrow), Hypoglycaemia (broad)

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

Write-up: DEATH Narrative: PRIOR TO DEATH, spoke with pt''s daughter and she reported that pt is unable to keep his appt for the second Covid vaccine appt because is sick today. Per daughter, pt has been lethargic, not enough sleep last night because of frequent urination at least every 30 to 45 minutes looks exhausted and with poor appetite. Pt has not been drinking fluids at least 6 to 8 glasses a day and daughjter tries to make sure pt drinks fluids, the best he can. Per daughter, pt''s vitals signs are as follows: BP: 93/48mmhg PR: 93/min. Temp: 98.1 F and O2 sat: 95%.


VAERS ID: 1068887 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-06
Onset:2021-02-13
   Days after vaccination:38
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: UNSURE DETAILS OF EVENT, NO DOCUMENTATION IN PROGRESS NOTES


VAERS ID: 1068888 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   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


VAERS ID: 1068357 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-13
Onset:2021-02-13
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension
Preexisting Conditions: Medical History/Concurrent Conditions: Prostate cancer
Allergies:
Diagnostic Lab Data: Test Date: 20210119; Test Name: Blood pressure; Test Result: Inconclusive ; Result Unstructured Data: 133/84 mmHG
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: No pulse and no heart beat; couldn''t wake him up; passed away; A spontaneous report was received from a daughter concerning a 84-year old, male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) experienced no pulse or heartbeat, couldn''t wake him up and passed away. The patient''s medical history, as provided by the reporter, included high blood pressure and prostate cancer. No relevant concomitant medications were reported. On 19 Jan 2021, the patient had a blood pressure reading of 133/84 at a cardiology visit. On 13 Feb 2021, approximately 3 hours prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (batch number 031M20A) intramuscularly for prophylaxis of COVID-19 infection. On 13 Feb 2021 at 3:30 pm, the patient could not be woken up and was found with no pulse or heartbeat. Action taken with the drug in response to the events was not applicable. The outcome of the events, no pulse or heartbeat and couldn''t wake him up, were not provided. The patient died on 13 Feb 2021. The cause of death was unknown.; Reporter''s Comments: Very limited information regarding this event/s has been provided at this time. The patient''s medical history of high blood pressure and prostate cancer remains the risk factors. The cause of death was unknown. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1068564 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-26
Onset:2021-02-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac death, Death, Myocardial infarction
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amoxicillin 500mg-potassium clavulanate 125mg tablet; aspirin 81mg; atorvastatin 40mg; carvedilol 12.5mg; clopidogrel 75mg; enalapril maleate 20mg tablet; furosemide 40mg tablet; mupirocin 2% topical ointment; pantoprazole 20mg tablet; pota
Current Illness: unknown
Preexisting Conditions: chronic kidney disease stage 3; congestive heart failure; diabetes; hypertension; hyperlipidemia; morbid obesity; bilateral paresis of lower extremity; peripheral edema; sleep apnea; stented artery; history of malignant neoplasm of prostate
Allergies: nkda
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: On 3/2/2021, clinic was notified by patient''s family that patient had deceased on 2/28/2021 from a heart attack. Unsure of any relation to the Moderna vaccine but reporting for due diligence.


VAERS ID: 1068814 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-02-16
Onset:2021-02-25
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007NCOA / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   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: Allopurinol; gemfibrosil; indomethacin; lisinopril
Current Illness: none
Preexisting Conditions: Gout
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: 9 days after vaccination, the patient was found deceased in his home, sitting on his couch. Determined to be due to pulmonary embolism.


VAERS ID: 1068890 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-13
Onset:2021-02-11
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Spinal operation
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: death Narrative: unclear of details, s/p spine surgery on 2/2/21 and discharged on 2/6/21


VAERS ID: 1068901 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-30
Onset:2021-02-21
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Aortic dissection, Aortitis, Arteritis coronary, Cardioversion, Chest pain, Computerised tomogram, Computerised tomogram normal, Death, Echocardiogram, Electrocardiogram, Electrocardiogram normal, Fatigue, Inflammation, Laboratory test, Pain in jaw, Pulse absent, Red blood cell sedimentation rate normal, Respiratory arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vasculitis (narrow), Osteonecrosis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prednisone BP medication
Current Illness: COVID prior to vaccination - still having symptoms SOB, Tired, foggy head -thinking
Preexisting Conditions: GCA Arthritis
Allergies:
Diagnostic Lab Data: 2/17-2/19 hospital admit Medical Center Labs, CT, Echo 2/21 EMTs conducted EKGs
CDC Split Type:

Write-up: ER admit for CP and Jaw pain, exhaustion, Aortic arteritis normal SED rate found on CT scan hospital admit IV medications required Solumedrol and Actemra questionable how much medications received d/t IV''s not working. Released from care on 2/19 with prednisone . Symptoms still present off and on. 2/21 922pm CP Jaw Pain severe EMT''s called EKG done reported no heart attack, pain better, EMTs left. 10/15 severe Pain collapsed with no pulse and no breathing, EMTs returned unable to obtain a shock-able rhythm time of death pronounced. reason for death on certificate Aortitis - hospitalist thinks aortic dissection d/t severe inflammation


VAERS ID: 1068931 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-02-17
Onset:2021-02-28
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Death, Haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bymetanide (1MG tablet) 1x daily Lisinopril (10MG tablet) 1x daily Terazosin (10MG tablet) 1x daily
Current Illness: No other illnesses. He spent six days at a nearby hospital last week. Came home Thursday, February 25, 2021, as his blood work indicated that he had stopped bleeding and was stable. Per family, "he was in good spirits Friday and Saturday which started to change Sunday morning." He passed way in his sleep sometime late Sunday night or very early Monday morning. I believe his date of death will be 3/1/2021.
Preexisting Conditions: Diverticulitis Spinal Stenosis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Case passed away on 2/28/21. During post vaccination monitoring, case did not have any adverse reactions. When writer spoke to him on 2/26/21 to schedule his second dose, he sounded well.


VAERS ID: 1068963 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-17
Onset:2021-02-18
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-26
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cranberry Tablet, Ferrous Sulfate, Levothyroxine, Metoprolol, Mirtazapine, Omeprazole, Risperidone, Vitamin C, Vitamin D3, Asprin, Alprazolam, Vitamin B Complex, B 12 injections
Current Illness: Adenocarcinoma of colon, hypothyroidism, Alzheimer''s dementia with behaviors disturbance, Anxiety, A Fib, GERD, recurrent UTI, Vitamin B 12 deficiency.
Preexisting Conditions: See Item 11
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: approximately 24 hours post vaccine Patient developed a low grade fever of 99.5 and had increased fatigue. 48 hours later she had decreased neurological functioning. 02/23 she had difficulty swallowing. 02/23 She was admitted to hospice services. 02/26 she passed just before 10 am.


VAERS ID: 1068993 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-01-23
Onset:2021-02-20
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Hypertension, morbid obesity
Allergies: Unknown
Diagnostic Lab Data: Autopsy performed 3/1/2021
CDC Split Type:

Write-up: Spontaneous intracerebral hemorrhage and death on 2/20/2021


VAERS ID: 1069009 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Axillary vein thrombosis, Chest X-ray abnormal, Erythema, Pleural effusion, Pneumonia
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Embolic and thrombotic events, venous (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: None
Current Illness: Swollen hands
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Chest X ray
CDC Split Type: PR-46-21

Write-up: Several days after vaccination his left arm turned red. He was taken to the hospital where he was evaluated and admitted with a diagnosis of left axillary vein thrombosis. A chest X-ray was taken and he presented bibasilar atelectasis and pneumonia with pleural effusions.


VAERS ID: 1069026 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-05
Onset:2021-02-26
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EL3247 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, Endotracheal intubation, Mechanical ventilation
SMQs:, Angioedema (broad), 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: 2021-02-26
   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: Patient admitted with severe COVID on 2/12. Prolonged hospital course requiring intubation. Treated with mechanical ventilation, proning therapy, as well as medical therapy to no avail. Other "significant conditions contributing to death" but not resulting in the underlying cause given in PART I: HTN, T2DM, ESRD, CAD
CDC Split Type:

Write-up: Death Narrative: Family was able to be present at bedside shortly after patient was extubated. Fentanyl bolus given 10-15 minutes prior. Patient passed away soon after endotracheal tube removed. Time of death 10:14am.


VAERS ID: 1069118 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-25
Onset:2021-03-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Dizziness, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: albuterol sulfate, Aspir-81, bethanechol chloride, Bevespi, Aerosphere, cholestyramine (with sugar), citalopram, clopidogrel, duloxetine, famotidine, gabapentin, lisinopril, magnesium oxide, megestrol, metoprolol tartrate, mupirocin, nitrog
Current Illness: First covid vaccine received 1/28/2021 without incident. Had been hospitalized prior to vaccination for intractable vomiting.
Preexisting Conditions: history of acute respiratory failure, carotid artery stenosis, chronic back pain, chronic esophagitis, chronic hyperglycemia, chronic obstructive lung disease, chronic sinusitis, coronary arteriosclerosis, depressive disorder, exposure to SARS-CoV-2, history of polyp of colon, hyperlipidemia, hypertensive disorder, hypoxia, nicotine dependence, non-small cell lung cancer, osteoarthritis, peripheral nerve disease, peripheral vascular disease, tremor
Allergies: codeine, Zithromax
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Within 10 minutes following the second vaccination, patient reported dizziness and nausea, had an episode of vomiting but recovered within 30 minutes. It was reported to our clinic that the patient was found deceased on March 1, 2021 at approximately 10 pm. Cause of death is not determined at this time.


VAERS ID: 1069140 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Bacofleno, Agrenox, Synthroid, Fenofibrate, Busoiron, Lasix, Lipthol, Amiodarone, Clonopin
Current Illness: None reported
Preexisting Conditions: Hypertension, stroke, pacemaker
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-47-21

Write-up: The day after the administration of the vaccine, the fever began, the patient claim that he had no blood pressure problems. He was given acetaminophen every 4 hrs. and vitamin C and D. On February 11, he was stabilized, he had his regular meals without any problem but in the afternoon his temperature rose again and they put him to bed. The patient died that same afternoon around 4:00 pm


VAERS ID: 1069316 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-02-12
Onset:2021-02-21
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: death


VAERS ID: 1069647 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-19
Onset:2021-02-21
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Chills, Condition aggravated, Death, Decreased appetite, Depressed level of consciousness, Fatigue, Lethargy, Loss of consciousness, Pyrexia, Respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Furosemide, Midodrine, Amiodarone, Escitalopram, Aspirin, Finasteride, Tamsulosin, Rosuvastatin, Potassium Chloride, Oxycodone, Budesonide, Albuterol, Alprazolan
Current Illness: s/p CABG with valve replacement (1/28/21) with slow recovery (in ICU 2 weeks)
Preexisting Conditions: COPD, prostatitis, Celiac disease, arthritis, LBP
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Beginning in the evening 2/19/21, fever/chills/fatigue; worsening of symptoms 2/20/21 with lethargy/lack of appetite/weakness; unable to arouse on 2/21/21 then breathing stopped, patient''s spouse called 911 performed CPR, EMS continued for 15 min then while in ambulance to hospital where he was pronounced dead. Official time of death 2:20pm


VAERS ID: 1069685 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Death, Dyspnoea, Hypopnoea, Pallor
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: allopurinol, duloxetine, glipizide, melatonin, torsem
Current Illness: COVID 19
Preexisting Conditions: heart failure, stage 4 KD, SOB, malnutrition, dysphagia, muscle weakness, unsteady, GERD, metabolic encephalopathy
Allergies: Morphine
Diagnostic Lab Data: none, resident was a DNR/DNI
CDC Split Type:

Write-up: 3/2/21 became SOB, treated with oxygen and head of bed up in bed, only at dessert and drank supplement, for evening meal, no pain noted. 3/3/21 staff helped get her up in morning, went to weight room to take her weight, she then appeared to be struggling to breath, she was brough back to her room and the aides summoned nurse for assessment, was put back into bed, nurse noted poor color and shallow breathing, resident passed away shortly after that.


VAERS ID: 1069728 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-02
Onset:2021-03-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dizziness, Loss of consciousness, Resuscitation, Seizure like phenomena, Unresponsive to stimuli
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), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Everything was done in ED in the hospital on early morning of 3/3/2021
CDC Split Type:

Write-up: Patient Started having dizziness, feeling faint at around midnight on 3/3/2021. He then lost consciousness, had seizure-like activity and was taken to hospital via EMS. In the hospital patient was unresponsive and received resuscitation attempts unsuccessfully. Per family, after about 45 minutes, code was called and patient expired.


VAERS ID: 1069830 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-08
Onset:2021-01-25
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Basophil count normal, Basophil percentage, Brain herniation, Cerebral haemorrhage, Cerebral mass effect, Computerised tomogram head abnormal, Death, Encephalitis, Eosinophil count increased, Eosinophil percentage, Granulocyte count, Granulocyte percentage, Haematocrit decreased, Haemoglobin decreased, Imaging procedure artifact, Lymphocyte count, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Meningioma, Monocyte count increased, Monocyte percentage abnormal, Neutrophil count increased, Neutrophil percentage, Platelet count normal, Red blood cell count decreased, Red cell distribution width normal, Subdural haemorrhage, Vasogenic cerebral oedema, White blood cell count increased
SMQs:, Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Noninfectious encephalitis (narrow), Accidents and injuries (broad), Hyponatraemia/SIADH (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: aspirin 81 mg daily; Tylenol arthritis 650 mg daily; calcium and vit d; meclizine 12.5 mg daily; Fosamax 70 mg every 7 days; Toprol 50 mg ext release daily; cozaar 50 mg daily; levothyroxine 100 mcg daily; crestor 10 mg MWF; plaquenil 400
Current Illness:
Preexisting Conditions: arthritis, osteoporosis, prior heart stent
Allergies: NSAIDS
Diagnostic Lab Data: ED visit with labs: Abnormal Result Collected: 1/25/2021 19:41 Last updated: 1/25/2021 19:58 Status: Final result WBC: 13.4 K/uL [Ref Range: 4.8 - 10.8] RBC: 3.65 M/uL [Ref Range: 4.20 - 5.40] HEMOGLOBIN: 11.3 g/dL [Ref Range: 12.0 - 16.0] HEMATOCRIT: 34.6 % [Ref Range: 36.0 - 46.0] MCV: 94.8 fL [Ref Range: 84.0 - 103.0] MCH: 31.0 pg [Ref Range: 27.0 - 34.0] MCHC: 32.7 g/dL [Ref Range: 30.0 - 35.0] RDW: 11.9 % [Ref Range: 11.0 - 14.5] RDW-STDEV: 41.1 fL [Ref Range: 37.0 - 54.0] PLATELETS: 230 K/uL [Ref Range: 140 - 440] MPV: 8.8 fL [Ref Range: 8.9 - 12.8] NEUTROPHILS: 70 % [Ref Range: 42 - 75] LYMPHOCYTES: 12 % [Ref Range: 24 - 44] MONOCYTES: 9 % [Ref Range: 2 - 10] EOSINOPHILS: 7 % [Ref Range: 0 - 7] BASOPHILS: 1 % [Ref Range: 0 - 1] IMMATURE GRANULOCYTES: 0 % [Ref Range: 0 - 2] NEUTROPHIL ABSOLUTE: 9.47 K/uL [Ref Range: 2.00 - 8.00] LYMPHOCYTE ABSOLUTE: 1.56 K/uL [Ref Range: 1.20 - 4.00] MONOCYTE ABSOLUTE: 1.23 K/uL [Ref Range: 0.10 - 0.60] EOSINOPHIL ABSOLUTE: 0.99 K/uL [Ref Range: 0.00 - 0.70] BASOPHILS ABSOLUTE: 0.13 K/uL [Ref Range: 0.00 - 0.20] IMMATURE GRANULOCYTES ABSOLUTE: 0.06 K/uL [Ref Range: 0.00 - 0.10]
CDC Split Type:

Write-up: From CT Scan in ED at 7:40 pm on 1/25/2021 -- There is a large intraparenchymal hemorrhage with Surrounding vasogenic edema within the left occipital lobe. There is additional subdural hemorrhage layering along the left frontal, temporal and parietal convexity which may be decompressing from the area of intraparenchymal hematoma. No visualized intraventricular hemorrhage.There is some trace hemorrhage layering along the left tentorium cerebelli. Severe associated mass effect with left-to-right midline shift of 2.1 cm. There is subfalcine and downward transtentorial herniation with complete effacement of the basilar cisterns. Evaluation of the craniocervical junction is limited due to beam hardening artifact. Near-complete effacement of the left lateral ventricle. No head trauma or fall. Deceased 1/26/2021


VAERS ID: 1069938 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-04
Onset:2021-02-20
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown blood thinner
Current Illness: unknown, none listed on pre checklist
Preexisting Conditions: unknown, takes blood thinner
Allergies: nkma
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: expired at Hospital


VAERS ID: 1070005 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-07
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 AR / 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: 2021-02-03
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension, CAD, Hypothyroidism, Hypercholesterolemia
Preexisting Conditions: Hypertension, CAD, Hypothyroidism, Hypercholesterolemia
Allergies: NKA
Diagnostic Lab Data: Positive Covid Test
CDC Split Type:

Write-up: Patient contracted Covid some period of time after receiving the vaccine.


VAERS ID: 1070038 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-01-14
Onset:2021-01-22
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plavix Aspirin Lisinopril Diazepam Morphine Sulfate Lyrica Spiriva Respinate Proair Air
Current Illness: COPD
Preexisting Conditions: COPD Vascular Disease Chronic Pain Opioid Dependence HTN
Allergies: No known allergies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Client passed away 8 days after being vaccinated. It is unknown if it occurred from the vaccine or other comorbidities.


VAERS ID: 1070040 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-10
Onset:2021-02-22
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-24
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Duloxetine, LIsinopril/Hctz, Oxycodone 10/325, Gabapentine 600
Current Illness: Thyroid nodule
Preexisting Conditions: Diabetes, HTN, Depression, chronic pain
Allergies: Morphine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital 2/22/21


VAERS ID: 1070051 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-06
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 AR / IM

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin, Pennsaid, Carbidopa-Levodopa
Current Illness: HTN, Aortic Valve Disorder, Coronary Atherosclerosis of Native Coronary Artery, Hyperlipidemia, Aortic aneurysm
Preexisting Conditions: HTN, Aortic Valve Disorder, Coronary Atherosclerosis of Native Coronary Artery, Hyperlipidemia, Aortic aneurysm
Allergies: Unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown


VAERS ID: 1070562 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-01
Onset:2021-03-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, 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: 2021-03-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Relatively severe aortic valve stenosis, bradycardia, orthostatic hypotension and Parkinson''s disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The coroner called Dr. on 3.2.2021 to advise that he had a witnessed collapse and Mr. was taken to the ED where he was pronounced.


VAERS ID: 1070937 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-02-18
Onset:2021-03-03
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   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: Unwitnessed Cardiac arrest. ACLS protocols were performed. Cessation of resuscitation was called in the field by Dr.


VAERS ID: 1071117 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-01-31
Onset:2021-02-07
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Haemorrhage, International normalised ratio, Urinary tract infection, Urine analysis
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ANTICOAGULATION
Current Illness: Anticoagulant therapy (Long term history of anticoagulation therapy.)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210210; Test Name: INR; Test Date: 20210210; Test Name: urine analysis; Result Unstructured Data: diagnosed with a UTI
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; UTI; Abnormal bleeding; A spontaneous report was received from a healthcare professional concerning a patient who received the Moderna COVID-19 Vaccine (mRNA-1273) and experienced abnormal bleeding, UTI, and passed away. The patient''s medical history included a long term history of anticoagulation therapy. Concomitant product use included anticoagulation therapy. On 31Jan2021 prior to the onset of the events the patient recieved their first dose of mRNA-1273 (Lot number:not reported) intramuscularly for prophylaxis of COVID-19 infection. On 07Feb2021, the patient complained of abnormal bleeding. Patient was seen at clinic on 10Feb2021 and was diagnosed with a UTI and given antibiotics. An INR was also completed that day due to patient having a long term history of anticoagulation therapy. Results of that showed the INR to be 12. Prior to vaccination, patient''s INR was normal and no changes to medications and diet were made after vaccination and prior to complaint starting. On 12Feb2021 the patient passed away. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 12Feb2021. The cause of death was unknown. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns an 82 year old male patient, with history of long term anticoagulation therapy (unknown indication), who experienced a fatal event of death and abnormal hemorrhage, 13 days after receiving second dose of mRNA- 1273 (Lot# Unknown). Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071120 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-02-12
Onset:2021-02-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Atrial fibrillation, Atrial flutter, Heart rate increased
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: TRAVATAN
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: Atrial fibrillation; Feeling fluttery; Heart rate was racing and was increasing, went up to 175 just sitting; A spontaneous report was received from a consumer concerning a 64-year-old female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced atrial fibrillation, feeling fluttery, and heart rate was racing and was increasing, went up to 175 just sitting. The patient''s medical history was not provided. Concomitant medications included Travatan for glaucoma. On 12 Feb 2021, prior to the onset of the events, the patient received the first of two planned doses of mRNA-1273 (lot/batch: 030M20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. On 12 Feb 2021, five hours after vaccination, the patient experienced a fluttery feeling, heart rate was racing and was increasing, heart rate went up to 175 just sitting. She took an EKG on her watch and it was atrial fibrillation. When she was sleeping, her heart rate was at 102 or the 90s, normally it would be in the 60s. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not reported. At the time of this report, the outcome of the events, atrial fibrillation, feeling fluttery, and heart rate was racing and was increasing, went up to 175 just sitting, was unknown.; Reporter''s Comments: This case concerns a 64 year old female patient, who was on hospice care experienced a fatal event of death, 1 day after receiving second dose of mRNA- 1273 (Lot# 030M20A). Very limited information regarding this event has been provided at this time. Further information has been requested.


VAERS ID: 1071128 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2021-01-04
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unresponsive; A spontaneous report was received from Pfizer concerning a 32-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 28 DEC 2020, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 04 JAN 2021, at 7:20 am, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 04 Jan 2021. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: This case concerns a 32-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The cause of death was unknown. Plans for an autopsy were not provided. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071129 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-01-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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: Unresponsive; A spontaneous report was received from Pfizer concerning a 43-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 08 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 09 JAN 2021, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 08 Jan 2021. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071130 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-28
Onset:2020-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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:
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: Unresponsive; A spontaneous report was received from Pfizer concerning a 45-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 28 Dec 2020, approximately 24 hours prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 29 Dec 2020, the patient was found deceased at home. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 29 Dec 2020. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: Very limited information regarding this event has been provided at this time.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071131 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-31
Onset:2020-12-31
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unresponsive; A spontaneous report was received from Pfizer concerning a 50-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 31 Dec 2020, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) intramuscular for prophylaxis of COVID-19 infection. On 31 Dec 2020, the patient died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 31 Dec 2020. The cause of death was unknown. Plans for an autopsy were unknown.; Reporter''s Comments: This case concerns a 51 year old, female patient, who experienced an unexpected event of Death, after receiving 1st dose of mRNA- 1273 (Lot# unknown). Very limited information regarding this event has been provided at this time. There is no contact information and no further follow up information is expected.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071132 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-01-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
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: chronic hypoxia respiratory failure; Unresponsive; A spontaneous report was received from Pfizer concerning a 51-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and had developed hypoxia a sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 07 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 07 Jan 2021, around 6:00 pm, the patient became increasingly hypoxic. He was transported to the hospital for acute on chronic hypoxia respiratory failure. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 12 Jan 2021 at 11:25pm. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: Very limited information regarding these events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


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