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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

This is page 8 out of 48

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VAERS ID: 1071133 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-08
Onset:2021-01-08
   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: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
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 52-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 08 Jan 2021, approximately 2 hours prior to the onset of event, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient was monitored for the appropriate amount of time by nursing staff, following vaccination. 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 at 2:15pm. The cause of death was not provided/unknown. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: This case concerns a 52-year old, female patient, who experienced a sudden death 1 day after administration of first dose of mRNA-1273. The cause of death was not provided. Plans for an autopsy were 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: 1071134 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-23
Onset:2021-01-08
   Days after vaccination:16
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: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (no reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a reporter concerning a 56-year old female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and had experienced death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 23 Dec 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 08 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. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071135 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
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: 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: 2021-01-09
   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 56-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 08 Jan 2021, 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 was found deceased in her home. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 09 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: 1071136 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-04
Onset:2021-01-11
   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: Pyrexia, Respiratory failure, Sepsis, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: sepsis; respiratory failure; Fever; Unresponsive; A spontaneous report was received from Pfizer concerning a 56-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced respiratory failure, sepsis, fever and sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 04 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 11 Jan 2021, the patient began to have a fever. She was sent to the emergency room for evaluation. That evening, she died. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 11 Jan 2021. The cause of death was reported as respiratory failure and sepsis. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: This is a case of 56-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sepsis, fever, respiratory failure and sudden death. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Respirtory Failure; Sepsis


VAERS ID: 1071137 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2020-12-30
Onset:2021-01-04
   Days after vaccination:5
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: 2021-01-04
   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 58-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 30 Dec 2020, 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, 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 unknown/not reported. 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: 1071138 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
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: 2021-01-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
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: Sudden death; A spontaneous report was received from Pfizer concerning a 60-year old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 05 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 08 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 unknown/not reported. Plans for an autopsy were unknown/not provided.; Reporter''s Comments: Very limited information regarding the event has been provided at this time and is insufficient for causality assessment. Further information has been requested.; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1071139 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-13
   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: 2021-01-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (no reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Sudden death; A spontaneous report was received from Pfizer concerning a 60-year old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced sudden death. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 12 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (lot/batch: unknown) for prophylaxis of COVID-19 infection. On 13 Jan 2021, the patient was found to be deceased at 3:00 am. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 13 Jan 2021. The cause of death was unknown/not reported. 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: 1071300 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Ohio  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

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

Write-up: Died; A spontaneous report, was received from a consumer on a social media, concerning a 38-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 of death has been provided at this time. No further information will be available.; Sender''s Comments: MODERNA, INC.-MOD-2021-018380:Same reporter; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1071367 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-02-11
Onset:2021-02-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood pressure measurement, Cardiac failure, Death, Electrocardiogram, Fatigue, Feeling cold, Hyperhidrosis, Hypersomnia, Hypotension, Illness, Mobility decreased, Tremor
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: COUMADIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Heart failure, congestive
Allergies:
Diagnostic Lab Data: Test Date: 202101; Test Name: Blood Pressure; Result Unstructured Data: Low; Test Date: 202101; Test Name: EKG; Result Unstructured Data: Normal
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Blood pressure went down until he died; Couldn''t hear his heartbeat; neck was sweating; He was cold; Couldn''t get up; Death; Sick; immediately very tired; he was tired; Hands were shaking; Slept for too long; A spontaneous report was received on 18 Feb 2021 from a consumer concerning a 81-years-old, male patient who received Moderna''s COVID-19 vaccine and developed immediately very tired, hands were shaking, neck was sweating, was cold, sick, couldn''t get up, couldn''t hear his heartbeat and blood pressure went down until he died. Patients'' medical history, as provided by patient''s spouse, was emergency room(ER) admission in November 2020 because he had a congested chest (he had fluid around his heart). At that time, they gave him pills for kidney function. Other concomitant medication reported was Coumadin, blood thinner. Two weeks before receiving the vaccine, patient''s EKG was normal. On 11 Feb 2021, in the morning, patient received their first of two planned doses of mRNA-1273(BATCH/LOT # 007M20A) probably in the right arm for the prophylaxis of COVID-19 infection. On 11 Feb 2021, approximately after 15 minutes of receiving vaccine, they left and patient was immediately very tired, his hands were shaking. So, patient''s spouse made them down sleep for too long. On Friday, 12 Feb 2021 she tried to pick him up, but he was tired, exhausted, and sick. On Saturday, 13 Feb 2021, she brought him a coffee and he couldn''t hold it because his hands were shaking, so she gave him the coffee and then made him pee on the bed because he couldn''t get up. At lunch time she made him eat something and he fell sleep again. His wife was hanging around him all day and around 7:30pm she realized that he was cold, and his neck was sweating, she couldn''t hear his heartbeat. So, she called emergency services and when they arrived, her husband''s blood pressure went down until he died. Treatment for the events were not provided. Action taken with mRNA-1273 was not applicable. Patient was pronounced dead on 13 Feb 2021 20:00. The cause of death was not provided. The plans for an autopsy were not provided. The events of blood pressure went down until he died and couldn''t hear his heartbeat were fatal. The outcome for the remaining events were unknown.; Reporter''s Comments: This case concerns an 81 year old, male patient, who experienced a serious event of death among others, 2 days after receiving mRNA- 1273 (Lot# 007M20A). 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: 1071618 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-06
Onset:2021-01-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: dupixent, furosemide, klor-con m10, levothyroxine, atenolol,
Current Illness: none
Preexisting Conditions: irregular heart beat
Allergies: biaxin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chills; headache; extreme fatigue; gas or chest pain that was thought to be gas and went away Died 4 days later


VAERS ID: 1071903 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-02-26
Onset:2021-02-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

Administered by: School       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: reported none at time of vaccination
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: reported none at time of vaccination
Diagnostic Lab Data: none known
CDC Split Type:

Write-up: No reported adverse effects after vaccine was administered. Someone reported to our clinic that patient was found dead at home on Sunday


VAERS ID: 1072156 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-22
Onset:2021-02-23
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Anxiety, Blood culture negative, Cardiac disorder, Cardiac failure, Cellulitis, Culture urine negative, Culture wound negative, Depression, Echocardiogram, Haemodynamic instability, Intensive care, Mental status changes, Postoperative wound infection, Pyrexia, Septic shock, Sleep apnoea syndrome, White blood cell count increased
SMQs:, Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: allopurinol 300mg daily aripiprazole 5mg daily cephalexin 500mg q12h cholecalciferol 2000 units daily hydroxychloroquine 200mg 2x daily levothyroxine 125mcg daily presnisone 5mg daily ruxolitinib 15mg 2x daily sertraline 100mg daily valacyc
Current Illness: erythema of face consistent with mild cellulitis recent MOS procedure for skin cancer
Preexisting Conditions: myelofibrosis History of aortic valve replacement in 2014 hx of depression, anxiety
Allergies: amiodarone, doxycycline, penicillin
Diagnostic Lab Data: Blood cultures, wound culture, urine culture - no growth WBC 16.1 on admission ECHO - no vegetation seen on aortic valve
CDC Split Type:

Write-up: Vaccine manufacturer and lot number unknown, vaccine given at alternate location. 2/23/21 8:27 PM: The patient is a 68-year-old male comes to the emergency department by paramedic ambulance for altered mental status that, began at around noon in association fever temp 102.9. PMH of myelofibrosis (on Jakafi and hydroxychloroquine), depression, anxiety, OSA, and history of AVR. Given history of myelodysplasia and Jak inhibitor predisposing to some opportunistic infections most notably viral reactivation with history of HSV and possible bacterial endocarditis he was admitted to the ICU for further monitoring and pressors. Patient has a MOS procedure 14 days prior - Status post MOSs procedure with large wound deficit on forehead -- Does not appear to be overtly infected at the time of admission. ED physician indicated mild facial cellulitis. 2/23/21- WBC 16.1 on admission. ECHO 2/26 indicated - no vegetation visualized. Of note second COVID vaccine 2 days prior to admission. Dr. felt incident was possible cardiogenic shock secondary to COVID vaccine. He did not feel the patient has a source of infection upon admission. Questionable given wounds on forehead Dr. (CMO) review of case- his impression was septic shock with and underlying case of chronic cardiac compromise making the hemodynamics worse


VAERS ID: 1073225 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-02
Onset:2021-02-22
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Ascites, Asthenia, Bacteraemia, Catheter site haemorrhage, Complication associated with device, Condition aggravated, Death, Fall, Haemorrhage, Hip fracture, Hip surgery, Hypotension, Sepsis, Tachycardia
SMQs:, Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (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: Tylenol with codeine, albuterol, aspirin, cetirizine, dialyvite, dilaudid, fluticasone, furosemide, multivitamin, glucosamine, lactulose, lantus, nystatin, omeprazole, spironolactone, tramadol, vitamin e, xifaxan
Current Illness: Chronic Illness with debilitation
Preexisting Conditions: chronic hyponatremia, chronic low back pain, ascites, cirrhosis of liver, non-alcoholic fatty liver, dyslipidemia, diabetes, esophageal varisces. obstructive sleep apnea
Allergies: NSAIDS
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 30 days: Admit 2/8/21-2/13/21 s/p fall with left hip fracture (repaired), severe debility with recurrent falls discharged to SNF. Not doing well postop at the SNF, brought to ED due to failed foley insertion with bright red blood upon arrival to ER febrile, hypotensive, tachycardic, severe sepsis. Gran negative bacteremia likely from chronic ascites, family decided on comfort care and he expired within hours of admission.


VAERS ID: 1073344 (history)  
Form: Version 2.0  
Age: 102.0  
Sex: Female  
Location: Illinois  
Vaccinated:2020-12-30
Onset:2021-01-17
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: cardizem, metformin, dyazide, pottassium, remeron, seroquel
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient died.


VAERS ID: 1073361 (history)  
Form: Version 2.0  
Age: 106.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-25
Onset:2021-02-19
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-02-19
   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: allopurinol, iron, cytomel, duoneb, prilosec, levothyroxine
Current Illness:
Preexisting Conditions:
Allergies: PCN, ASA, Amantadine, IVP dye
Diagnostic Lab Data:
CDC Split Type:

Write-up: passed away


VAERS ID: 1073471 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
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: 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: Hospice care
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Was found deceased a little less than 12 hours following COVID vaccination; A spontaneous report was received from a reporter concerning a 96-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and was found deceased a little less than 12 hours following COVID vaccination. The patient''s medical history included hospice care. No relevant concomitant medications were reported. On an unknown date, prior to the onset of the event, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, the patient was found deceased a little less than 12 hours following COVID vaccination, and he had had some changes over the last two days. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. On an unknown date the patient died. The cause of death was unknown. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 96 year old male patient, who was on hospice care experienced a fatal event of death, after receiving 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: 1073773 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 RA / IM

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

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: galantamine, atorvastatin
Current Illness:
Preexisting Conditions: Alzheimer''s/Dementia, BPH, HLD, HTN, Aortic stenosis, Osteopenia, allergic rhinitis
Allergies: penicillin
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient was found deceased later in the afternoon.


VAERS ID: 1073808 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-04
Onset:2021-03-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   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: Amlodipine, Carvedilol, Aspirin, Atorvastatin, Duolextine, Norco, Gabapentin, Potassium, Flomax, Claritin, Ibuprofen
Current Illness: PTSD, H/O AAA, HTN, Afib, hemiplegia secondary to CVA, depression
Preexisting Conditions: PTSD, H/O AAA, HTN, Afib, hemiplegia secondary to CVA, depression
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Prt was found deceased


VAERS ID: 1073813 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-31
Onset:2021-02-05
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-03-04
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: 2021-02-05
   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: UNCLEAR WHY PATIENT WAS HOSPITALIZED AS LIMITED INFORMATION IN RECORD


VAERS ID: 1073895 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-28
Onset:2021-02-22
   Days after vaccination:25
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

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? 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: Patient passed away after getting the 1st dose of COVID vaccine. He seemed otherwise very healthy.


VAERS ID: 1073902 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-01-29
Onset:2021-02-25
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient seemed otherwise healthy before the vaccination. Patient was hospitalized then shortly passed after getting the 1st dose.


VAERS ID: 1074067 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03M20A / UNK LA / SYR

Administered by: Private       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: albuterol, ammonium lactate cream, eliquis, aspirin, lipitor, clozaril, decadron, fluticasone, zyprexa, zofran, senokot, zoloft, flomax, spiriva
Current Illness: kidney / bladder cancer with extension into soft tissue inferior vena cava clot extending to liver
Preexisting Conditions: atherosclerosis, history of CVA, history of stage 1 squamous cancer of LUL, LU lobectomy, sleep apnea, emphasema, tardive dyskenesia, squamous cell cancer skin, constipation, schizoaffective disorder, hyperlipidemia
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient received Moderna COVID-19 vaccine on 2/25/2021. Patient found dead by family the morning of 2/26/2021. Family requested an autopsy.


VAERS ID: 1074271 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-28
Onset:2021-03-02
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Mental status changes, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-03
   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: furosemide, lactulose, zofran, compazine, spironolactone, tenofovir, advil, on chemotherapy
Current Illness: metastatic Cholangiocarcinoma, cirrhosis
Preexisting Conditions: as above
Allergies: sulfa, cotrimazole
Diagnostic Lab Data:
CDC Split Type:

Write-up: altered mental status, acute on chronic thrombocytopenia, death


VAERS ID: 1074361 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

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

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: Zyrtec HCllOmg. Namenda 10mg, Citalopram 20mg. Temazepan 15m
Current Illness: None
Preexisting Conditions: HBP, dementia, COPD
Allergies: None
Diagnostic Lab Data:
CDC Split Type: PR-49-21

Write-up: General malaise, acetaminophen was given every 6 to 8 hours


VAERS ID: 1074401 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

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

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: Plavix 75mg, lmdur 30mg, Norvasc 2.5mg, Losartan50mg, Xanax 1m
Current Illness:
Preexisting Conditions: HBP, heart disease, colostomy
Allergies: Aspirin, Penicillin, Shell fish
Diagnostic Lab Data:
CDC Split Type: PR-50-21

Write-up: General malaise, acetaminophen was gives every 6 to 8 hours


VAERS ID: 1074599 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-02
Onset:2021-02-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 1 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COPD
Preexisting Conditions: Medical History/Concurrent Conditions: Hospice care
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a other health care professional concerning a 57-year-old, male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patient''s medical history included chronic obstructive pulmonary disease (COPD). Concomitant product use was not provided. On 02 Feb 2021, prior to onset of the events, the patient received his first of two planned doses of mRNA-1273 (Lot number: 043L20A) in the left arm for prophylaxis of Covid-19 infection. 03 Feb 2021, it was reported that the patient died. The patient was not experiencing any symptoms prior to death. He was on hospice care, not hospitalized. No further information was provided. Treatment information was unknown. The cause of death was not reported. Plans for an autopsy were unknown. Action taken with the mRNA-1273 in response to the event was not applicable.; 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


VAERS ID: 1074753 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Rhode Island  
Vaccinated:2021-02-11
Onset:2021-02-20
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   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: Lisinopril 20mg/ HCTZ 25mg
Current Illness:
Preexisting Conditions: HTN, CAD, OAD, Brian Aneurysm, osteoporosis, GERD, post cardiac arrest 1/2021, MI
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt. had a cardiac arrest and expired on 2/20/21.


VAERS ID: 1074784 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-01-14
Onset:2021-01-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: Not applicable
Current Illness: Pneumonia
Preexisting Conditions: Not aware
Allergies: None voiced
Diagnostic Lab Data: See hospital admission record
CDC Split Type:

Write-up: Nurse called clients'' son to remind her of the second dose needed and was informed that client had passed away from Pneumonia the Sunday after she received the vaccine 1/17/2021.


VAERS ID: 1074955 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-02-13
Onset:2021-02-14
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death, Fall, Feeling abnormal, Head injury, Muscular weakness, Respiratory arrest, Resuscitation
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metroprolol, zetia, Multag for AFIB, metformin,lisinopril, Immodium, Atorvastatin, was on a blood thinner but stopped 1/25/21
Current Illness: DX with Covid -19 on Jan 2, 2021, had surgery on Jan 28th, 2021 to remove scar tissue between the bladder and prostate.
Preexisting Conditions: Afib, diabetes, hypertention, blood clotting disorder
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: at midnight client got up to go to the bathroom. His legs became weak and he fell and hit his head on the wall. He called for his wife and said he didn''t feel right. He denied any pain. She called EMSA and he stopped breathing while she was waiting on them. She gave him CPR with instructions from the dispatcher. He was pronounced dead at 1:30am. She has tried to call the clinic 3 times and left messages and no one has called her back, Her PCP told her this needed to be reported .


VAERS ID: 1074982 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Illinois  
Vaccinated:2020-12-29
Onset:2020-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 66
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine, Prilosec, Vasotec, Tylenol, coreg, eliquis
Current Illness:
Preexisting Conditions:
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1075017 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Illinois  
Vaccinated:2020-12-30
Onset:2021-02-09
   Days after vaccination:41
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03K20A / 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: Toprol omeprazole prednisone
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1075042 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-29
Onset:2021-03-04
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1075057 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-25
Onset:2021-02-12
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-05
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: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine Asa 81 ,glipizide Lexapro losartan Prilosec seroquel
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1075090 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-25
Onset:2021-02-23
   Days after vaccination:29
Submitted: 0000-00-00
Entered: 2021-03-05
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: 2021-02-23
   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: Aricept Lexapro lisinopril Toprol vit D Norvasc Seroquel Flomax
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1075296 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-03-02
Onset:2021-03-03
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Do not know
Current Illness: Do not know
Preexisting Conditions: Sleep apnea, blood pressure, obesity Probably other but do not know
Allergies: Do not know
Diagnostic Lab Data: She was taken to County coroner.
CDC Split Type:

Write-up: Patient was found dead this morning.


VAERS ID: 1075349 (history)  
Form: Version 2.0  
Age: 103.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-25
Onset:2021-02-25
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-03-05
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: 2021-02-25
   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: Fosamax chlorthalidone losartan clonidine toprol
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1075354 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-07
Onset:2021-02-26
   Days after vaccination:50
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / -

Administered by: Senior Living       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: Patient passed away within 60 days of receiving a COVID vaccine


VAERS ID: 1075363 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: TBD
Current Illness: NA
Preexisting Conditions: DM Type II
Allergies: TBD
Diagnostic Lab Data: Coroner report/autopsy
CDC Split Type:

Write-up: Death due to Moderna 2nd dose, pulmonary thromboembolism


VAERS ID: 1075388 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-02-15
Onset:2021-02-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood lactic acid decreased, Burning sensation, C-reactive protein normal, Cardio-respiratory arrest, Computerised tomogram head normal, Death, Fatigue, Herpes zoster, Hypoaesthesia, Loss of consciousness, Metabolic function test normal, Myalgia, Neck pain, Pain in extremity, Pyrexia, Rash pruritic, Resuscitation, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (narrow), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Arthritis (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Opportunistic infections (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-27
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, allopurinol, amlodipine, ezetimibe, furosemide, latanoprost, lisinopril, loratadine, mesalamine, metformin, metoprolol, mometasone, multivitamin, omeprazole,
Current Illness: none
Preexisting Conditions: CLL, Essential hypertension, NIDMM, hyperlipidemia, diverticulosis,
Allergies: Dust, Penicillian
Diagnostic Lab Data: CT of head - neg CBC - WBC 24.8 - consistent with CLL CMP - WNL CRP - 0.9 Lact Acid - 1.43 Labs were not collected on 2nd visit
CDC Split Type:

Write-up: The day after the shot she developed fever for 2 days as high as 101. She developed a pruritic burning rash to posterior right leg extending down the lateral lower leg. She had fatigue and myalgias. Diagnosed with shingles on 2/23. and informed to not receive the 2nd vaccine. She presented to the Emergency room on 2/27 with fatigue, numbness right side of the face, no reports of shortness of breath or chest pain. Ambulated in to ER. After her work up she was discharged home - she present back to the ER within 30 minutes. PTA arrival at the ER for the 2nd time - she complained of left neck and arm pain - then went unconscious. She arrived to the ER in full arrest - pronounced deceased after resuscitation efforts were not effective


VAERS ID: 1075608 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-03
Onset:2021-03-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Hx of Ca of the breast, last chemotherapy treatment 2/15/21
Preexisting Conditions: Breast cancer
Allergies: Denies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient waited 15 mins after covid vaccination on Wednesday 3/3, cleared by EMT to leave. I was notified by nurse at the senior building where patient resides that she had expired Thursday evening at home. Paramedics were called. No other additional information.


VAERS ID: 1075639 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-02-27
Onset:2021-03-01
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood glucose increased, Cardiac arrest, Coma scale normal, Diarrhoea, Endotracheal intubation, Fall, General physical health deterioration, Hyperkalaemia, Hypoxia, Incoherent, Intensive care, Lactic acidosis, Leg amputation, Multiple organ dysfunction syndrome, Peripheral coldness, Pulse absent, Shock, Skin exfoliation, Surgery, Tremor
SMQs:, Torsade de pointes/QT prolongation (broad), Severe cutaneous adverse reactions (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant 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 (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Pseudomembranous colitis (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Desmopressin levothyroxine Atorvastatin trulicity once a week
Current Illness: Hypothyroidism Diabetes Morbid obesity Hyperlipidemia Diabetes insipidus
Preexisting Conditions: Diffuse large B Cell lymphoma status post allogeneic BMT 5/3/2019
Allergies: Citrus Peanuts
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient is a 53 year old man with a past medical history of follicular lymphoma diagnosed in 2008, more recently with DLBCL with CNS involvement (involving hypothalamus; dx 8/2018; s/p HD MTX, s/p BMT- followed by Dr.), autoimmune hepatitis, obesity, adipic DI, central hypothyroidism and type 2 DM who presented to Hospital via EMS after a fall at home with multisystem organ failure leading to intubation in the ED and subsequent transfer to Oncology ICU for further management. He was in his usual state if health until Sunday. On Saturday he got COVID vaccine at 4pm, that evening he had no issues. Sunday night around 10pm he didn''t make complete sense and his wife was concerned because of his history of DM and treated CNS lymphoma. BG was 320-340 at that time. Monday he was good and Monday night he started to have shaking of his left hand. Tuesday he had one episode of diarrhea. Later he was more shaky in the shower and he started to fall and his wife was unable to grab him and he slid down the wall and could not get up. Family was called to help and he was not making sense so they called EMS. Wife reports that he was down approximately 3 hours before EMS was able to get him up. In EMS he was noted to have a large area of skin desquamation from the right posterior knee to the ankle. His GCS was 15. He had stable blood pressure and heart rate. He was hypoxia to the 50s and oxygen was applied. In the ED he was found to be in multisystem organ failure and was intubated and had rapid progression of shock requiring Epinephrine, Levophed and Vasopressin. Crash lines were placed and he was sent to hospital. Upon arrival he was noted to have a cold pulseless right lower extremity and surgery was called. He was evaluated by Trauma Surgery, Orthopedic surgery and Vascular surgery and eventually underwent above the knee amputation. Unfortunately they were not able to remove all nonviable tissue and he continued to deteriorate. He was taken level 1 back to the OR and an additional 10 cm of nonviable tissue was removed. Unfortunately upon arrive he suffered cardiac arrest in the setting of severe lactic acidosis and hyperkalemia.


VAERS ID: 1075657 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-01
Onset:2021-03-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Condition aggravated, Death
SMQs:, Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650MG BID, Eliquis 2.5MG BID, Furosemide 20MG BID, Morphine 5MG every 2 hours as needed, Potassium Chloride 10 mEq daily, Spironolactone 12.5MG daily, Zolpidem 5MG daily
Current Illness: Currently on Hospice
Preexisting Conditions: Personal history of COVID-19, Acute combined systolic (congestive) and diastolic (congestive) heart failure, Other specified diseases of liver, Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity, Other pulmonary embolism without acute cor pulmonale, Cardiomyopathy, unspecified, Coronary angioplasty status, Essential (primary) hypertension, Hyperlipidemia, unspecified, Age-related osteoporosis without current pathological fracture, Edema, unspecified, Chronic kidney disease, stage 3 (moderate), Anemia, unspecified Note: Acute chronic, Constipation, unspecified, Unspecified fracture of shaft of right fibula, initial encounter for closed fracture, Unspecified sensorineural hearing loss, Syncope and collapse, Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture, Zoster without complications (History of), Acute respiratory failure with hypoxia, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Peripheral vascular disease, unspecified, Cerebrovascular disease, unspecified Nonrheumatic aortic (valve) stenosis Atherosclerotic heart disease of native coronary artery without angina pectoris Nonrheumatic aortic (valve) insufficiency Alzheimer''s disease, unspecified
Allergies: Penicillin
Diagnostic Lab Data: Death on 03/04/2020 but was on Hospice
CDC Split Type:

Write-up: Resident was having back pain but did have previous back pain prior too.


VAERS ID: 1075725 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-01
Onset:2021-03-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest pain, Decreased appetite, Fluid intake reduced, Lethargy
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   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: Bumetanide 2 MG daily, Metoprolol 25 MG daily, Morphine 4 MG daily plus every hour as needed, Nitroglycerin 0.4 MG PRN, Ondansetron 4 MG BID,
Current Illness:
Preexisting Conditions: Anemia, unspecified, Transient cerebral ischemic attack, unspecified, Malignant neoplasm of esophagus, unspecified, Acute pyelonephritis Muscle weakness (generalized) Lack of physical exercise Unspecified systolic (congestive) heart failure Chronic kidney disease, stage 3 (moderate) Atherosclerotic heart disease of native coronary artery without angina pectoris Unspecified osteoarthritis, unspecified site Essential (primary) hypertension Hyperlipidemia, unspecified Vitamin B12 deficiency anemia, unspecified Gastro-esophageal reflux disease without esophagitis Presence of cardiac pacemaker Barrett''s esophagus with high grade dysplasia Abdominal aortic aneurysm, without rupture Congenital malformations of other endocrine glands Cerebral infarction, unspecified Idiopathic gout, unspecified site
Allergies: Amoxicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident started have chest pain on 3/02 and on 03/03 he was lethargic and wasn''t eating or drinking Resident was on Hospice


VAERS ID: 1075871 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-02
Onset:2021-02-04
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / -

Administered by: Public       Purchased by: ?
Symptoms: Death, Feeling abnormal
SMQs:, Dementia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-20
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: She was vaccinated on 2/2/21 and started feeling bad on 2/4/21. She was treated by her doctor, improved somewhat, got worse, then went to the hospital on 2/16/21. She died on 2/20/21.


VAERS ID: 1076158 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-24
Onset:2021-02-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-25
   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: albuterol, Anoro Ellipta, donepezil, gabapentin, Intellence, losartan, meotprolol, mybertiq, rouvastatin, synmtuza, tamsulosin,
Current Illness: none
Preexisting Conditions: systolic heart failure, HIV, HTN, DM2, history of prostate cancer, COPD,
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found dead at his home on 2/25/2021. He was last seen at home by his sister at 8:30pm on 2/24/21.


VAERS ID: 1076162 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-11
Onset:2021-01-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 1/11/2021. Patient passed away 1/15/2021, cause not reported, unaware if related.


VAERS ID: 1077008 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-02-26
Onset:2021-02-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Arthralgia, Death, Influenza like illness, Pain in extremity, Syncope, Tremor
SMQs:, Torsade de pointes/QT prolongation (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   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: Celebrex 100mg BID Synthroid 75mcg daily Moxifloxacin 0.5% eye drops Omeprazole 20mg Prilac OTC: Multivitamin (Womens), Vitamin D, Vitamin E
Current Illness:
Preexisting Conditions: Hypertension, Hyperlipidemia, Gout, GERD, Hypothyroidism, Osteoarthritis, Chronic Kidney Disease, Esophageal Strictures s/p dilation
Allergies: Ramipril (Altace) Simvastatin (Zocor)
Diagnostic Lab Data: Patient did not receive medical evaluation prior to death.
CDC Split Type:

Write-up: Per patient''s daughter the patient had severe flu like symptoms, shaking, extreme pain in wrists/fingers/feet. Patient collapsed at home and pronounced dead at scene.


VAERS ID: 1077014 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-02-05
Onset:2021-02-01
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: .
Preexisting Conditions: Multiple including end stage/O2 dependent COPD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1077021 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-02-06
Onset:2021-02-09
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: IBU, Norco, Albuterol, Amlodipine, Atorvastatin, Asprin, Flomac, Garlic Oil, Lexapro, Singulair, Symbicort
Current Illness: Breathing Problem, Chest pain, Emphysema, Heart Attack/Cough, Lung Disease, Thyroid Disease
Preexisting Conditions: none
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed away three days after receiving the vaccine.


VAERS ID: 1077236 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-01
Onset:2021-03-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Agonal respiration, Asthenia, Cardiac arrest, Cough, Fall, Head injury, Pulseless electrical activity, Resuscitation
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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: "sleeping pill"
Current Illness: cough after vaccine and weakness
Preexisting Conditions: none
Allergies: unknown
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Family states patient had been coughing and was weak after the vaccine. Patient walked to the bathroom and then fell striking her head found in PEA with agonal breathing. Despite aggressive CPR medications patient remained in asystole. Unknow if Moderna or Phifzer


VAERS ID: 1077275 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-15
Onset:2021-02-16
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xanax, Levothyroxin, Seroquel
Current Illness: Alzheimer?s,
Preexisting Conditions: Alzheimer?s
Allergies: Statins
Diagnostic Lab Data: None
CDC Split Type:

Write-up: At about 11:00 am which was about 22 hours after receiving 2nd dose of Moderna patient exhibited difficulty breathing and soon breathing became more difficult to point where her shoulders were lifting to breathe. At 6:45 pm she passed away.


VAERS ID: 1080424 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID-19 Positive 1/21/21 at Hospital. WBC 16.1 on 2/7/2021
CDC Split Type:

Write-up: Narrative: above in section "Other relevant history"


VAERS ID: 1080425 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-02-20
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Atrial septal defect, COVID-19, COVID-19 pneumonia, Convalescent plasma transfusion, Death, Dyspnoea, Echocardiogram, Ejection fraction decreased, Encephalopathy, Gastrointestinal disorder, Haemodynamic instability, Intensive care, Liver injury, SARS-CoV-2 test positive, Shock, Supraventricular tachycardia, Tachycardia, Thrombocytopenia
SMQs:, Cardiac failure (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Anaphylactic reaction (narrow), Haematopoietic thrombocytopenia (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Congenital, familial and genetic disorders (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Accidents and injuries (narrow), Cardiomyopathy (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 10
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: Narrative: Patient with h/o ESRD on HD MWF, HTN presented to ER on 2/20/21 with worsening dyspnea and GI symptoms; tested positive for COVID-19. Patient had received first COVID vaccination approx. 9 days prior. Patient admitted to ICU for treatment of COVID+ PNA. During admission, patient often could not tolerate removal of fluid during HD d/t tachycardia. He received dexamethasone, convalescent plasma for COVID. Patient underwent TTE which was notable for septal wall motion abnormalities and grossly reduced EF. Admission also c/b acute liver injury, possible cholecystitis, thrombocytopenia, SVT, encephalopathy. Patient then developed progressive shock and hemodynamic instability on 3/2 and passed away on 3/2/21.


VAERS ID: 1080427 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-12
Onset:2021-01-13
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death, SARS-CoV-2 test positive, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID-19 Positive 1/21/21 at Hospital. WBC 16.1 on 2/7/2021
CDC Split Type:

Write-up: Narrative: above in section "Other relevant history"


VAERS ID: 1080429 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-10
Onset:2021-02-11
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 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: no relevant lab tests available within 30-days of death. August 2020 PFTs fvc-95 fev1-2.62, 110 fev1/fvc-87 tlc-82 rv/tlc-32 Impression: Normal spirometry. Normal total lung capacity. Severely reduced diffusing capacity
CDC Split Type:

Write-up: DEATH Narrative: no documentation regarding any immediate reaction after vaccine administration. 83 y.o. male with pmh severe pulmonary hypertension, s/p TAVR last year, severe asbestos related lung disease on chronic oxygen, recently started on palliative care. Was found by daugher deceased on the morning of 2/11/2021. Autopsy declined by family.


VAERS ID: 1080430 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-02-14
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: Death was not determined to be related to COVID vaccination. COVID vaccination (dose 1) occurred on 1/27/21 with no noted side effects. Death occurred on 2/14/21.


VAERS ID: 1078002 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Cough, Death, Fatigue, Headache, Pain, Pyrexia
SMQs:, Anaphylactic reaction (broad), 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: 2021-03-05
   Days after onset: 11
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: no
CDC Split Type:

Write-up: Fever, tiredness, headache, body ache and chills and cough. Patient passed away at homeThursday, March 5 around 5:00 a.m.


VAERS ID: 1078239 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-06
Onset:2021-03-06
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Myocardial rupture
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, buspirone
Current Illness: Unknown
Preexisting Conditions: Hypertensive cardiovascular disease with coronary artery disease, cerebrovascular disease
Allergies: Unknown
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Death. Ruptured myocardial infarction.


VAERS ID: 1078246 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-01
Onset:2021-03-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Myocardial rupture
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Atherosclerotic heart disease, nephrosclerosis
Allergies: Unknown
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Death. Ruptured myocardial infarct.


VAERS ID: 1078352 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-02
Onset:2021-03-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Death, Fatigue, Headache, Pain, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Medical examiner report is pending.
CDC Split Type:

Write-up: Developed fatigue, body aches, headache 1 day after vaccination on 3/3. The morning of 3/5 complained of chest pain. Took Tylenol at 8:30 am. At 10:30 am his family found him unresponsive. EMS was called and he was pronounced dead in the home.


VAERS ID: 1079251 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #029A21A / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient died the day after vaccination on 03/06/2021
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Not recorded
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died the day after she received her vaccine


VAERS ID: 1079904 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Unknown  
Location: California  
Vaccinated:2021-02-17
Onset:2021-02-22
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024MZ0A / UNK - / -

Administered by: Other       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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: SUBJECT WAS FOUND DECEASED ON 22 FEB 2021 AT AROUND 11:30 PM


VAERS ID: 1079958 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Multiple organ dysfunction syndrome, Pulse absent, Pulseless electrical activity, Resuscitation
SMQs:, 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), Cardiac arrhythmia terms, nonspecific (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atenolol, Oxycodone, Pepcid, Prevacid, Tessalon Perles, Trospium, Gabapentin, MEthotrexate, Plaquenil, Prilosec,
Current Illness:
Preexisting Conditions: HTN, RN, GERD, Potherpetic Neurology, GERD, Metatarsalgia, Knee joint Pain, Detrusor Instability, Viral meninigitis,
Allergies: Lime, PCN, Septra
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt found down and pulseless in home by husband. EMS called, Pt found to be in PEA arrest. Pt achieved ROSC with CPR and Epinephrin. Pt Passed away on 09/07/2021 at 1330. Pt was in multisystem organ failure.


VAERS ID: 1079976 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: New York  
Vaccinated:2020-12-23
Onset:2020-12-23
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L29A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cough, Death, Dysgeusia, Exposure to SARS-CoV-2, Feeling abnormal, Gastrointestinal tract irritation, Headache, Malaise, Micturition urgency, Pain, Pollakiuria, Resuscitation, SARS-CoV-2 test negative, Somnolence, Syncope, Upper respiratory tract infection
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (broad), Hypoglycaemia (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 41
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: After 1st vaccination (12/23/20): Triamterene/HCTZ, Losinopril, DayQuil, Mucinex, prescribed Augmentin 12/25/20 After 2nd (1/25/21): Addition of Zinc, Quercetin, Vitamin C, Augmentin rx''d 2/1/21
Current Illness:
Preexisting Conditions: HTN
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: 12/23/20 (Moderna #1) - Malaise, cough on 12/24, went to walk-in on 12/25 c/o cough, malaise, rx''d Augmentin x14d, Rapid covid negative (and PCR resulted negative). 12/27 slept all day, 12/28 back to work. 1/12/21 metallic taste in mouth, severe GI sx, malaise, aches, headache. 1/14 seen at walk-in and covid swabbed Negative. 1/21/21 exposed to parents who found out they were covid + on 1/22/21. 1/25/21 (Moderna #2) - Continued with persistent cough and GI sx. Then also developed urinary frequency and urgency. Seen at urgent care 2/1 c/o cough, dx URI, rx''d augmenting. Woke up morning of 2/2/21 abruptly, stood up, said something was wrong, and collapsed. CPR attempted immediately, EMS brought him to ER where he was pronounced dead.


VAERS ID: 1080033 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-01-14
Onset:2021-01-22
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Chest X-ray abnormal, Chills, Death, Dyspnoea, Oxygen saturation decreased, Pneumonia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None
Preexisting Conditions:
Allergies: Aspirin
Diagnostic Lab Data: Positive COVID test results Chest X-rays showing COVID pneumonia
CDC Split Type:

Write-up: COVID symptoms started within 8-9 days of vaccination. No fever, general not feeling, chills. Turned into very difficult breathing, low oxygen levels and pneumonia. Tested positive for COVID at Hospital ER on Wednesday, January 27. Died in the hospital Saturday morning, January 30, 2021.


VAERS ID: 1080075 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-02-25
Onset:2021-02-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 1 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 3
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: Metformin
Current Illness:
Preexisting Conditions: Diabetes
Allergies: Kiwi
Diagnostic Lab Data: CT of head/brain
CDC Split Type:

Write-up: Hemorrhagic stroke. = Death


VAERS ID: 1080431 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Aphasia, Death, Lip swelling, Pulse absent, Pulseless electrical activity, Resuscitation, Swollen tongue, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiac arrhythmia terms, nonspecific (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (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? 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: Narrative: 67 year-old male received his 1st COVID vaccine dose at a clinic on 2/25/21 at ~ 11:45am. No known prior COVID infection. No history of vaccine allergies or allergies to any component of the COVID vaccine. Does have history of allergic reactions including hives, angioedema or anaphylaxis to some medications (neomycin, Neosporin, bacitracin) and environmental allergens (yellow jackets, fir trees). Patient reported previously daily use of diphenhydramine (2 caps every morning) and kept an epi-pen on hand. The afternoon of 2/26/21, patient presented to his neighbor''s house requesting assistance with an epi-pen. Neighbor reported significant swelling around tongue and lips, and ability to faintly speak. Neighbor administered epi-pen, but unsure if it worked, so administered a 2nd epi-pen. Within a minute or two after the 2nd dose, patient slumped over and became non-responsive. EMS was called and neighbor began CPR. EMS reported that patient was non-responsive upon arrival. A King airway was placed and a Lucas device used for chest compressions. Three rounds of epinephrine were administered during transport to the local emergency room. Patient remained unresponsive with evidence of PEA during transport. Arrival at the ER occurred ~ 4:25pm. On arrival patient noted to be unresponsive with CPR in progress. Dose of epinephrine administered ~ 3 minutes after arrival in ER. No femoral pulse palpable, cardiac monitor did show some electrical activity. Evaluation of oral cavity showed significant swelling of tongue. Additional dose of epinephrine given. Patient remained with no palpable central pulse and showed continued evidence of PEA. Patient was estimated to have been down $g 45 minutes. Patient pronounced deceased at 4:59pm.


VAERS ID: 1080433 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-25
Onset:2021-02-07
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiovascular disorder
SMQs:, Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? 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: unknown cardiovascular event


VAERS ID: 1080434 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-24
Onset:2021-03-02
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Obesity
SMQs:, Hyperglycaemia/new onset diabetes mellitus (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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient passed away on 3-2-21, patient received the vaccine on 2-24-21. Patient was obese and had several co-morbid conditions.


VAERS ID: 1080335 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Anaphylactic reaction
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (narrow)

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

Write-up: Anaphylaxis; A spontaneous report was received from a physician assistant concerning a patient of unspecified age and gender, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced anaphylaxis. 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 their first of two planned doses of mRNA-1273 (Lot number: unknown) for prophylaxis of COVID-19 infection. On an unknown date, after receiving vaccine, the patient died due to anaphylaxis. No further details were available at the time of this report. Treatment for the event was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event anaphylaxis was fatal .The patient died on an unspecified due to anaphylaxis. Autopsy details were not provided.; Reporter''s Comments: Very limited information regarding the event of anaphylaxis has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Anaphylaxis


VAERS ID: 1080671 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-26
Onset:2021-02-02
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Chills, Confusional state, Cough, Death, Decreased appetite, Dyspnoea, Mental status changes, Nausea, Pyrexia, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

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

Write-up: Patient received vaccine 1/26/2021, complained of fever and chills post vaccine. Daughter reported worsening symptoms to confusion, decreased appetite, N/V and chest pain. Dry cough and SOB. Patient admitted to facility for Chest pain, AMS on 2/2/2021. Expired 2/2/2021.


VAERS ID: 1080932 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-12
Onset:2021-01-23
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19, Endotracheal intubation
SMQs:, Anaphylactic reaction (broad), Angioedema (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), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: HYPERTENSION, COPD, NON-SMALL CELL CANCER RIGHT LUNG
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: INTUBATION 1/23/21;
CDC Split Type:

Write-up: DIAGNOSED WITH COVID 1/21/21; RECIEVED BAMLANIVUBAM INFUSION; HOSPITAL ADMISSION 1/23/21 WITH ACUT RESPIRATORY FAILURE DUE TO COVID. INTUBATED X 10 DAYS


VAERS ID: 1081009 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: combivent Respimat, Januvia 100mg,Metformin 500mg, vitamin C 100mg,Ferrous Sulfate 325mg,Famotidine 20mg,Sertraline 50mg,Carvedilol 12.5mg,Oyster shell calcium 500mg,Gabapentin 300mg,furosemide 20mg,EC Aspirin 325mg,atorvastatin 40mg,clopid
Current Illness: Cancer
Preexisting Conditions: diabetes, heart disease
Allergies: tramadol, morphine products
Diagnostic Lab Data:
CDC Split Type:

Write-up: there were no signs of adverse reaction at the time of injections and she waited 15 minutes at the site to watch for side effects. and none were evident or reported. We were notified that she passed away on Saturday, March 6.


VAERS ID: 1081033 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-02-22
Onset:2021-02-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood bicarbonate increased, Brain natriuretic peptide decreased, Brain natriuretic peptide normal, Carbon dioxide increased, Death, Dyspnoea, Oedema, White blood cell count normal
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (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: Acetaminophen 500 PO Q4hrs PRN, Furosemide 20 mg PO daily, Cranberry fruit extract 500 mg PO daily, Cod liver Oil 1 cap PO daily, Brimonidine 0.025% Eye drops, Artificial Tears, Milk of magnesia, guafenesin DM, Debrox otic, Nystatin Powder
Current Illness: Chronic respiratory failure with hypoxia, and edema.
Preexisting Conditions: Closed head injury without loss of consciousness, contusion, edema, chronic respiratory failure with hypoxia, subclinical hypothyroidism.
Allergies: Levofloxacin, bee pollen, and NSAIDs
Diagnostic Lab Data: On 2/7 patient was admitted to the emergency department. Labs CO2: 43 mmol/L (High) BNP: 24.5 (pg/mL) Normal white count
CDC Split Type:

Write-up: Patient expired 2 days after receiving the vaccination. Patient had other signs of deterioration over the course of the previous month with worsening edema and difficulty breathing. Unlikely to be related according to our assessments, but wanted to err on the side of caution.


VAERS ID: 1081132 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-02-05
Onset:2021-02-26
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Platelet count decreased, 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: 2021-03-07
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin Adult Low Dose 81 MG Tablet Delayed Release 1 tablet Orally Once a day Lisinopril 5 MG Tablet 1 tablet Orally Once a day Vitamin B12 1000 MCG Tablet Extended Release 1 tablet Orally Once a day Rosuvastatin Calcium 5 MG Tabl
Current Illness:
Preexisting Conditions: Dyslipidemia, Hypertension, HIV+
Allergies: NKA
Diagnostic Lab Data: Platelets - 16k (2/16/21), Platelets - 4k (2/27/21)
CDC Split Type:

Write-up: Severe thrombocytopenia approx. 10 days after vaccine administration.


VAERS ID: 1081155 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Montana  
Vaccinated:2021-02-12
Onset:2021-03-06
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt died on 3/6/2021. Received Vaccine on 2/12/2021. Unknown cause of death.


VAERS ID: 1081279 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: South Dakota  
Vaccinated:2021-03-02
Onset:2021-03-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Asthenia, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium normal, Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood magnesium normal, Blood potassium normal, Blood sodium increased, Blood urea increased, Blood urea nitrogen/creatinine ratio increased, Carbon dioxide increased, Chest X-ray abnormal, Confusional state, Death, Dyspnoea, Eosinophil count normal, Eosinophil percentage, Fall, Fatigue, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Immature granulocyte count, Lung opacity, Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin increased, Mean cell volume increased, Mean platelet volume normal, Monocyte count increased, Monocyte percentage increased, Neutrophil count normal, Neutrophil percentage, Platelet count normal, Protein total decreased, Red blood cell count decreased, Red cell distribution width normal, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (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), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol sulfate 90 mcg/actuation aerosol inhaler (ProAir HFA) 2 puffs inhalation 4H PRN albuterol sulfate 2.5 mg NEB TID atorvastatin 40 mg tablet 0.5 tabs PO DAILY budesonide 0.5 mg/2 mL suspension for nebulization 1 vial NEB BID carved
Current Illness: Has underlying COPD, Was discharged from hospital 1/25/21 for pneumonia. Was declining prior to vaccination: more SOB, falling, abdomen bloated, coughing a little more, tired and weak.
Preexisting Conditions: COPD, CKD-3, CAD, Anemia, heart failure with reduced ejection fraction, a fib.
Allergies: atenolol, simvastatin, terazosin
Diagnostic Lab Data: "Hazy opacities on CHX -right lung. . WBC 6.1 K/uL (4.5-11.0) 03/02/21 17:00 RBC 3.10 M/uL (4.70-6.10) L 03/02/21 17:00 Hgb 10.5 g/dL (14.0-17.5) L 03/02/21 17:00 Hct 33.6 % (40.0-50.0) L 03/02/21 17:00 MCV 108.4 fL (80.0-100.0) H 03/02/21 17:00 MCH 33.9 pg (26.0-34.0) 03/02/21 17:00 MCHC 31.3 g/dL (32.0-36.0) L 03/02/21 17:00 RDW 12.1 % (11.5-15.0) 03/02/21 17:00 Plt Count 193 K/uL (140-450) 03/02/21 17:00 MPV 8.2 fL (7.0-11.0) 03/02/21 17:00 Immature Gran % (Auto) 0.3 % 03/02/21 17:00 Neut % (Auto) 70.6 % (40.0-75.0) 03/02/21 17:00 Lymph % (Auto) 11.9 % (5.0-50.0) 03/02/21 17:00 Mono % (Auto) 15.2 % (2.0-14.0) H 03/02/21 17:00 Eos % (Auto) 1.5 % (0.0-7.0) 03/02/21 17:00 Baso % (Auto) 0.5 % (0.0-2.0) 03/02/21 17:00 Abs Immat Gran (auto) 0.02 K/uL (<0.03) 03/02/21 17:00 Absolute Neuts (auto) 4.31 K/uL (1.80-7.70) 03/02/21 17:00 Absolute Lymphs (auto) 0.73 K/uL (1.00-4.80) L 03/02/21 17:00 Absolute Monos (auto) 0.93 K/uL (0.00-1.00) 03/02/21 17:00 Absolute Eos (auto) 0.09 K/uL (0.00-0.50) 03/02/21 17:00 Absolute Basos (auto) 0.03 K/uL (0.00-0.20) 03/02/21 17:00 Sodium 147 mmol/L (133-145) H 03/02/21 17:00 Potassium 4.5 mmol/L (3.5-5.1) 03/02/21 17:00 Chloride 98 mmol/L (98-109) 03/02/21 17:00 Carbon Dioxide 45 mmol/L (21-31) H 03/02/21 17:00 Anion Gap 4 mmol/L (3-15) 03/02/21 17:00 BUN 53 mg/dL (7-25) H 03/02/21 17:00 Creatinine 1.7 mg/dL (0.7-1.3) H 03/02/21 17:00 Estimated GFR (MDRD) 38 mL/Min (60-130) L 03/02/21 17:00 Est GFR (Cockcroft-G) 28 mL/Min ($g=50) L 03/02/21 17:00 Est GFR (CKD-EPI) 35 mL/Min (60-130) L 03/02/21 17:00 BUN/Creatinine Ratio 31.2 (10.0-20.0) H 03/02/21 17:00 Glucose 131 mg/dL (70-99) H 03/02/21 17:00 Calcium 9.5 mg/dL (8.6-10.3) 03/02/21 17:00 Magnesium 1.9 mg/dL (1.6-2.6) 03/02/21 17:00 Total Bilirubin 0.4 mg/dL (0.3-1.0) 03/02/21 17:00 AST 16 U/L (13-39) 03/02/21 17:00 ALT 11 U/L (4-33) 03/02/21 17:00 Alkaline Phosphatase 66 U/L (34-104) 03/02/21 17:00 Total Protein 6.2 g/dL (6.4-8.9) L 03/02/21 17:00 Albumin 3.5 g/dL (3.5-5.7) 03/02/21 17:00 Globulin 2.7 g/dL (1.5-4.5) 03/02/21 17:00 Albumin/Globulin Ratio 1.3 (0.8-2.0) 03/02/21 17:00
CDC Split Type:

Write-up: Patient seen by physician for weakness, tired, increase SOB, falls, increase confusion and then subsequently hospitalized . Patient then expired on 3/7/21.


VAERS ID: 1081304 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-07
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025A21A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1081305 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-26
Onset:2021-02-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 AR / IM

Administered by: Military       Purchased by: ?
Symptoms: Autopsy, Cardiac disorder, 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: 2021-02-27
   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: Cardiac disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden death approximately 24 hours after receiving 2nd COVID vaccine - symptoms unknown - autopsy revealed cardiac disease as the cause of death


VAERS ID: 1081547 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-03-05
Onset:2021-03-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   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: LIQUID PROTEIN, PRILOSEC, LACTOBACILLUS, ELIQUIS
Current Illness: NONE
Preexisting Conditions: A-FIB, PERIPHERAL VASCULAR DISEASE, HERNIA REPAIR WITH BOWEL RESECTION JANUARY 2021
Allergies: NONE
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: NO IMMEDIATE ADVERSE EVENTS PRESENT FOLLOWING IMMUNIZATION. RESIDENT WAS ALERT, RESPONSIVE, TALKATIVE, WITHOUT COMPLAINTS, AND ENGAGING IN NORMAL ACTIVITIES AFTER IMMUNIZATION, AS WELL AS THE FOLLOWING DAY. HE WAS FOUND IN BED THE SECOND MORNING AFTER VACCINATION (AT 6:25AM) WITHOUT VITAL SIGNS AND HAD EXPIRED PEACEFULLY IN HIS SLEEP. HE WAS A DNR, NO LIFE SUSTAINING MEASURES WERE PERFORMED.


VAERS ID: 1082161 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Nevada  
Vaccinated:2021-03-03
Onset:2021-03-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 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: Unknown
CDC Split Type:

Write-up: Cardiac Arrest/Death Date of death 03/03/2021 time 01:54 pm


VAERS ID: 1082345 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-02-05
Onset:2021-03-05
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, PCO2 increased, Respiratory failure, SARS-CoV-2 test negative, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: I am not sure if it was related to the vaccine, but the rapid antigen for Sars-CoV2 was positive and the PCR was negative. CT of the chest was positive for pneumonia. Several ABG values with PaCO2 levels above the 80''s
CDC Split Type:

Write-up: This patient developed a severe pneumonia, clinically diagnosed as COVID-19 pneumonia, with hypercapnic and hypoxemic respiratory failure, and expired. I am not sure if it was related to the vaccine, but the rapid antigen for Sars-CoV2 was positive and the PCR was negative. I am reporting this event because of the lack of clarity on this issue and the positivity of the Sars-CoV2 was beyond the parameters of 14 days in the phase three trials.


VAERS ID: 1082467 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-02-17
Onset:2021-03-06
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Mitral valve tear was reported by husband.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt passed away on 3/6/21.


VAERS ID: 1082707 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-03-05
Onset:2021-03-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1082717 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-02-16
Onset:2021-02-17
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 RA / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Positive for Covid 1/16/2021 and negative for Covid 1/17/2021
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: Autopsy performed 2/20/2021. Reason for death: UNKNOWN.
CDC Split Type:

Write-up: Patient dropped dead 24 hours after receiving the vaccine. The vaccine killed her. She received the vaccine 2/16/2021 and died 2/17/2021


VAERS ID: 1082759 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-04
Onset:2021-03-07
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   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: Dialysis
Current Illness: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Preexisting Conditions: Congestive heart failure, stage 4 renal failure, sepsis and COPD
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1082787 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-02-23
Onset:2021-03-07
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death on 3/7/21


VAERS ID: 1082850 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-19
Onset:2021-02-20
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram spine, Electrocardiogram, Laboratory test, Mobility decreased, Nausea, Vomiting, X-ray limb
SMQs:, Acute pancreatitis (broad), Parkinson-like events (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-03-07
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin, atorvastatin, Cymbalta, lyrica, finastride, hydrochlorathiazide iron, losartan, metoprolol tamsulosin, ambien
Current Illness: none
Preexisting Conditions: psoriasis (lips), neuropathy, HTN, anxiety/depression, type 2 DM
Allergies: Penicillin, sulfa
Diagnostic Lab Data: labs, EKG, CT abd, Ct c spine, shoulder xray, CT of Head
CDC Split Type:

Write-up: pt became nauseated and vomiting 1 day after getting vaccine, reported on Mon 2/22/21 but states was getting better, received call from sister on 2/25/21 that pt could not get out of bed on own - was sent to ER at that time


VAERS ID: 1083117 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-05
Onset:2021-03-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: DX: stroke, emphysema
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt. received his second moderna vaccine on 03/05/2021 and his son reported that the pt. passed away after receiving his vaccine.


VAERS ID: 1083728 (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: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal discomfort, Death
SMQs:, Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   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: Medical History/Concurrent Conditions: Diabetes; Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Dead on the bed with his legs dangling off one side of the bed; Complained about an upset stomach; A spontaneous report was received from a nurse concerning a 70-year-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273). The patient''s medical history included hypertension and diabetes. No concomitant medications were provided. On 20 Feb 2021, Saturday, the patient received their dose of mRNA-1273 (Batch Number: Unknown) for prophylaxis of COVID-19 infection. On 21 Feb 2021, Sunday 9:36 AM the patient''s experienced an upset stomach and attributed it to dinner last night and later on 22 Feb 2021, Monday he was found dead on the bed with his legs dangling off one side of the bed. The cause of death was unknown. Treatment information for event upset stomach included half a spoon of an Indian thing. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the event upset stomach was fatal and patient died on 21 Feb 2021.; Reporter''s Comments: This is a 70-year-old, male patient, who received Moderna''s COVID-19 vaccine and history of risk factors for CAD such as hypertension and diabetes, was found dead 2 days after vaccination. Very limited information regarding this events has been provided at this time. Further information has been requested; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1084145 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-03-01
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 057G20A / 2 - / -

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

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

Write-up: At home Care Hospice Patient


VAERS ID: 1084180 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-05
Onset:2021-03-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Condition aggravated, Death, Pulse absent, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: NA
Current Illness: Coronary Artery Disease; COPD
Preexisting Conditions: Coronary Artery Disease; COPD
Allergies: Codeine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient came with husband to Vaccine clinic today 3/5 for 2nd dose of vaccine. Did well during and immediately after vaccine. Husband states patient has c/o severe chest pressure and pain for several weeks but has refused to come to ER for evaluation. Today, after getting vaccine dose and going to local bank, patient was in passenger side of truck when chest pain started again. Husband begged patient to let him take her to the ER but she said no, I?m fine and I don?t want to go. She then went unresponsive. At a stop light, he was next to a couple of cops who he was able to wave down and proceed to escort them in to ER. Upon arrival to the ER, patient was unresponsive and pulseless. CPR was initiated, 1 defib, and 1mg of epi was given. Return of pulse was obtained, but husband asked for no life support and only comfort measures. Patient was admitted for comfort measures. I do NOT think this was related to her vaccine, but rather the unfortunately end to a sub-acute chest pain patient that declined multiple urgings to seek care. Patient then expired on 3/5/21 at 2037.


VAERS ID: 1084419 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-03-05
Onset:2021-03-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 1 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Airway patency device insertion, Blood glucose increased, Cardiac arrest, Cardiac assistance device user, Cardiac disorder, Condition aggravated, Death, Dyspnoea, Mechanical ventilation, Respiratory arrest, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), 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: 2021-03-05
   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: Metformin Glipizide Metoprolol
Current Illness: Shortness of breath for a week before his passing, he did not seek medical attention for this.
Preexisting Conditions: Cardiac History Hypertension Diabetes
Allergies: No
Diagnostic Lab Data: No
CDC Split Type:

Write-up: EMS reported sudden onset of shortness of breath, patient grabbed his chest and collapsed. He stopped breathing. Wife began CPR with chest compressions at 5:00. Fire dept. arrived resumed CPR and attached AED but there was no shock advise. They placed an OPA as well (inserted an airway) and started ventilation. Asystole was confirmed, they continued CPR. After 5:25 they gave 3 rounds Epineferin and ended CPR at 5:46. They also checked his blood sugar and it was 136. Possible reaction to covid vaccine. Possible death due to history of cardiac issues. His PCP is requesting an autopsy


VAERS ID: 1084685 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-03-08
Onset:2021-03-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 002A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: We received a phone call stating that the patient passed away overnight.


VAERS ID: 1084793 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute abdomen, Cardiogenic shock, Death, Fluid replacement, Gastrostomy, Hypoglycaemia, Hypotension, Sepsis
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypoglycaemia (narrow), Dehydration (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650mg q6h prn, Eliquis 5mg BID, Albuterol MDI q6h prn, Atenolol 75mg daily , Atorvastatin 80mg daily , Questran 4gm daily, Lexapro 25mg daily, ferrous sulfate 300mg daily, fluconazole 400mg daily, Lasix 10mg daily, Lispro in
Current Illness: angioedema thought to be secondary to lisinopril esophageal perforation abdominal ascites
Preexisting Conditions: AFIB HTN GERD depression
Allergies: Lisinopril Naproxen Gadolinium
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hypotension in the 70s/40s despite IV fluid replenishment. Per our MD DC/transfer note: PEG displacement, ongoing sepsis, hypoglycemia. Assess for other reason for hypotension including sepsis, cardiogenic shock, acute abdominal processes. patient was transferred to the Hospital ER where she expired


VAERS ID: 1084800 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-03-08
Onset:2021-03-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: liver transplant. Doctor advised pt to get the covid vaccine.
Allergies: NKDAnone reported
Diagnostic Lab Data: Sent to ME office for autopsy
CDC Split Type:

Write-up: Death. EMS called to residence 9 hours later for cardiac arrest. Pt pronounced at Emergency Room. Pt sent to ME office for autopsy.


VAERS ID: 1085019 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Washington  
Vaccinated:2020-03-03
Onset:2021-03-05
   Days after vaccination:367
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Death
SMQs:, Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Multi vitamin, promethazine 25 mg, omeprazole 20 mg, cyclobenzaprine, 10 mg, oxycodone/APAP 5/325mg, gabapentin 800 mg, simvastatin 20 mg tab, metformin 1000 mg tab, nortriptyline 50 mg cap, zolpidem 10 mg tab, Ketorolac 60 mg injection 2 t
Current Illness: Chronic pain, HTN, DM, Cervicalgia, nausea, insomnia
Preexisting Conditions: Tobacco abuse, HTN, Diabetes mellitus, DJD, Cervicalgia, osteoarthritis, chronic pain, opioid use, diabetic polyneuropathy, carpal tunnel syndrome bilaterally, atopic dermatitis, bursitis , history of DVT, LE edema, chronic nausea, hyperlipidemia, insomnia,
Allergies: Benzodiazepines, celecoxib, codeine, diphenhydramine HCL, inositol Niacinate, Metaxalone, Niacinamide, oxycodone HCL, ASA, horse/equine containing products,, erythromycin base products, shellfish derived, bee venom
Diagnostic Lab Data: Unknown if autopsy will be performed.
CDC Split Type:

Write-up: Had vaccine on 3/3/2021 at approximately 1 PM. She was found on her couch deceased on 3/8/2021. Possible death on 3/5/2021. She called her sister and told sister that back hurt worse than usual and she would lay on the couch and rest. This is where she was found. Unknown if from vaccine, but due to vaccination on Wednesday proceeding her death, report is being filed.


VAERS ID: 1085032 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-02-25
Onset:2021-02-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Impaired work ability, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: NKA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient received dose #2 of her Moderna COVID vaccine on 2/25/21. Patient called in to work the next day 2/26/21 because she was not feeling well. Patient did not show up to work on Monday 3/1/21 and her supervisor, called the PD to check in on her and she was found deceased in her home.


VAERS ID: 1085185 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Virginia  
Vaccinated:2021-01-05
Onset:2021-01-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Arthralgia, Back pain, Body temperature, COVID-19, Coronavirus test positive, Headache, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Arthritis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 28
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: TRULICITY; METFORMIN; JARDIANCE; LOSARTAN; AMLODIPINE; SYNTHROID; SIMVASTATIN; ALLOPURINOL; ESTROGEN; COLCHICINE; CALCIUM; ZINC; VITAMIN C ACID
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data: Test Date: 20210105; Test Name: Body temperature measurment; Result Unstructured Data: High; Test Date: 20210109; Test Name: COVID-19; Test Result: Positive ; Result Unstructured Data: Positive
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: testing positive for COVID; Fever for 3 hours after the vaccine/ High temperature; Joint pain; Severe upper back pain; Headache; A spontaneous report was received from a nurse concerning a 44-year-old female patient who experienced fever for 3 hours after vaccination, headache, joint pain, and severe upper back pain. The patient''s medical history was not provided. Products known to have been used by the patient, within two weeks prior to the event, included dulaglutide, metformin, empagliflozin, losartan, amlodipine, levothyroxine, simvastatin, allopurinol, estrogen, colchicine, calcium, zinc, multivitamin and vitamin C. On 05 Jan 2021, the patient received mRNA-1273 (Lot number 026L20A) intramuscularly for prophylaxis of COVID-19 infection. On 05 Jan 2021, patient experienced fever for 3 hours after vaccination. The patient also experienced headache, joint pain, and severe upper back pain. The patient stated her temperature was high from 05 Jan 2021 until 09 Jan 2021 when it went down. Treatment information was not provided. Follow-up received on 21 Feb 2021, from the patient''s husband, included that the patient tested positive for Covid-19 on 09 Jan 2021 and was hospitalized on 11 Jan 2021. The patient never recovered from her symptoms and the patient died on 02 Feb 2021. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events Coronavirus test positive was fatal and for headache, joint pain, severe upper back pain and temperature were unknown. The cause of death was reported as Coronavirus test positive and autopsy details was unknown.; Reporter''s Comments: This case concerns a 44-year-old female who was hospitalized with a serious unexpected event of COVID-19 with fatal outcome along with NS unexpected back pain and NS expected fever, headache, arthralgia. Event onset was 5 days after the first dose of mRNA-1273. Treatment not reported. Event outcomes fatal. Autopsy results unknown. Based on current available information and temporal association between use of the product and the start date of the event, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Testing positive for COVID


VAERS ID: 1085193 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-22
Onset:2021-02-22
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Loss of consciousness, Vaccination site pain
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Unconscious; Felt a bit sore at the injection site; A spontaneous report was received from a consumer and healthcare facility staff member concerning a 69 years old, female patient who experienced little bit sore at the injection site, unconscious and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On 22 Feb 2021, prior to the onset of the symptoms, the patient received their second of two planned doses of mRNA-1273 (Batch number not provided) intramuscularly for prophylaxis of COVID-19 infection. The patient experienced sore at the injection site and unconsciousness both since 22 Feb 2021. The husband of the patient performed CPR as instructed by 911 and EMT''s and police performed medical procedure which included injections and electrical shock both on 22 Feb 2021. The patient died on 22 Feb 2021. Treatment information was not provided. The patient received both scheduled doses of mRNA-1273 prior to the events; therefore, action taken with the drug in response to the events is not applicable. The patient died on 22 Feb 2021. The cause of death was unknown. Plans for an autopsy were not provided.; Reporter''s Comments: This is a case of death of a 59-year-old, female patient who experienced injection site sore and became unconscious on the same day after mRNA-1273 administration and subsequently expired. Although critical details such as the patient''s medical history and actual cause of death is lacking, based on the current available information which shows a strong temporal association with the product use, thus, a causal relationship cannot be excluded. injection sore is consistent with product safety profile and cannot be excluded.; Reported Cause(s) of Death: Unknown cause of death


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