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

Found 17,128 cases where Vaccine targets COVID-19 (COVID19) and Patient Died



Case Details

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VAERS ID: 1016067 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-02-04
Onset:2021-02-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Metolazone, potassium CL, Torsemide, Acetaminophen, Loperamide, melatonin, tramadol, certirzine, Eliquis,
Current Illness: nasal congestion
Preexisting Conditions: diabetes, heart failure, Afib, HTN
Allergies: Procaine, epinephrine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident was weak, fatigued and had a fever of 101. F the following morning after receiving the 2nd dose of vaccine. Later in the day she was feeling better and vital signs were WNL. The next morning, she was found unresponsive and pronounced dead by paramedics.


VAERS ID: 1016097 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-20
Onset:2021-02-08
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, carvedilol, clopidrogrel, cyclobenzaprine, docusate sodium, ferrous sulfate, guaifenesin, norco, insulin nph, levothyroxine, magnesium, metformin, nitrostat, rosuvastatin, spironolactone, tramadol, warfarin
Current Illness:
Preexisting Conditions: CABG-2014, CAD, HTN, hyperlipidemia, systolic murmur, type 2 diabetes, diabetic neuropathy, cervical dystonia, benign essential tremor, degenerative disc disease, intermittent claudication, PVD, former smoker-greater than 30 pack year, cervical spinal stenosis, long-term use of anticoagulant
Allergies: Hydrochlorothiazide, ACE inhibitors, Lisinopril, Valsartan, Angiotensin Receptor blockers
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 02/08/21


VAERS ID: 1016111 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-01-24
Onset:2021-02-06
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Pain in extremity
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lipatore high blood pressure meds a-fib medications
Current Illness: no
Preexisting Conditions: High Blood Pressure High Cholesterol A-Fib
Allergies: Penicillin Amoxicillin Sulfa Drugs
Diagnostic Lab Data: yes but unsure of what labs and tests she had. We don''t have her death certificate yet.
CDC Split Type:

Write-up: her arm was sore but no other adverse reactions until Saturday, Feburary 6th 2021 she had stroke between 4 and 6pm. She died within 6 to 7 hours later.


VAERS ID: 1016155 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-02-04
Onset:2021-02-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bundle branch block left, Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Conduction defects (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Align Capsule 1 capsule QD Aspirin 81 mg QD Cholecalciferol 125 mcg QD Donepezil HCl 10 mg QHS Ensure Max Protein BID Furosemide 20 mg QD Potassium Chloride ER 10 MEQ BID Proventil HFA TID
Current Illness: Acute Exacerbation CHF Cellulitis of intergluteal fold due to decubitus ulcer
Preexisting Conditions: Unspecified Dementia without Behavioral Disturbance Edema Hypokalemia Chronic Bronchitis Heart Failure Vitamin D Deficiency Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris History of Aortic Stenosis LBBB
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 2/7/2021 at 0630, resident found in recliner without pulse or respirations. Resident had not been found to have any adverse reactions to the vaccine between the time of the vaccine on 2/4 until found deceased on 2/7.


VAERS ID: 1016222 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-21
Onset:2021-01-25
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Angina pectoris, Blood test abnormal, Death, Dyspnoea, Electrocardiogram, Injection site pain, Resuscitation, Syncope, Transfusion
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Coreg, Ranexa, Bayer low dose Aspirin, Brilinta, Tums, Pantoprazole, Nitro 0.4mg sq prn, Imdur, Rosuvastatin, Glimiperide, Sucralfate
Current Illness: 3 weeks prior to immunzation hospitalized for one day due to symptomatic anemia and got a blood transfusion
Preexisting Conditions: Hypertension, CAD s/p cabg 1996 s/p multiple stents last 2013, history of stroke 1996, high cholesterol, diabetes type 2, iron deficiency anemia
Allergies: Contrast dye, lisinopril
Diagnostic Lab Data: No labs or tests were done, she was transported to hospital for further resuscitation measures but not successful.
CDC Split Type:

Write-up: My mom only had site soreness after her covid vaccine on 1/21 which resolved within a couple days. However, she died in the early morning hours of 1/25, she was fine the day before, no sign of injury. We found her collapsed on the ground and although we tried cpr she was already dead. She had gone to the hospital on 12/28 for shortness of breath, angina and symptomatic anemia, her ekg was unchanged and blood work normal except for anemia. The cardiologist did not think a cardiac cath was needed. Her shortness of breath improved with a blood transfusion and a dose of lasix (no heart failure).


VAERS ID: 1016605 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

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

Write-up: Sepsis; A spontaneous report was received from a consumer post , concerning an approximately 55-year-old, male physician who received Moderna''s COVID-19 vaccine (mRNA-1273) and developed sepsis, resulting in death. There was no medical history provided. There were no concomitant medications provided. On an unknown date (Thursday), the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. According to the post, two days after vaccine administration, the patient died of sepsis on Saturday. Action taken with mRNA-1273 in response to the event was not applicable. The event, sepsis, was considered fatal. The patient''s date of death was not provided. The cause of death was reported as sepsis.; Reporter''s Comments: This case concerns a 55-year-old, male subject, who experienced a serious unexpected event of Sepsis. Sepsis occurred after first dose of mRNA-1273 vaccine administration. On an unknown date, two days after vaccine administration, the patient died of sepsis. Treatment for the event was not provided. The patient''s medical history was not provided. The patient is a physician. Concomitant product use was not reported. Very limited information regarding this event has been provided at this time and no definite diagnosis or autopsy report have been provided. Based on the current available information and temporal association between the use of the product and the start date of the event of Sepsis, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Sepsis


VAERS ID: 1016709 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-08
Onset:2021-02-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Dyspnoea at rest, Hypopnoea, Oral pain, Respiratory failure
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), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: OXYCONE, LASIX, FLOMAS, CEPHALEXIN,EFFEXOR, EXELON, SEROQUEL, OMEPRAZOLE
Current Illness: ACUTE RESPIRATORY FAILURE, PALLATIVE CARE
Preexisting Conditions: ATRIAL FIBRILLATION, ALZHEIMERS, CHARLES BONNET SYNDROME, NON RHEUMATIC MITRAL VALVE DISORDER
Allergies: PENICILLIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: ON 02/08/2021 AROUND 0600 RESIDENTCOMPLAINED OF MOUTH PAIN AND RECEIVED OXYCODONE. DURING THE COURSE OF THE MORNING, RESIDENT EXHIBITED A FEW EPISODES OF LABORED/SHALLOW BREATHING AND SOB AT RESTING. 0XYGEN SATURATION RATE WAS 93-98% ON ROOM AIR, LUNG SOUNDS CLEAR IN ALL LOBES AND PULSE AND TEMPERATURE WITHIN NORMAL RANGE. AS THE DAY PROGRESSED, VITAL SIGNS REMAINED STABLE BUT RESIDENT CONTINUED TO HAVE PERIODS OF SOB/LABORED BREATHING.FAMILY AND NURSE PRACTIONER UPDATED AND THE ORDER WAS RECEIVED TO SEND PATIENT TO MEDICAL CENTER ER FOR EVALUATION PER AMBULANCE. RESIDENT TRANSPORTED AT 1425. RESIDENT RETURNED FROM THE ER AT 1830 ON HOSPICE CARE WITH THE DIAGNOSIS OF: ACURE RESPIRATORY FAILURE WITH HYPOXIA AND END OF LIFE DECISION MAKING. RESIDENT WAS MADE COMFORTABLE AND MONITORED DURING THE NIGHT AND EXPIRED AT 0630 ON 02/09/2021.


VAERS ID: 1016770 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-02
Onset:2021-02-06
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN531881 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dilantin 300mg Aspirin 81mg Atorvastatin 40mg Levothyroxine 100mcg Ferrous Sulfate 325mg Symbicort 160/4.5mcg inhaler Ventolin 90mcg inhaler Calcium 600mg Latanoprost eye drops
Current Illness: None
Preexisting Conditions: Fahr syndrome, Dementia, hypercholesteremia, metabolic encephalopathy, syncope, hypothyroidism, seizures, Coronary Artery Disease, iron deficiency anemia, asthma, ataxia.
Allergies: No known allergies
Diagnostic Lab Data: NA, client death.
CDC Split Type:

Write-up: Patient received 2nd dose of Pfizer vaccine on 2/2/21 and on 2/6/21 he died in his sleep in the a.m. No other signs or symptoms were observed prior to death.


VAERS ID: 1016907 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 2 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, aspirian, bisacodyl, buspirone, celebrex, cetaphil, levothyroxine, isoartan, MOM, miralax, mult vit, namenda, nizoral, remeron, senna plus.
Current Illness:
Preexisting Conditions: acute respiratory disease, unspecified dementia, weakness, hx of falling, ostearthritis, hypothyroidism, unsteady on feet, cognitive communication deficit, expressive long. disorder, anxiety, hypertension.
Allergies: KNA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident coughing in dining room, staff suctioned, physician stated to transfer via 911 to hospital, 6:33 PM. Hospital notified Nursing Home staff resident passed away at 8:25 PM. No adverse reaction noted to the Covid vaccine 24 hours after each dose at Nursing Home. There was no airway obstruction, cardiorespiratory arrest, death was natural at hospital.


VAERS ID: 1017011 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New York  
Vaccinated:2021-01-22
Onset:2021-01-26
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Dialysis
Preexisting Conditions: Chronic Kidney Failure Respiratory Failure
Allergies: NKA
Diagnostic Lab Data: Asymptomatic prior to expiration.
CDC Split Type:

Write-up: Resident expired 01/26/21 at 5:25am.


VAERS ID: 1017051 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Anaemia, Cardiac failure congestive, Cardio-respiratory arrest, Chest pain, Death, Dyspnoea, Intensive care, Pulseless electrical activity, Transfusion, Vasopressive therapy
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Haematopoietic erythropenia (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: coronary artery disease with prior two-vessel CABG in 2006, Ischemic cardiomyopathy, hypertension, hyperlipidemia, bilateral carotid artery disease, paroxysmal atrial fibrillation, systolic heart failure, pulmonary hypertension, and moderate -severe aortic stenosis, ulcerative
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt received vaccine on 2/3. early on 2/4 developed chest pain, dyspnea, and was seen in ED and diagnosed with acute exacerbation of CHF and NSTEMI type 2, and anemia. on 2/5 transfusion was started and pt developed worsening dyspnea and then PEA arrest. Pt achieved ROSC and was transferred to the cardiac intensive care unit where he required vasopressor support. he subsequently declined and died on 2/7


VAERS ID: 1017128 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021130110

Write-up: Passed away; This is a spontaneous report from a Pfizer-sponsored program Corporate (Pfizer) Social Media Platforms. This is a spontaneous report from a contactable consumer reporting for friend''s mother. A 50-years-old female patient received the second dose of bnt162b2 (BNT162B2) vaccine , via an unspecified route of administration on an unspecified date at single dose for Covid-19 immunisation . The patient medical history and concomitant medications were not reported. The patient received the first dose of BNT162B2 vaccine on an unknown date. The patient passed away on an unspecified date. The patient was a healthy woman, who just got her 2nd dose of the vaccine a couple of days before. The patient died in her sleep. Doctor labeled her death as ''natural causes''. It was not reported if an autopsy was performed. No follow-up attempts are Possible. Information on lot/batch cannot be obtained.; Reported Cause(s) of Death: Passed away


VAERS ID: 1017129 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Nevada  
Vaccinated:2020-12-17
Onset:2020-12-28
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan, aspirin.
Current Illness:
Preexisting Conditions: Hypertension. Diet & exercise-controlled diabetes. History of DVT 4 yrs prior to event. After completing a course of Xarelto has been on aspirin ever since.
Allergies: None known
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Sudden cardiac death. Autopsy report: right coronary artery thrombosis.


VAERS ID: 1017176 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Missouri  
Vaccinated:2020-12-30
Onset:2021-01-05
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Atrial fibrillation, Blood pressure decreased, Cardiac failure congestive, Cardiomyopathy, Death, Laboratory test abnormal, Multiple organ dysfunction syndrome, Oedema peripheral, Oxygen saturation decreased, Urinary incontinence
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Apixaban, Aspirin, Atorvastatin, Budesonide, Carvedilol, Docusate, Ferrous Gluconate, Furosemide, Lisinopril, Omperazole, Tiotropium Bromide inhaler, Amlodipine, Tylenol, Albuterol, Naproxen
Current Illness: Hypertension, Chronic ischemic heart disease, COPD, Atrial Fibrillation, Cardiomyopathy, Edema, Dementia, Anemia, Hyperlipidemia
Preexisting Conditions: COPD, Chronic ischemic heart disease, A fib, Hypertension
Allergies: NKA, NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had Covid-19 in October of 2020. He recovered. He received the vaccination on 12/30/2020 with no complaints. On 01-05-2021 it was noted to he was incontinent of urine and bilateral lower extremity edema. Lab work was completed showed acute kidney injury. He had decreased blood pressure and oxygen saturations on 01-06-2021 He was admitted to the hospital with rapid progression of symptoms and suggested multi-system failure. He had a long cardiac history. On 01-14-2021 he passed away with a diagnosis of Cardiomyopathic CHF, A.Fib contributory.


VAERS ID: 1017212 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-06
Onset:2021-02-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SC

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

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

Write-up: The patient suffered a cardiac arrest and remains in the hospital at this time.


VAERS ID: 1017339 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-30
Onset:2021-02-05
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, SARS-CoV-2 test negative, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.


VAERS ID: 1017367 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-01-05
Onset:2021-01-14
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Individual was healthy prior to vaccination.
Preexisting Conditions: Individual had Alzheimer''s disease.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Individual collapsed 9 days post-vaccination with no known reason. Despite being healthy prior to vaccination, individual''s condition deteriorated rapidly. Individual passed away on 1-17-2021.


VAERS ID: 1017381 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-06
Onset:2021-02-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away 2 days after receiving the vaccine. oxygen level has decreased shortly 1 day after receiving the vaccine.


VAERS ID: 1017393 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-26
Onset:2021-02-01
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

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

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

Write-up: Patient received the vaccine on 1/26/2021 and per employee at facility patient passed away on 2/01/2021.


VAERS ID: 1017509 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Blood culture positive, Death, Endotracheal intubation, Escherichia bacteraemia, Magnetic resonance imaging abnormal, Ovarian cancer
SMQs:, Acute pancreatitis (broad), Angioedema (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ovarian malignant tumours (narrow), Respiratory failure (broad), Non-haematological malignant tumours (narrow), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine vitamin c calcium vitamin D cetirizine questran vit b12 estradiol gabapentin MOM Magnesium oxide potassium chloride Avastin, Carboplatin, Gemcitabine
Current Illness: Advanced Ovarian Cancer
Preexisting Conditions: spinal stenosis
Allergies: penicillins
Diagnostic Lab Data: As noted above.
CDC Split Type:

Write-up: Day after receiving the vaccine, the patient complained of abdominal pain which worsened over the day. She went to the ED and was hospitalized. Abdominal pain complaints increased and continued, she decompensated rapidly, was intubated and subsequently died 3 days later. Imaging results showed, progressive ovarian cancer in the bowels. Blood culture revealed that she had E.Coli in her blood. It is thought that this is NOT related to the vaccine.


VAERS ID: 1017549 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-04
Onset:2021-02-09
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow)

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: Medications amlodipine atorvastatin budesonide cephalexin ciclopirox desloratadine epinephrine flaxseed oil fluticasone propionate glucosamine HCl hydrocodone-acetaminophen ipratropium bromide Keflex lisinopril-hydrochlorothiazide olopatadi
Current Illness:
Preexisting Conditions: Problem List: abscess of sublingual space abscess of submandibular region chronic ethmoidal sinusitis chronic maxillary sinusitis disorder of salivary gland essential hypertension history of asthma hyperglycemia hyperlipidemia leukocytosis localized enlarged lymph nodes mass of hand seasonal allergic rhinitis
Allergies: Penicillins, Levofloxacin, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dr. received an urgent request to call a local Justice of the peace regarding one of her patients who was found dead in her home today. At this time no foul play is suspected. Dr. said the patient was relatively healthy with no major issues other than some hypertension


VAERS ID: 1017563 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-09
Onset:2021-01-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Pyrexia, SARS-CoV-2 test negative
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: gabbapentin, morphine
Current Illness: arthritis, heart issues
Preexisting Conditions: neuropathy pain
Allergies: none that we know of
Diagnostic Lab Data: He tested negative for Covid. They thought it was heart related. They kept him in the hospital. Then they sent him to Nursing Home where they believe he contracted COVID. He went back to the hospital and passed away.
CDC Split Type:

Write-up: Patient got the injection and quickly developed a fever and felt weak. Family was contacted and he was sent to Hospital.


VAERS ID: 1017660 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-10
Onset:2021-01-26
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Death, Respiratory failure
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: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient contracted COVID and was hospitalized. He later died- respiratory failure secondary to COVID-19 pneumonia. This was not related to a vaccine adverse event, but reporting based on requirements.


VAERS ID: 1017675 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-03
Onset:2021-01-10
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELI1284 / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: capsacin pad, Ativan liquidMorphine Sulfate 20mg/ml
Current Illness: COPD, Diabetes Mellitus type 2
Preexisting Conditions: Nalignant neoplasm of cecum, COVID positive 10/2020, cerebral infarction,athersclerotic heart disease, heart failure, AV block
Allergies: sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 96 year old resident was diagnosed with COVID on 10/28/2020. She has a significant, complicated medical history and did not return to her pre-infection level of health. She began declining in early January and was made care and comfort measures only on 1/2/2021. Most of her medications were d/c''d except for those that provided comfort. No obvious reaction to the vaccine was seen and we do not suspect that her death was vaccine related, however we were directed by Dept of Epidemiology to report her death as it was within one week of receiving the vaccine.


VAERS ID: 1017744 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-26
Onset:2021-01-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Unknown


VAERS ID: 1017960 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-03
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy.


VAERS ID: 1017971 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-02
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

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

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


VAERS ID: 1017974 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-01
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


VAERS ID: 1017978 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-06
Onset:2021-02-01
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 2 LA / IM

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

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

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy


VAERS ID: 1018126 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-02-04
Onset:2021-02-08
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: chronic conditions listed below
Preexisting Conditions: per wife-diabetes, hypertension, hypercholesterolemia, depression, cvd, previous stroke
Allergies: na
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccination on 2/4. Patient''s wife reported that he felt a slight soreness in his arm the day following the shot, but had no other symptoms. On 2/8 he passed away. Wife reports that it was related to his heart and they never made it to a hospital. The wife also reported that the patient had been in poor health prior to the vaccination


VAERS ID: 1018146 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-01-28
Onset:2021-02-01
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Intracranial aneurysm
SMQs:, Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, carpidopa-levodopa, colchicine, januvia, sertraline HCL, finasteride, valsartan, febuxostat, daily vitamin centrum, vitamin d
Current Illness: None
Preexisting Conditions: Type 2 diabetes, BPH, gout, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Four days later, my father had a severe brain aneurysm.


VAERS ID: 1018278 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-01-27
Onset:2021-02-09
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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: Lisinopril, Flonase, famotidine
Current Illness:
Preexisting Conditions: Hypertension, breast cancer
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: death- unexplained cause


VAERS ID: 1018448 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-02-01
Onset:2021-02-06
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin 81 mg qd. vitamin D. duloxetine, cymbalta 20 mg qd. Jalyn one daily. ferrous sulfate. namenda. spiriva inhaler. zinc 50 mg qd
Current Illness: none
Preexisting Conditions: dementia. hx stroke. carotid disease. emphysema. hyperlipidemia. BPH
Allergies: oxycodone. penicillin. simvastatin
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/6/2021 stroke. 2/8/2021 he died


VAERS ID: 1019548 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-27
Onset:2021-01-30
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute hepatic failure, Asthenia, Bacteraemia, Chills, Death, Disseminated intravascular coagulation, Fatigue, Loss of personal independence in daily activities, Malaise, Metabolic disorder, Nausea, Pneumonia, Sepsis
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CVA, hypertension, pulmonary hypertension, GERD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received her first covid vaccine on 1/27/21. on 1/30/21 she presented to the emergency department complaining of nausea, she had a negative work up, felt better and was sent home. on 2/5/21 she returned to the emergency department more ill-appearing and complaining of "feeling sick". she had fatigue, chills, decrease in activity level. her work up at this visit revealed multiple metabolic abnormalities, sepsis and bacteremia. She ultimately passed away at this visit with at cause of death listed as acute liver failure, pneumonia, and DIC$g


VAERS ID: 1019573 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: South Dakota  
Vaccinated:2021-01-18
Onset:2021-01-19
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute kidney injury, Blood disorder, Cardiac disorder, Hypoxia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad)

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

Write-up: Systemic: Blood Disorder (diagnosed by MD)-Severe, Systemic: Cardiac Disorder (diagnosed by MD)-Severe, Systemic: Other- Acute Kidney Injury, Hypoxia; lasted 10 days


VAERS ID: 1019661 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-06
Onset:2021-02-07
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: lipitor 20mg daily, zetia 10mg daily, HCTZ 12.5mg daily prn, lisinopril 20mg daily, vitamin d daily, motrin prn, magnesium oxide 400mg daily, MVI daily, fish oil daily, asa 81mg daily, eye drops (latanoprost, cosopt, prednisolone)
Current Illness: hip replacement, HLD, HTN, atherosclerotic heart disease, cataract surgery
Preexisting Conditions: hip replacement, HLD, HTN, atherosclerotic heart disease, cataract surgery
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted to hospital evening of 2/7/21 with acute ischemic stroke and received tenectaplase. Diagnosis Left MCA stroke. Reporting event given was just over 24 hours after first COVID vaccine dose.


VAERS ID: 1019669 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Connecticut  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: heart failure with EF of 20-30%, coronary artery disease, type two diabetes, obstructive sleep apnea, diabetic nephropathy
Allergies: sulfonamides
Diagnostic Lab Data:
CDC Split Type:

Write-up: the following morning the patient became unresponsive while taking a shower, became asystolic and died despite about an hour of ACLS and 8 rounds of epi


VAERS ID: 1019670 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-27
Onset:2021-02-02
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Anion gap, Aspartate aminotransferase increased, Asthenia, Bacterial test positive, Base excess, Basophil count increased, Bilirubin urine, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bicarbonate increased, Blood bilirubin normal, Blood calcium decreased, Blood chloride decreased, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase normal, Blood creatinine increased, Blood glucose increased, Blood lactic acid normal, Blood pH decreased, Blood potassium normal, Blood sodium decreased, Blood sodium normal, Blood urea increased, Blood urea nitrogen/creatinine ratio increased, C-reactive protein normal, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Chromaturia, Creatine urine increased, Crystal urine present, Death, Differential white blood cell count normal, Dysuria, Endotracheal intubation, Eosinophil count decreased, Erythema, Fluid overload, Full blood count normal, Globulins decreased, Glomerular filtration rate decreased, Glucose urine absent, Haematocrit normal, Haemoglobin decreased, Hypoperfusion, Hypotension, Immature granulocyte count increased, Influenza virus test negative, Intestinal ischaemia, Lipase, Lung opacity, Lymphocyte count normal, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume increased, Mean platelet volume normal, Metabolic function test, Metamyelocyte percentage, Monocyte count decreased, Monocyte count normal, Neutrophil count, Neutrophil count normal, Nitrite urine absent, Opiates negative, Oxygen saturation decreased, PCO2 increased, PO2 normal, Platelet count normal, Pleural effusion, Pneumonia aspiration, Pneumonitis, Procalcitonin decreased, Protein total decreased, Protein urine present, Pulse absent, Pyrexia, Red blood cell count decreased, Red blood cell sedimentation rate normal, Red blood cells urine, Red cell distribution width increased, Resuscitation, Rib fracture, SARS-CoV-2 test negative, Small intestinal obstruction, Specific gravity urine normal, Toxicologic test normal, Troponin I normal, Urinary casts, Urinary lipids present, Urinary occult blood positive, Urine analysis, Urine analysis abnormal, Urine analysis normal, Urine ketone body present, Urine leukocyte esterase, Urobilinogen urine, Vomiting, White blood cell count normal, White blood cells urine positive, pH urine normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Lactic acidosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Ischaemic colitis (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Osteoporosis/osteopenia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Cerebral Palsy, Anxiety, Crohns, Bipolar, GERD, Nutrition deficiency, Iron deficiency
Allergies: lactose
Diagnostic Lab Data: 2/2/2021- CDC, CMP, Lipase, UA, CXR. COVID negative, Influenza Negative. WBC 8.2, HCT 48.2, HGB 16.3, CRP 4.9, NA 135, K+ 4.0, CHL 94, Bicarb 33, BUN 29, Creatinine 0.8, Glucose 145, Alkaline Phosphatase 106, Lipase 24. UA negative. 2/4/2021- 02/04 02/04 02/04 2145 2039 2039 Blood Gas VBG pH (7.31 - 7.41) 6.99 VBG pCO2 (40 - 50 mmHg) 73 VBG pO2 (40 - 50 mmHg) 81 VBG HCO3 (22.0 - 26.00 mmol/L) 17.7 VBG O2 Sat (Meas) (%) 85.8 VBG Base Excess (-2 TO 3 mmol/L) -14.9 VBG Lactic Acid (0.5 - 2.2 mmol/L) 10.1 Chemistry Sodium (135 - 148 mmol/L) 133 Potassium (3.6 - 5.2 mmol/L) 4.2 Chloride (98 - 107 mmol/L) 101 Carbon Dioxide (21 - 32 mmol/L) 18 Anion Gap (mmol/L) 14 BUN (7 - 25 mg/dL) 40 Creatinine (0.7 - 1.5 mg/dL) 1.4 Estimated GFR ($g60) 56 BUN/Creatinine Ratio 28.6 Glucose (70 - 110 mg/dL) 212 Calcium (8.4 - 10.2 mg/dL) 7.4 Total Bilirubin (0.1 - 1.5 mg/dL) 0.4 AST (5 - 40 U/L) 41 ALT (7 - 52 U/L) 40 Alkaline Phosphatase (34 - 104 U/L) 112 Creatine Kinase (35 - 232 U/L) 95 CK-MB (CK-2) (0.6 - 6.3 ng/mL) 2.8 Troponin I (<=0.03 ng/mL) 0.05 C-Reactive Prot, Quant (0.1 - 0.3 mg/dL) 5.7 Serum Total Protein (6.0 - 8.3 g/dL) 4.3 Albumin (3.5 - 5.0 g/dL) 2.6 Globulin (g/dL) 1.7 Albumin/Globulin Ratio 1.5 Procalcitonin (< 0.1 ng/mL) 0.7 Hematology WBC (4.0 - 11.0 K/uL) 6.9 RBC (4.30 - 5.70 M/uL) 4.39 Hgb (13.0 - 17.4 g/dL) 13.4 Hct (39.0 - 52.2 %) 42.8 MCV (80 - 100 fL) 98 MCH (25.0 - 35.0 pg) 31 MCHC (31 - 36 g/dL) 31 RDW Coeff of Var (11.0 - 16.0 %) 14.6 Plt Count (150 - 450 K/uL) 239 MPV (9.4 - 12.4 fL) 9.5 Immature Gran % (Auto) (0.1 - 0.3 %) 13.8 Neut % (Auto) (37.0 - 80.0 %) 56.2 Lymph % (Auto) (10.0 - 50.0 %) 21.8 Mono % (Auto) (0.0 - 12.0 %) 4.9 Eos % (Auto) (0.0 - 5.0 %) 0.6 Baso % (Auto) (0.0 - 3.0 %) 2.7 Immature Gran # (Auto) (0.01 - 0.03 K/uL) 0.96 Absolute Neuts (auto) (2.00 - 8.00 K/uL) 3.90 Absolute Lymphs (auto) (1.00 - 5.00 K/uL) 1.51 Absolute Monos (auto) (0.00 - 1.20 K/uL) 0.34 Absolute Eos (auto) (0.00 - 0.50 K/uL) 0.04 Absolute Basos (auto) (0.00 - 0.30 K/uL) 0.19 Total Counted (CELLS) 100 Neutrophils % (Manual) (37 - 80 %) 41 Band Neutrophils % (< 6 %) 12 Lymphocytes % (Manual) (10 - 50 %) 37 Monocytes % (Manual) (0 - 12 %) 8 Eosinophils % (Manual) (1 - 7 %) 0 Basophils % (Manual) (<4 %) 0 Metamyelocytes % (%) 2 Nucl RBC Rel Cnt (Man) (/100 WBC) 2 ESR (0 - 20 mm/hr) 4 Toxicology Urine Opiates Screen (NEG) NEG Ur Oxycodone Screen (NEG) NEG Urine Methadone Screen (NEG) NEG Ur Propoxyphene Screen (NEG) NEG Ur Barbiturates Screen (NEG) NEG U Tricyclic Antidepress (NEG) NEG Ur Phencyclidine Scrn (NEG) NEG Ur Amphetamines Screen (NEG) NEG U Methamphetamines Scrn (NEG) NEG U Benzodiazepines Scrn (NEG) NEG Urine Cocaine Screen (NEG) NEG U Marijuana (THC) Screen (NEG) NEG Urines Urine Source URINE - FOLEY CATH Urine Color YELLOW Urine Appearance (CLEAR/HAZY) TURBID Urine pH (5 - 9) 5.5 Ur Specific Gravity (1.005 - 1.030) $g=1.030 Urine Protein (NEG/TRACE mg/dL) $g=300 Urine Glucose (UA) (NEG mg/dL) NEGATIVE Urine Ketones (NEG mg/dL) 15 Urine Occult Blood (NEG) LARGE Urine Nitrite (NEG) NEGATIVE Urine Bilirubin (NEG) MODERATE Urine Urobilinogen (0.2 - 1.0 E.U./dL) 0.2 Ur Leukocyte Esterase (NEG) NEGATIVE Urine RBC (<3 /HPF) 11-20 Urine WBC (<6 /HPF) $g100 Ur Squamous Epith Cells (/HPF) RARE Amorphous Crystals (/HPF) MOD Urine Bacteria (/HPF) FEW Hyaline Casts (NONE SEEN /LPF) FEW Fine Granular Casts (NONE SEEN /LPF) FEW Urine Mucus (/LPH) FEW Ur Oval Fat Bodies (NONE SEEN /HPF) FEW Vol Urine Centrifuged (mL) 5 U Random Total Protein (mg/dL) 446 U Rand Prot/Creat Ratio (LT 0.2 RATIO) ND Urine Creatinine (mg/dL) 94
CDC Split Type:

Write-up: 2/2/2021- seen in Ed with c/o intermittent fever following 2nd dose. Redness to bilateral upper extremities, c/o some pain with urination, weak. V/S stable, afebrile in ED. Assess for infection. No significant abnormal labs (see below), hydrated and discharged. 2/4/2021- arrived in ED with c/o vomiting, seen earlier by PCP that day labs drawn. Shortly after arriving in the ED copious amouts of emesis noted, the patient went into full cardiac arrest and CPR was started. -Please see HPI above, in addition after intubation the patient coded again. More epinephrine and lidocaine were given. CPR was resumed. We did obtain ROSC and targeted temperature management was pursued. He is placed on a lidocaine drip and a right femoral central line was placed by myself. At this time, norepinephrine drip was initiated given his continued hypotension. Post intubation chest x-ray suggests possible abdominal pathology and once the patient was stabilized further, he was sent to the CT scanner where CT head without IV contrast and CT chest, abdomen and pelvis with IV contrast was obtained. He did lose pulses once in the radiology suite. This was brief. IV fluids were initiated and he received over 2 L of crystalloid therapy. He continued to be hypotensive in the emergency department and vasopressin was added. He also had a single dose of Neo-Synephrine and IV push fashion to help bring his blood pressure up. CT scan reveals probable bilateral aspiration pneumonia/pneumonitis and dilated loops of small bowel without a transition point and pneumatosis involving loops in the left upper quadrant. I did try to initiate consult with critical care and possible transfer, however he continued to be unstable and coded requiring CPR multiple times. He was given IV bicarbonate given his prolonged CPR state and pH. Ultimately, the family decided to make the patient comfort measures only given his critical illness. Shortly after making this decision he did pass away in the emergency department. RADIOLOGY DIAGNOSTIC - CHEST PORTABLE 02/04 2051 *** Report Impression - Status: SIGNED Entered: 02/04/2021 2059 IMPRESSION: 1. Findings highly suspicious for portal venous gas which can be seen in the setting of bowel ischemia. Consider CT for further evaluation and/or surgical consultation. 2. Endotracheal tube 3.7 cm above the carina. 3. Low lung volumes with mild patchy perihilar opacities. Final Report Signed by: M.D., Sign Date/Time: 02/04/2021 8:55 PM Impression By: MD CT SCAN - CT HEAD WO 02/04 2140 *** Report Impression - Status: SIGNED Entered: 02/04/2021 2200 IMPRESSION: Negative for acute intracranial process. No evidence of mass effect, acute hemorrhage or definite acute cortical infarct. Final Report Signed by: M.D., Sign Date/Time: 02/04/2021 9:57 PM Impression By: - MD CT SCAN - CT CHEST/ABD/PELVIS W 02/04 2140 *** Report Impression - Status: SIGNED Entered: 02/04/2021 2214 IMPRESSION: 1. Ill-defined patchy opacities within the bilateral upper lobes, right middle lobe, in consolidative opacities within bilateral lower lobes which could represent aspiration, and/or multifocal pneumonia. 2. Small right trace left pleural effusions. 3. Diffusely dilated small bowel without a transition point and mucosal hyperenhancement involving the colon with areas of pneumatosis involving loops of small bowel within the left upper quadrant and portal venous air consistent with hypoperfusion complex. There is a small caliber appearance of the aorta and a flattened appearance of the IVC is well. 4. Intravascular air within the IVC and bilateral iliac veins could be secondary to right femoral central lying injection. 5. Somewhat abnormal enhancement pattern of the kidneys with hypoenhancement of the medullary pyramids which may suggest hypoperfusion injury as well. 6. Probable nondisplaced rib fractures on the right at ribs 2 through


VAERS ID: 1019850 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-12-30
Onset:2021-02-10
   Days after vaccination:42
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood sodium decreased, Cardiac arrest, Endotracheal intubation, Pulse absent, Pulseless electrical activity, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: sulfa
Diagnostic Lab Data: Ordered BAG/MASK OXYGEN 1 Time ONE TIME 02/10/21 0727 EPINEPHrine PF 0.1 mg/mL (1:10,000) injection ONCE PRN 02/10/21 0657 sodium bicarbonate 8.4 % injection ONCE PRN 02/10/21 0657 EPINEPHrine PF (ADRENALIN) 1 mg/mL (1:1,000) injection ONCE PRN 02/10/21 0656 atropine syringe ONCE PRN 02/10/21 0655
CDC Split Type:

Write-up: HPI Patient is a 77 y.o. male who presents with in full cardiac arrest. Patient is resident of local nursing home. According to nursing home staff, a tech was in his room talking with him as patient was laying in bed. Tech began walking out of patient''s room and turned around to tell him one last thing when the tech noticed patient had gone unresponsive. Patient had no spontaneous respirations or pulse, subsequently CPR was started immediately. 911 was called. This occurred around 5:30 a.m.. Upon EMS arrival on scene, they found a male unresponsive with CPR being performed. There was no spontaneous respirations or circulation. Thus, ET tube was placed and ACLS guidelines initiated. Patient was found to be in PEA, and according to EMS, patient was given a total of 6, 1 mg epinephrine IV push and 1, 1 Amp sodium bicarb. Patient was worked on at the scene for approximately 40 min before being transferred to ER. Upon arrival to ER trauma room 1 patient is still in full arrest. ET tube in place with good ventilation. Patient remains in PEA. Chest compressions and ACLS guidelines initiated. In reviewing patient''s chart and nursing home notes, patient is a full code. Patient has a significant cardiac history including known coronary artery disease with 4 vessel CABG. Patient also has history of 3rd degree heart block and pacemaker placement. Patient has history of ischemic cardiomyopathy but last echo performed in 2020 shows ejection fraction of 45%.


VAERS ID: 1019911 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Mechanical ventilation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Tested positive for COVID-19 on 01/26/2021 (Antigen positive) - presented to ED due to shortness of breath and fatigue
Preexisting Conditions: Active Problems Noted Date Hypokalemia 1/28/21 Pneumonia due to COVID-19 virus 1/28/21 Acute hypoxemic respiratory failure 1/28/21 Stone of salivary gland or duct 1/8/21 Recurrent major depressive disorder, in partial remission 1/7/21 Secondary hyperparathyroidism of renal origin 1/7/21 Abnormal blood smear 7/22/20 Alkaline reflux gastritis 1/2/20 Severe obesity (BMI 35.0-39.9) with comorbidity 12/20/18 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin 12/20/18 Morbid obesity due to excess calories 6/18/18 Psoriasis 12/13/17 Proteinuria 10/20/17 Bilateral leg edema 12/5/16 Hypertriglyceridemia 6/27/16 Essential hypertension with goal blood pressure less than 130/85 6/27/16 Anxiety, generalized 6/27/16 Hypothyroid 11/24/14 Aortic valve replaced 7/7/14 Pulmonary emphysema 1/22/09 Obstructive sleep apnea syndrome 8/4/1943 Resolved Problems Noted Date Resolved Date Other chest pain 10/29/19 10/30/19 Chest pain 10/29/19 10/30/19 Type 2 diabetes mellitus without complication, without long-term current use of insulin 6/24/19 7/6/20 Sialadenitis 1/4/19 1/2/20 Obesity (BMI 35.0-39.9 without comorbidity) 12/20/18 1/29/21 Abdominal pain 11/21/18 1/2/20 Type 1 diabetes mellitus with stage 3 chronic kidney disease 6/18/18 6/18/18 CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min 10/20/17 1/2/20 Sarcoidosis of lung 6/27/16 6/26/20 Uncontrolled type 2 diabetes mellitus with stage 3 chronic kidney disease, without long-term current use of insulin 6/27/16 12/13/17 Overview: Recent onset HbA1C 4/21/16 11.9. Last FBS-110 5/17/16 Diabetic eye exam 9/23/16 no diabetic retinopathy. fup one year. Hypothyroidism (acquired) 6/27/16 12/13/17 Exertional dyspnea 6/27/16 6/26/20 Tobacco abuse 11/19/08 9/23/11 documented as of this encounter (statuses as of 01/29/2021) Patient Active Problem List Diagnosis ? Obstructive sleep apnea syndrome ? Pulmonary emphysema (*) ? Aortic valve replaced ? Hypothyroid ? Hypertriglyceridemia ? Essential hypertension with goal blood pressure less than 130/85 ? Anxiety, generalized ? Bilateral leg edema ? Proteinuria ? Psoriasis ? Morbid obesity due to excess calories (*) ? Obesity (BMI 35.0-39.9 without comorbidity) ? Severe obesity (BMI 35.0-39.9) with comorbidity (*) ? Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin (*) ? Alkaline reflux gastritis ? Abnormal blood smear ? Recurrent major depressive disorder, in partial remission (*) ? Secondary hyperparathyroidism of renal origin (*) ? Stone of salivary gland or duct ? Hypokalemia ? COVID-19 virus infection ? Acute hypoxemic respiratory failure (*) Past Medical History: Diagnosis Date ? Anxiety ? Arthritis ? Asthma ? Back pain ? Chronic kidney disease, stage II (mild) 10/20/2017 ? Dependent edema ? DJD (degenerative joint disease) ? Gastritis ? Glucose intolerance (impaired glucose tolerance) ? History of pulmonary function tests 10/20/2010 showing decreased lung flow consistent with normal variant versus mild obstruction and emphysema ? History of stress test 12/2009 Normal ? Hyperlipidemia ? Hypothyroid Previously had hyperthyroidism ? Kidney stone 05/1999 Right ? Proteinuria 10/20/2017 ? Psoriasis ? Sarcoidosis ? Sleep apnea Past Surgical History: Procedure Laterality Date ? AORTIC VALVE REPLACEMENT 05/2001 #25 St. Jude''s aortic valve replacement ? APPENDECTOMY 1960''s ? CHOLECYSTECTOMY 1994 ? COLONOSCOPY 2010 ? COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD N/A 11/21/2018 COLONOSCOPY with hot polypectomy snare ? OTHER SURGICAL HISTORY 09/2018 spot removed from left arm ? TOTAL KNEE ARTHROPLASTY Right 11/19/2012 ? UPPER GI ENDOSCOPY,DIAGNOSIS N/A 11/21/2018 EGD with cold biopsies performed ? WISDOM TOOTH EXTRACTION
Allergies: Review of patient''s allergies indicates: Allergies Allergen Reactions ? Other [Uncoded Nonscreenable Allergen] Rash Neoprene
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client was administered the vaccine while symptomatic (01/25/21) although client did not know he was symptomatic for COVID-19. He had been exposed to a family member who had tested positive and should have been in quarantine but wasn''t either because it was not felt he was considered a close contact by his family opinion or his family member never notified public health of this close contact...?. Clinet had presented to the ED following day after vaccination for shortness of breath and fatigue and an antigen test showed he was positive for COVID-19. He was sent home that same day 01/26/21. He was back in ED on 01/28/21 for worsening symptoms and admitted to hospital and later placed on ventilator. He passed away on 02/09/2021 (date of death was per his wife).


VAERS ID: 1019964 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-07
Onset:2021-02-07
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ferrous sulfate, Proteinex, Tylenol, Eliquis, Aspirin, Lipitor, Vitamin D3, Cholestyramine, finasteride, flavoxate, lactobacillus, loratadine, magnesium oxide, metoprolol, protonix, miralax, potassium cl, Tamsulosin, acetic acid (for foley)
Current Illness: Peg tube placement Malignant neoplasm of esophagus
Preexisting Conditions: Attention and concentration deficit, Hyperlipidemia, Acute embolism thrombosis of Deep veins or upper extremity, cognitive communication deficit, cerebral infarction, Dysphagia, Thrombocytopenia, Obstructive and reflux uropathy, Hypomagnesemia, Allergic rhinitis, GERD, Hydronephrosis with renal and ureteral calculous obstruction, Benign prostatic hyperplasia with lower urinary tract symptoms, anemia, ulcerative pancolitis, cerebral cysts, chronic obstructive pyelonephritis, hypo-osmolality and hyponatremia, HTN, Vascular dementia with behavioral disturbances, DM II, Moderate protein-calorie malnutrition, Vitamin D deficiency, Folliculitis, Hypokalemia, Aphasia following cerebral infarction, metabolic syndrome
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: The resident received his COVID-19 Moderna vaccination on 2/6/2021 2:11 pm and expired on 2/7/2021 at 6:04 am. There were no signs or symptoms of vaccination reaction leading up to death.


VAERS ID: 1019979 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-28
Onset:2021-01-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Death, General physical health deterioration, Hypoxia, Mechanical ventilation, Oxygen saturation abnormal, Respiratory distress, Tachycardia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ALBUTEROL HFA (8.5GM) 90 MCG INHA Exp: 05/06/2021 SIG: 90mcg Inhalation every four (4) to six (6) hours as needed x 180 day(s) -- Limited to two (2) canisters every six (6) months Artificial Tears Ophthalmic Solution 1.4 % Exp: 02/23/2021 S
Current Illness: Vitamin Deficiency
Preexisting Conditions: GERD, COPD, HTN, Hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: Patient was assessed at hospital and transferred to another facility on 2/3/21. At this time, the COVID protocol was followed. His condition deteriorated and he was placed on a vent 2/9/21. He was pronounced deceased 2/10/21 at 0610.
CDC Split Type:

Write-up: Patient received the Moderna COVID vaccine 1/28/21. He was tested for COVID 19 on 1/29/31. Results were received 1/30/21, at which time he was evaluated and found to be hypoxic with tachycardia. He was sent to the local ER and returned this same day. On 2/2/21, he was evaluated by the provider, who sent him to the emergency room with acute respiratory distress and poor O2 sats


VAERS ID: 1020002 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-19
Onset:2021-02-05
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol, Bumetanide, Metolazone, Candesartan, Carvedilol, Gabapentin, Insulin Pantoprazole, Tamsulosin, Warfarin
Current Illness: CHF
Preexisting Conditions: CHF, DM, CAD, CKD, Sleep apnea, COPD
Allergies: cyclobenzaprine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Given First Moderna covid vacc 1/19/2021. Doing well on multiple contacts from health care providers, then 2/5/2021 was driving, pulled over to the side of the road into a yard, got out of the car and told an observer that he could not breathe, collapsed face down in the snow, EMS called, unable to revive him.


VAERS ID: 1020018 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated:2021-02-08
Onset:2021-02-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 AR / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient reported to be unresponsive on the morning after receiving his second dose of Moderna COVID-19 vaccine. Patient had expired during the night.


VAERS ID: 1020079 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-14
Onset:2021-01-31
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Dyspnoea, General physical health deterioration, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Symbicort, sotalol, mexilitine, tiotropium, carbidopa/levodopa, aripiprazole, allopurinol, citalopram, insulin, pantoprazole, pravastatin, tamsulosin, tioptropium, warfarin, bumetanide, bupropion
Current Illness:
Preexisting Conditions: Ischemic Cardiomyopathy, Coronary Artery Disease (MI x2 1989 and 1995), VT (ablation 2009) with Boston Scientific ICD Sick Sinus Syndrome (PPM), Type 2 Diabetes, Chronic Kidney Disease, Hypertension, Hyperlipidemia Peripheral Vascular Disease, Parkinson''s Disease Antiphospholipid Antibody Syndrome Heparin Induced Thrombocytopenia
Allergies: Heparin Atorvastatin
Diagnostic Lab Data: Related to hospital stay. Unavailable currently.
CDC Split Type:

Write-up: Received Moderna covid vaccination 1/14/2021. 1/16/2021 received report of cough and difficulty breathing. Proceeded to hospital and was diagnosed Covid+ on testing. Continued to decline, died 1/31/2021.


VAERS ID: 1020119 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-18
Onset:2021-02-03
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 7+ UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Internal haemorrhage, Shock, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), 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), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Chronic lukemia
Allergies: None
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: My mother died suddenly on February 3rd. She went into shock/cardiac arrest and appeared to have internal bleeding. No autopsy has been performed. Unsure if it was related to the COVID vaccine.


VAERS ID: 1020183 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-02
Onset:2021-02-07
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Angina
Allergies: Unknown
Diagnostic Lab Data: Death Certificate.
CDC Split Type:

Write-up: Death. I actually not sure which Covid Vaccine she took. I just know the date and time she took it at her local school where she worked. Died in her sleep after complaining of a headache. I talked to her around 5pm on sunday through a videochat and she seemed happy and well. But a local friend commented that she had complained of a headache late in the afternoon.


VAERS ID: 1020195 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-12
Onset:2021-01-15
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, COVID-19, Colonoscopy normal, Condition aggravated, Death, Dyspnoea, Occult blood negative, Oesophagogastroduodenoscopy normal
SMQs:, Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol, amlodipine, Atorvastatin, carvedilol, ipratropium, asa
Current Illness: None
Preexisting Conditions: HTN, Osteoarthritis, brain aneurysm
Allergies: None
Diagnostic Lab Data: Per hospital record which is currently unavailable
CDC Split Type:

Write-up: Received Moderna #1 on 1/12/2021. 1/15/2021 developed worsening shortness of breath. Went to hospital and diagnosed with anemia, 4 negative fecal tests, neg EGD and colonoscopy. Discharged and readmitted (circumstances unknown for this episode) then readmitted a third time 1/20/2021 for shortness of breath. Diagnosed covid + at third hospitalization and continued to get worse. He died 1/23/2021.


VAERS ID: 1020227 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-02-05
Onset:2021-02-07
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ALENDRONATE SODIUM 70MG TABLET (4''S) TAKE ONE (1) TABLET ACTIVE BY MOUTH ONE TIME EACH WEEK WITH WATER 30 MINUTES BEFORE EATING OR TAKING OTHER MEDICATIONS CALCIUM W/ VITAMIN D 600/500 SLOW RELEASE TAKE 2 TABLETS ACTIVE BY MOUT
Current Illness: Pt had COVID with symptom onset 1/27/21, pos test 1/28/21 admitted to Hosptial and was treated w/ remdesivir at , discharged 1/30 on Dexamethasone 6mg daily, no need for O2 supplement. First moderna COVID vaccine was 1/5/21.
Preexisting Conditions: 1)*AU SEVERE LOSS 2)Anemia - 3)Tubular adenoma of colon - 4)*SCLERAL PLAQUE EXCISION OS - STILL PO 2+ MONTH 5)Osteoarthritis - bilateral knees...worse in right knee -QUALIFIERS: Severity Moderate to severe 6)Chronic obstructive lung disease - 7)Onychomycosis - x10 -QUALIFIERS: Severity Mild to moderate Clinical course Chronic 8)Artificial lens present - OU 9)Hypermetropia - OD 10)Presbyopia - OU 11)Regular astigmatism - OD 12)Arcus of cornea - OU 13)Scarred macula - OS 14)Osteoporosis - 15)Osteoarthritis of knee - 16)Hypothyroidism - 17)Benign prostatic hyperplasia - 18)Hip pain, Right - Had right hip fracture pinning and has post traumatic DJD 19)Chronic pain - 20)Dry eyes - 21)Sensorineural hearing loss, Bilateral - 22)Nonexudative age-related macular degeneration, Bilateral -
Allergies: Allergies: CODEINE
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This is the patient who passed away 2d after his second COVID vaccine. Of note, the 2/8 telephone note makes it sound like he was hospitalized at time of death - that is incorrect. His daugther listed as EM contact works in the eye clinic here. He had mild illness, completed 10d isolation but missed his scheduled booster dose on 2/2 due to isolation. He was called on 2/5 when there was a booster visit cancellation and received his booster dose on that day. His daugther reported that he was doing fine and looking well on 2/7 AM, ate breakfast, shortly after stood up and just collapsed.


VAERS ID: 1020443 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-01-30
Onset:2021-02-03
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acidosis, Apnoea, Cardiac arrest, Chest pain, Dyspnoea, Endotracheal intubation, Hypoxia, Malaise, Resuscitation, Ultrasound abdomen, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown, per patient''s daughter patient had unevaluated chest pain for 2 days prior to presentation
Preexisting Conditions: Unknown
Allergies: No known drug allergies
Diagnostic Lab Data: No tests were performed.
CDC Split Type:

Write-up: For the two days prior to presentation the patient had been complaining of chest pain, his breathing seemed to be labored Monday. He and the family thought the pain was due to shingles as he carried this diagnosis from a month ago. Patient had also received the COVID vaccine 2 days prior to presentation and assumed he was feeling unwell due to the vaccine. Family wanted to take him to the hospital yesterday and earlier today but he refused. She left him in his home earlier this afternoon prior to presentation and returned to check on him finding him unresponsive and apneic at which time EMS was activated. #cardiac arrest -- suspect primary cardiac given collateral from family at home, consider hypoxemia which was corrected with advanced airway and 100% FiO2, patient clinically euvolemic and with soft brown stool in diaper not suggestive of GI hemorrhage, attempt to address acidosis with CPR and bicarbonate, not hypoglycemia, on bedside ultrasound FAST neg and no pericardial effusion suggestive of tamponade and +lung sliding bil not spontaneous pneumothorax Assessment/Diagnosis: -cardiac arrest, cause unspecified


VAERS ID: 1020654 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-02-04
Onset:2021-02-05
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, 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), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xarelto, Verapamil ER, Amlodipine, Durezol, Trelegy Ellipta, Gabapentin, Oxycodone, Sertraline, Carafate, Trazadone, Atorvastatin, Calcium and Vit. D, Vit. D 25mcg, Vit. B-12, Famotadine, Ferrous Sulfate, Metoprolol Succinate XR, Pantoprazo
Current Illness: Acute Onchronic Respiratory Failure, Aspiration Pneumonia, and NSTEMI, Diarrhea, Hypertrophic cardiomyopathy, Gram positive bacteremia, Acute kidney injury, Afib,
Preexisting Conditions: COPD, Non-small cell lung cancer, CAD, Rheumatoid Arthritis, Chronic Normocytic Anemia, GERD, HTN, Hypokalmia, Aneurysm of the thoracic aorta,
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient found unresponsive in room with no pulse or respirations. She was pronounced dead by paramedics at 06:25am on 2/5/2021.


VAERS ID: 1020684 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-01-13
Onset:2021-01-16
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Anticonvulsant drug level decreased, Blood pressure abnormal, Death, Heart rate abnormal, Pneumonia, Seizure
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (broad), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: history of seizure disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine at Public Health Clinic. Patient ended up having a seizure 3 days later and ended up in the hospital. Found to have right lobe pneumonia and low depakote level. Patient noted to have multiple seizures at hospital, issues with stabilizing HR and BP, and passed away on 1/20/21.


VAERS ID: 1020702 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-01-20
Onset:2021-02-09
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 - / 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: Hydrochlorothiazide, Hydroxyzine, Mirena, Ocrevus, Prednisone, triamcinolone acetonide, valacyclovir, vitamin D 3
Current Illness:
Preexisting Conditions: calcaneal spur displacement of intervertebral disc without myelopathy female stress incontinence foot pain hand joint pain herpes simplex low back pain menorrhagia multiple sclerosis neck pain numbness of lower limb peripheral edema polyneuropathy
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Passed away the morning of 2/9/21.


VAERS ID: 1020724 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-01-21
Onset:2021-02-02
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID19,
Preexisting Conditions: hypertension and Coronary Artery Disease
Allergies: codeine, penicillin
Diagnostic Lab Data: COVID19 Roche LIAT PCR test - Detected
CDC Split Type:

Write-up: Patient sent to the ED or sudden onset of shortness of breath on 02/02/2021. Per documentation by the MD, the patient had COVID19 "several weeks ago" and the nursing facility felt like he had recovered. A rapid test done in the ED was negative. When the patient worsened and seemed to be following the same path as other COVID patients, a send out PCR test was done, which was positive. The patient worsened and passed away that same day (02/05/2021) I was not made aware that the patient had the vaccine on 01/21/2021 until Monday 02/08/2021.


VAERS ID: 1020749 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-01-13
Onset:2021-01-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cyanosis, Death, Myocardial infarction
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: HTN, Diabetes, High Cholesterol
Allergies: Unknown
Diagnostic Lab Data: No test, lab, nor autopsy.
CDC Split Type: MS0032021

Write-up: Patient had no reaction at the clinic. Patient is a medical doctor whose partner called in this death. States patient had no complaint on 1/13 nor 1/14 while at work. States patient died at home on 1/15 a.m. Physician who stated she was called to the patient''s home @ 0157 1/15/2021 and found cyanotic from head to toe. State girlfriend found him sitting in the chair a few minutes before they called her. The Coroner did not order autopsy. Did not sent patient to the hospital. Sent him directly Funeral Home. Death Certificate Number 123-2021-002593 list cause of death as pending. I spoke with the patient''s primary doctor who gave me the history of HTN, Diabetes, & High Cholesterol. States he had not seen this patient since April 2020. They were also friends and he was not aware of any medical problems. The Coroner state she thinks patient has a heart attack. Neither the Coroner nor PMD think death was related to COVID Vaccine. Informed both that MSDH would have to complete VAERS. Both voiced understanding.


VAERS ID: 1020816 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-19
Onset:2021-01-25
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / UNK AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal wall haematoma, Acute respiratory failure, COVID-19 pneumonia, Death, Endotracheal intubation, Haemodynamic instability, Hypotension, Intensive care, Oxygen saturation abnormal
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt with acute resp failure, COVID PNA, that developed symptoms 9 days prior to admit and ultimately received first vaccine 6 days prior toa admit, then shortly after progressed with other covid symptoms and was admitted. She decompensated while intp and was transferred to ICU for rising O2 needs, ultimately had to be intubated. Became hypotensive due to massive hamatoma 2'' bleeding into abd rectus muscle. Sx and IR consulted and did beside exploration of hematoma. Initially blood pressure responded but overnight continued with refractory hypotension. Maxed out vasopressin and levophed, hemodynamics deteriorated. Pt passed soon after(2/2).


VAERS ID: 1020830 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-01-21
Onset:2021-01-30
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Aortic aneurysm rupture, Death
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UTO
Current Illness: Leaking Aortic Aneurysm -
Preexisting Conditions: Aortic Aneurysm
Allergies: None
Diagnostic Lab Data: Hospitalization with testing - UTO
CDC Split Type:

Write-up: This resident of the assisted living facility received his Covid-19 Moderna (1st) vaccination and he has a leaking Aortic Aneurysm which resulted in hospitalization and he entered into Hospice care on 1.30.2021 and passed away on 1.30.2021.


VAERS ID: 1021038 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had passed since the first dose was given.


VAERS ID: 1021040 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-01-06
Onset:2021-01-17
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

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: Unknown - LTCF will also be reporting
Current Illness: Unknown - LTCF will also be reporting
Preexisting Conditions: Obesity, others unknown
Allergies: Unknown - LTCF will also be reporting
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Pfizer-BioNTech COVID-19 Vaccine Hospital Emergency Room Provider reported cause of death as COVID vaccine administered 11 days prior to death. Additional information being reported from LTCF.


VAERS ID: 1021045 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / UNK RA / IM

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

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

Write-up: Patient had passed since the first dose was given.


VAERS ID: 1021052 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 9
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 had passed since the first dose was given.


VAERS ID: 1021058 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-02-01
   Days after vaccination:19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 9
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 had passed since the first dose was given.


VAERS ID: 1021171 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Albuterol, ASA, Zyrtec, D3, CPAP, Zetia, FeSO4, Flonase, Lantus, Atrovent solution, Losartan, Melatonin, Reglan, Metoprolol Succinate, Pantoprazole, Paroxetine, Polyethylene Glycol, Sucralfate, Tamsulosin, Stiolto Respimat
Current Illness: Hypertension, chest pain x 1 month, nausea (1/18/21 primary care visit); memory loss, small left cerebellar infarct (neurology 2/1/21)
Preexisting Conditions: HTN, CAD, cerebellar dysfunction, claudication, old myocardial infarction, COPD/dyspnea/sleep apnea, hx thoracic aortic aneurysm, CHF, DM II (insulin dependent), CKD stage 3, anemia, irregular heartbeat, PVC, hx of smoking, atelectasis, BPH, vascular dementia, angina of effort, GERD/abnormal barium swallow/DM gastroparesis, dyslipidemia, depression
Allergies: Statin intolerance (muscle tightening)
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient received first dose of Moderna COVID-19 vaccine on 2/3/21. Primary Care physician received call from coroner''s office 2/8/21 asking for information contributing to cause of death. Per Primary Care Physician notes, wife states she and patient took turns shoveling snow on 2/4/21. On one trip back into the house she found him unresponsive on the floor and called 911. Paramedics were unable to revive patient and he passed away (2/4/21).


VAERS ID: 1022902 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-19
Onset:2021-01-29
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Ammonia increased, Blood lactic acid, Cholangiocarcinoma, Computerised tomogram abnormal, Death, Endoscopy upper gastrointestinal tract normal, Gastrointestinal haemorrhage, Gastrointestinal tube insertion, Haematemesis, Paracentesis, Small intestinal obstruction
SMQs:, Liver related investigations, signs and symptoms (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (broad), Biliary malignant tumours (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death Narrative: 71 yo male who passed away on 1/29/2021, medical cause of death "cholangiocarcinoma, interval between onset and death 14 months. Since patient passed away within 42 days of the covid19 vaccine administration, we are required to complete a report to VAERS. Vaccine (Pfizer) was administered without complications. The patient denied any prior severe reaction to this vaccine or its components or a severe allergic reaction such as anaphylaxis to any vaccine or to any injectable therapy. Synopsis- 1/23 71 yo male presented to ED with upper GI bleed. PMH: DM, HTN, cholangiocarcinoma of biliary tract requiring recurrent paracentesis, COPD, perigastric and lower esophageal varices (not on beta blockers due to bradycardia). Pt has had 2 episodes of coffee ground emesis. Lactic 2.6, ammonia 52. Rec''d protonix, octreotide, and ceftriaxone in ED. Family has been previously encouraged to speak to palliative care but has never been willing to. GI consulted. 1/24 EGD completed. No signs of active bleed. MDs recommending hospice. CT + for small bowel ileus. 1/26 Requires placement of NG tube to suction. Palliative care consulted. 1/27 Paracentesis completed. 4100mls removed. 1/28 Pt changed to palliative status. 1/29 Pt passed away.


VAERS ID: 1021919 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-06
Onset:2021-01-17
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen therapy, Renal failure, Urinary retention
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Heart disease, unspecified; Renal disease
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; kidney failure (unable to urinate); shortness of breath; required oxygen; A spontaneous report was received from consumer concerning an 87-year-old, female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced shortness of breath, kidney failure and death. The patient''s medical history included advanced kidney and heart disease. No relevant concomitant medications were reported. On 06 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Lot: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 17 Jan 2021, the husband reported that the patient experienced adverse events. Symptoms included shortness of breath and kidney failure (unable to urinate). The patient was admitted to the hospital and discharged to hospice. Oxygen was administrated for shortness of breath. Action taken with mRNA-1273 in response to the events was not applicable. On 20 Jan 2021, the patient died. The cause of death was unknown. Autopsy details were unknown.; Reporter''s Comments: This case concerns a 87-year-old, female patient with the medical history of advanced kidney and heart disease, who experienced fatal unexpected event of dyspnea, renal failure and death. The events of dyspnea and renal failure occurred 12 days and the event of death occurred 15 days after the first dose of mRNA-1273 (Lot: unknown). The patient was admitted to the hospital and discharged to hospice. Oxygen was administrated for shortness of breath. The cause of death was unknown. Autopsy details were unknown. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. However, the history of advanced kidney and heart disease may remain as confounder. Additional information has been requested.; Reported Cause(s) of Death: Unknown cause of death


VAERS ID: 1021926 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-05
Onset:2021-01-08
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data: Test Date: 20210108; Test Name: Covid-19 test; Test Result: Positive ; Result Unstructured Data: Positive
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Positive result; A spontaneous report was received from a consumer concerning a female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed COVID-19 and passed away. The patient''s medical history was not provided. Concomitant product use was not reported. On 05 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient had a positive COVID-19 test. On 18 Jan 2021, the patient passed away. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 18 Jan 2021. The cause of death was not reported.; Reporter''s Comments: This spontaneous report concerns a female patient who experienced COVID-19 and passed away. The event of COVID-19 occurred 4 days after the first and only dose of the mRNA-1273 vaccine administered and death occurred 14 days after administration of the mRNA-1273 vaccine. Based on the information provided and the known etiology of COVID-19, it is unlikely to be associated with mRNA-1273 vaccine administration. With no definite information on the clinical details of the death, it is difficult to adequately assess a causal association with mRNA vaccine. Main field defaults to ?possibly related''; Reported Cause(s) of Death: unknown cause of death


VAERS ID: 1022127 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Alaska  
Vaccinated:2021-01-12
Onset:2021-01-19
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Heart disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021117157

Write-up: One week to the day after patient''s first vaccine he died of a heart attack; This is a spontaneous report from a contactable consumer and from a contactable physician. A 71-year-old male patient (husband) received first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 12Jan2021 at single dose on the right arm for COVID-19 immunization. The patient medical history included past heart conditions. No known allergies. Patient took other medications in two weeks. Facility type vaccine was doctor''s office/urgent care. No other vaccine received in four weeks. One week to the day after patient''s first vaccine he died of a heart attack on 19Jan2021 18:30. Cause of death was heart attack. No COVID prior vaccination. No COVID tested post vaccination. It was unknown if an autopsy was performed. The physician reported that the patient arrived DOA. Physician signed the death certificate based on the patient''s prior diagnosis. Physician would not provide additional cause of death medical background without consent. He was not aware of any adverse events experienced from the time of vaccination to the date of death. Follow-up (05Feb2021): This is a follow up spontaneous report from a contactable physician. This physician reported in response to HCP telephonic follow up activity which the following: patient death and cause of death were confirmed. Follow-up attempts are completed. No further information is expected. Information about Lot number is not available.; Sender''s Comments: Based on the temporal relationship, the association between the event fatal heart attack with BNT162b2 can not be fully excluded. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.; Reported Cause(s) of Death: One week to the day after patient''s first vaccine he died of a heart attack


VAERS ID: 1022160 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-02-05
Onset:2021-02-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: aspirin, b-12 shot, Bumex, Calcitrail, Colace, Eztimibe,Imdure, Lantus, Novolog, Lorazepam, Metrprol Suc, Nexium, Plavics, Rena, Sertaline, Synthyroid, VIT D
Current Illness: Kidney failure required dialysis 5x weekly
Preexisting Conditions: Cardiac, Diabetes, Kidney failure Kidney transplant with kidney failure
Allergies: no
Diagnostic Lab Data: none
CDC Split Type:

Write-up: 24 hours after shot had high fever 101, chills, weakness, became listless, family called 911, client became unresponsive and died in the Emergency room.


VAERS ID: 1022397 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-16
Onset:2021-02-09
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9289DEATH / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Resident was end of life/comfort measures which started 7/2/2020. diagnosed with covid 1/20/21. received first vaccination 1/16/21 and second dose 2/6/21. expired 2/9/21.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 2/9/21


VAERS ID: 1022440 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-01-23
Onset:2021-02-01
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute myocardial infarction, Chest pain, Death, Dyspnoea, Pericarditis
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: HTN, hyperlipidemia, pericarditis (diagnosed in 2014)
Allergies: None
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: The decedent experienced severe chest pain and dyspnea approximately nine days following the first series of the vaccine. He reported to family members that he was having a "severe reaction" to the vaccine and believed it was acute pericarditis due to the same symptoms he experienced prior. He reported that on 2/1/21 around 0300 hours, the symptoms were the most severe and he was going to seek medical attention, but did not. He waited till the convenient store opened and purchased OTC Tylenol for relief of symptoms. He continued to have dyspnea and chest pain up until 2/9/21, when he called 911 complaining of chest pain and was found to have a STEMI; subsequently died at Hospital in the ER.


VAERS ID: 1022529 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-27
Onset:2021-02-09
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Respiratory arrest, 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), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

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: Venlafaxine Hcl ER 150 daily, Multi vitamin, Aspirin 81mg, Nitro 0.4 prn, Vitamin E 200 daily, Ipratropium-Albuterol 0.5-2.5 inhalation q 6 hrs, omeprazole 20mg daily, isorbide monintrate ER 60mg daily, spironolactone 50mg , mens multi vita
Current Illness: pt was seen 1/8/21 for a Scatica flare Pt had a follow up colonscopy performed 1/21/21 where a couple polyps were found and diverticulosis
Preexisting Conditions: pt has COPD and used Oxygen at night, Coronary atherosclerosis, Diabetes Type 2, hypertriglyceridemia, OSA, hyperlipidemia, hypertension, IBS, pulmonary emphysema, acute or chronic heart failure, morbid obesity, atrial fibrillation, depression, hypercholesteremia, stage 3 kidney disease
Allergies: Amoxicillin(rash), Lisinopril (cough)
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt suffered Cardiac Arrest and respiratory arrest on 2/9/21 and passed away at a local hospital. He had multiple health conditions likely contributing to this. he arrested at home and CPR was attempted and unsuccessful. Pt received his Covid vaccine #1 on 1/27/21. No issues were noted after vaccine and was due for his 2nd dose next week. However, we were notified he passed away on 2/9/21. Very likely death not at all related to vaccine but wanted to document as patient was in the middle of the covid vaccine series.


VAERS ID: 1022552 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-01-14
Onset:2021-01-21
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died of cardiac arrest on 01/21/2021


VAERS ID: 1022685 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-09
Onset:2021-02-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 9581 / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Colitis ischaemic, Diarrhoea, Fatigue, Intestinal ischaemia, Megacolon, Nausea, Surgery, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Parkinson''s disease, Diabetes, Leukemia
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received Pfizer Covid Vaccine in the AM on 2/9/21. Arrived to emergency department later the same day complaining of nausea, weakness, fatigue, Vomiting, Diarrhea. Post operative diagnosis, Ischemic colon/toxic megacolon.


VAERS ID: 1022918 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-02-05
Onset:2021-02-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatine abnormal, Blood urea abnormal, Cardiac failure congestive, Cardiomegaly, Chest X-ray abnormal, Death, Feeling hot, Hiatus hernia, Hypoxia, Leukocytosis, Pleural effusion, Pulmonary oedema, Pulmonary vascular disorder, Renal failure, Spinal fracture, Urinary tract infection, Vomiting, White blood cell disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Alprazolam, Furosemide, Keflex, Losartan, Metoprolol, Protonix
Current Illness: Urinary Tract Infection
Preexisting Conditions: Atrial fibrillation, heart failure, Gerd, Dysphagia, PVD, dementia, anxiety disorder, osteoarthritis
Allergies: Ciprofloxacin, Shellfish
Diagnostic Lab Data: Labs and radiology examinations with abnormal results
CDC Split Type:

Write-up: Resident complained of feeling "hot" at supper time. Had emesis an hour or so later. Became hypoxic and was transferred to the hospital emergency room. Her evaluation in the ED revealed continued presence of UTI, leukocytosis (19.8), and renal insufficiency (BUN 22 Cr. 1.3) BP 99/63; P 74; Temp 98.1; RR 16; and O2 sat of 95% with 2 LPNC (she is typically on RA). CXR reported changes most consistent with CHF with cardiomegaly and bilateral pulmonary vascular prominence. Bibasilar pleural effusions greater on the right than left with pulmonary edema. Large hiatal hernia and likely old chronic wedge defromities involving the mid thoracic vertebral body. She was admitted for IV antibiotics. She expired 2/6/2021


VAERS ID: 1023061 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-30
Onset:2021-02-08
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Axillary pain, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine 100 mcg tab once a day
Current Illness: pt had teeth pulled for possible dental implants , non ulcer dyspepsia, treated for diverticulitis 1/6/21
Preexisting Conditions: COPD; hypothyroidism; cricopharyngeal achalasia post surgical treatment, aortic atherosclerosis, hx of perforated ulcer from aspirin use
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received the vaccine on 1/30/21 Pt reported symptoms of left armpit pain to wife on 2/7/21, went to work 4 am 2/8/21 and found face down, dead at work later that morning. Pt worked at a pet store, per wife he did complete his tasks and generally comes home by 7:30 am. Wife called when pt did not come back home and he was found dead.


VAERS ID: 1023673 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-01-14
Onset:2021-01-22
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, COVID-19 pneumonia, Death, Endotracheal intubation, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Interstitial lung disease (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), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: unknown
Current Illness: unknown
Preexisting Conditions: HTN, HLD, diabetes type II, iron deficiency anemia, GERD, BPH, COPD
Allergies: unknown
Diagnostic Lab Data: Patient tested positive by rapid PCR on 1/22/2021 through in-house hospital lab for COVID-19.
CDC Split Type: KYIR ID 5405946

Write-up: Patient was vaccinated on 1/14/2021. On 1/22/2021, patient tested positive for COVID-19 and admitted to the hospital for acute hypoxemic respiratory failure, COVID-19 pneumonia, and severe ARDS. Patient was intubated on 1/23/2021 and later died on 2/10/2021 after being extubated and placed on comfort measures.


VAERS ID: 1023791 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-27
Onset:2021-02-01
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram Oxalate,amlodipine,aspirin,cyanocobalamin,docusate sodium,ergocalciferol,evothyroxine,Melatin,multivitamin,pravastatin,loratadine,senna,Protonix,carvedilol,Lokelma,lidocaine adhesive patch,buprenorphine ,hydralazine,Miralax,hy
Current Illness: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Preexisting Conditions: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Allergies: methadone, morphine, nortriptyline
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DIED WITHIN 5 DAYS OF RECEIEVING THE 2ND DOSE, EXPERIENCED GENERALIZED WEAKNESS.


VAERS ID: 1023803 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-01-04
Onset:2021-01-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E51686 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Was contacted by the person''s daughter on 2/5/21. Patient started vomiting 2 days after vaccination. She aspirated and passed away 1/16/21. Patient had history of stroke and swallowing problems.


VAERS ID: 1023840 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-04
Onset:2021-02-08
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / 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: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ziprasidone, divalproex, haloperidol, allopurinol, Lisinopril, atorvastatin, aspirin, carvedilol
Current Illness: Hypertension, Morbid Obesity, DMII, Neuropathy, Cardiomyopathy, Hyperurecemia, Glaucoma, Polyp, Foliculitis, Bi-Polar disorder.
Preexisting Conditions: Same as above.
Allergies: NKDA, NKA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was administered Moderna Covid-19 Vaccine on 2/4/2021. Pt exhbited no symptoms of an adverse reaction of any sort. Pt was ambulating alert and attentive. Pt was observed for the alloted 15 mins by pharmacist and case worker who had escorted pt to vaccination clinic. It was reported that Either on sunday 2/7/2021 or monday 2/8/2021 pt had passed away. Circumstances revolving patient death is still unknown.


VAERS ID: 1023948 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-02-06
Onset:2021-02-08
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Alanine aminotransferase increased, Aspartate aminotransferase increased, Bacterial test positive, Blood sodium decreased, Blood urine present, Cardio-respiratory arrest, Death, Decreased appetite, Fatigue, Feeling abnormal, Lymphocyte count increased, Neutrophil count increased, Prothrombin time prolonged, Resuscitation, Troponin increased, Urine abnormality, Urine analysis abnormal, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Proteinuria (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin C 500 mg daily Bisacodyl 10 mg daily Calcium Carbonate/Vitamin D 500/200 twice daily Clomipramine 100 mg twice daily Divalproex DR 1000 mg twice daily Levothyroxine 50 mcg daily Lisinopril 10 mg twice daily Metoprolol Succinate ER 5
Current Illness: No
Preexisting Conditions: Intellectual Disability Disorder Behavior Disorder (OCD/IED) Hypertension Hyperlipidemia Hypothyroidism Constipation Osteopenia
Allergies: Carbamazepine Loxapine Sulfa Antibiotics Tetracyclines Penicillins
Diagnostic Lab Data: 02/09/21: Urinalysis showed trace blood, cloudy and 2+ bacteria Na= 125 WBC = 13.6 Lymphocytes 6.7 ANC = 10.7 Labs from hospital showed elevated troponin = 155; PT = 22.6; ALT = 405, AST = 205
CDC Split Type:

Write-up: 02/08/21--2 days after vaccine--Resident stated that she "didn''t feel good" (She is developmentally delayed and less able to communicate how she feels than those in the community) and stopped eating most foods; also had fatigue. Vitals, coloring, & behavior were normal. 02/09/21--Belly was firm and mildly distended (although she stated it didn''t hurt); she coded this evening and CPR was performed before EMT could transport her to the hospital. 02/10/21--Resident passed.


VAERS ID: 1023979 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-02-01
Onset:2021-02-10
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Medications Azopt 1% ophthalmic suspension, 1 drops, Eye-Both, BID bacitracin/neomycin/polymyxin B topical, 1 appl, Topical, BID, PRN Briviact, 50 mg, 5 mL, Oral, BID calcium carbonate 600 mg (elemental Ca 240 mg) oral tablet, 600 mg,
Current Illness: Dehydration Leukocytosis Dysphagia UTI - Sepsis-resolved Hypernatremia Paroxysmal atrial fibrillation with sick sinus syndrome; S/P pacemaker placement 12/29/20 Acute kidney injury secondary to hypovolemia Macrocytic anemia
Preexisting Conditions: Active Problems Coloboma of iris Atrial fibrillation Mild to moderate hearing loss Dysphagia Peripheral vascular disease Dementia with behavioral disturbance Seborrhea Lagophthalmos Benign prostatic hyperplasia Chronic constipation Gastroesophageal reflux disease Osteopenia Epilepsy Profound ID (IQ <20) ASCVD risk Age-related nuclear cataract, left eye Cardiomegaly Chronic Ileus and megacolon Chronic conjunctivitis Chronic diastolic (congestive) heart failure Chronic obstructive pulmonary disease, unspecified Colostomy and ileostomy status Cyst of right kidney, acquired Dementia with behavioral disturbance Dry eye syndrome of bilateral lacrimal glands Hypocalcemia Hypothyroidism Hypovitaminosis D Iron deficiency anemia Mild hearing loss Mood disorder Nonexudative age-related macular degeneration, left eye, intermediate dry stage Obstructive sleep apnea (adult) (pediatric) Ogilvie''s syndrome Other seasonal allergic rhinitis Presence of cardiac pacemaker 12/29/2020 Primary open-angle glaucoma, bilateral, moderate stage Proteinuria Recent weight gain Recurrent UTI - urinary tract infection Recurrent hypernatremia and dehydration Sick sinus syndrome Sick sinus syndrome s/p pacemaker 12/29/20
Allergies: NKDA
Diagnostic Lab Data: autopsy results are pending
CDC Split Type:

Write-up: Moderna administered 02/01/21. Patient expired 02/10/2020 unexpectedly


VAERS ID: 1024067 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-01-15
Onset:2021-01-31
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Chills, Death, Oropharyngeal pain, Productive cough, Pyrexia, SARS-CoV-2 test positive, Sputum discoloured
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrocodone/Chlorphen ER Suspension Tylenol Mucinex
Current Illness: N/A
Preexisting Conditions: None
Allergies: No
Diagnostic Lab Data: 1/23: COVID test administered 1/25: Reported positive for COVID 1/26: Patient was informed of positive result
CDC Split Type:

Write-up: 1/15: Pfizer vaccine dose 1 administered 1/16: Fever, chills 1/22: Sore throat, coughing w/white phlegm, taking Tylenol and Mucinex. Fever and chills from 1/16 subsided. Had telehealth consultation with PA. Per her notes, patient said he gets these symptoms annually, requested for an antibiotic. PA referred him for a COVID test. Ordered hydrocodone/chlorphen ER suspension for his cough and an antibiotic. Antibiotic was recommended if symptoms do not subside. 1/23: COVID test administered 1/25: Reported positive for COVID 1/26: Telehealth session w/PA: she informed patient of his positive test, advised to quarantine and seek medical help at hospital if symptoms worsen. Patient reported that his sore throat mostly subsided but is still coughing at night. Said that the pharmacy didn''t receive the prescription order for the antibiotic, so this was re-ordered. 1/31: Partner found him dead at 8:18AM on his bed. Death certificate issued by state says cause of death: COVID. Autopsy was not performed. Buried on 2/9/21.


VAERS ID: 1024157 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-01-11
Onset:2021-01-20
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Decreased appetite, Diarrhoea, Oxygen saturation decreased, Pain, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 9
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Simvastatin, HCTZ, Sertraline, Donepezil, Fenofibrate, Vitamin D3, Vitamin B12, Zyrtec, 81mg Aspirin, Colace
Current Illness: Alzheimer''s, Type II Diabetes
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: 7 days after receiving the vaccine, patient suffered excessive diarrhea and slight coughing. 9 days after vaccine, patient was tested for Covid 19, and received positive results. Patient was transported to hospital via ambulance but hospital returned her to the nursing home since chest was clear, no respiratory issues, and no fever. 10 days after receiving the vaccine, patient was turned over to hospice care but still in the nursing home. Hospice was called in to provide better physician advice and access 24/7. 14 days after receiving vaccine, patient began experiencing excruciating body aches, coughing, low oxygen levels, and no appetite. 18 days after vaccine, patient died.


VAERS ID: 1024226 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-06
Onset:2021-01-14
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dizziness, Haematemesis, Hypotension, Tachycardia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Respiratory failure (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CAD, Atrial Fibrillation, dementia, stroke, htn, ckd, AAA
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: New onset dizziness with hypotension, tachycardia, and vomiting blood. Sent to ER - told he went into cardiac arrest and died.


VAERS ID: 1024325 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-02-03
Onset:2021-02-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: SHINGLES ABOUT A MONTH AGO
Preexisting Conditions: AFIB, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL
Allergies: LATEX
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed away on February 5, 2021. There was no reaction after the shot was given, the patient''s son said the death was not related to the vaccine. The patient had a bad case of shingles about a month prior to receiving the vaccine which the son said had been hard on the patient, the patient was also 90 years old. Per the son, the patient''s doctor had wanted the patient to get the vaccine. Due to the close proximity of the date the vaccine was given and the date Patient passed away we wanted to complete the VAERS form.


VAERS ID: 1024343 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-02-05
Onset:2021-02-09
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 6201 / 2 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL 8982 / 1 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: HYDROXYCHLOROQUINE MONTELUKAST METOPROLOL XL PANTOPRAZOLE
Current Illness:
Preexisting Conditions: LUPUS
Allergies: ERYTHROMYCIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT ARRIVED TO ED ON 2/9 IN FULL CARDIAC ARREST


VAERS ID: 1024420 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: California  
Vaccinated:2021-01-21
Onset:2021-01-24
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Decreased appetite, Headache, Nausea, Pain in extremity, Psychomotor hyperactivity, Pyrexia, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (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), Dementia (broad), Akathisia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

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

Write-up: Patient had the first Moderna Covid vaccine on Thursday 1/21/2021. She had a bit of sore arm on that day and the day after. On Saturday 1/23/2021, she had a fever of 100.5 F (11AM), nausea, light headache and chills. The temperature went down after she took ibuprofen. Patient''s husband enrolled her to V-Safe to report all the adverse effects she experienced. On Sunday 1/24/2021, her temperature was 98.3F. She still had nausea and no appetite. She and her husband watched a football game in their bedroom upstairs. Husband noticed that his wife was pacing around the room many times. At 7Pm, Husband went downstairs for dinner but she refused to come down to eat. He went upstairs around 8pm, TV was still on. He turned off TV and went down stairs again thinking his wife felt as sleep while watching TV. He went back upstairs for bed around 10:30 PM. Husband said his wife had a deviated septum so she would snore very loudly when asleep. He didn?t hear her snoring so he went to check on her and found her not responsive. Husband called emergency services. Paramedic came at 10:45 and said patient was passed. Husband sent many texts to V-safe after that to report the incident. No response was received from V-safe. Patient?s doctor told her husband that she died due to cardiac arrest.


VAERS ID: 1024539 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-15
Onset:2021-01-28
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, COVID-19, Dyspnoea, Nausea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinol, citalopram, sodium bicarb., furosemide, ascorbic acid, folic acid, pravastatin, vitamin D2, levothyroxine, potassium chloride, calcium carbonate, b complex, omega 3s, prednisone, levocetirizine, tumeric, krill oil, metoprolol
Current Illness: shoulder pain, dermatitis, chronic kidney disease, edema, gerd, venous insufficiency, hypertension, RA, hypothyroidism, osteoporosis, depression, radiculopathy, rosacea.
Preexisting Conditions:
Allergies: alupent, coumadin, cephalexin, saccharin, gabapentin, codeine sulfate, sulpher, onion, perfumes and fragrances, adhesive.
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient tested positive for covid on 1/29/21. was hospitalized on 2/8/21 for shortness of breath, generalized weakness, nausea.


VAERS ID: 1024592 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-02
Onset:2021-02-11
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / UNK LA / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER DF1306 / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebral arteriosclerosis, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Ischaemic central nervous system vascular conditions (narrow), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol, Ativan, Vit B12, Colace, Ferrous Sulfate, Gabapen Gabapentin, Lansoprazole, LEvsin, Miralax, Mirtazapine, Morphine Sulfate, Multivitamin with minerals, Omeprazole, Senna, Trazadone, Valproic Acid, Vitamin C
Current Illness: acute pyelonephritis, acute respiratory failure
Preexisting Conditions: Metabolic Encephalopathy, Sepsis, anemia, neuropathy, chronic kidney disease, aspergers syndrome, hydronephrosis with uretral calculous obstruction, uterovaginal prolapse, obstructive and reflux uropathy, protein-calorie malnutrition, anxiety, major depressive disorder, gastro-esophageal reflux disese, diabetes mellitus 2.
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reactions noted. Resident is on hospice for end of life care for terminal diagnosis cerebral atherosclerosis. Experiencing respiratory distress 2/10/2021 r/t to hospice prognosis.


VAERS ID: 1024626 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-01
Onset:2021-02-06
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine,aspirin,losartan,metformin,pravastatin,polyethylene glyco,Colace,cholecalciferol
Current Illness: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Preexisting Conditions: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH ON 5TH DAY OF 2ND DOSE.


VAERS ID: 1024627 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2021-02-02
Onset:2021-02-05
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 6
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: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda
Diagnostic Lab Data:
CDC Split Type:

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died


VAERS ID: 1024743 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-01
Onset:2021-02-08
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Decreased appetite, Diet refusal, Lethargy
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: xalatan drops, cosopt drop, alphgan drops, Norco, Seroquel, dulcolax supp, Senna, depakote sprinkles, trazodone,
Current Illness: none
Preexisting Conditions: vascular dementia, glaucoma, osteoporosis
Allergies: none known
Diagnostic Lab Data: none
CDC Split Type:

Write-up: pt became lethargic, stopped eating. No fever; no nausea


VAERS ID: 1024788 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.


VAERS ID: 1024790 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.


VAERS ID: 1024795 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-01-13
Onset:2021-01-25
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.


VAERS ID: 1024817 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Guam  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aspiration, Blood pressure systolic decreased, Cardio-respiratory arrest, Death, Dialysis, Endotracheal intubation, Gastrointestinal haemorrhage, Mechanical ventilation, Pulse absent, Pulseless electrical activity, Respiratory arrest, Resuscitation, Seizure like phenomena, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Meds Prior to hospitalization: Propanolol, cilostazol, duloxetine HCL DR 30
Current Illness: NIDDM, HTN, CAD s/p CABG x4v, liver cirrhosis, ESRD on HD, cataracts, dysarthria, PAD s/p angioplasty 2020 bilateral lower extremity
Preexisting Conditions: social history of alcohol abuse
Allergies: Ampicillin sodium
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was coded and expired Code Blue: Patient was in dialysis, after 30 minutes his sbp dropped to 60s he was given 4 albumin. Patient who was responsive before that became unresponsive, had seizure like activity, lost pulse and spontaneous breathing. HD stopped. Code called. Cpr started. A few minutes into cpr patient started to profusely bleed - gi bleed and ventilation became very hard., intubation was very difficult and ventilation hard as we suctioned large amounts of aspirated blood. Patient was eventually intubated. More than 8 doses of epi ws given, sodium bicarbonate * 2 given with continuous cpr. It was mostly PEA with one shockable rhythym. And shock delivered for vfib. patient continued to profusely bleed, og insertion was not successful and effective ventilation was very tough due to massive aspiration,. Possible variceal rupture with cpr from his cirrhosis is likely scenario. After 30 minutes of unsuccessful ventilation and acls protocol. Code was stopped.


VAERS ID: 1024853 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-01-30
Onset:2021-02-08
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Aspiration, Death, Fatigue, Haemorrhage, Nasopharyngitis, Nausea, SARS-CoV-2 test negative
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: Chemo
Current Illness: Essential Thrombocytopemia Alzheimer?s
Preexisting Conditions: Essential Thrombocytopemia Alzheimer?s
Allergies: None
Diagnostic Lab Data: No medical tests or laboratory exams provided. Medical Examiner declined to physically view the body on site. Through photos or phone video declared death to be natural. Death certificate was later filled out by primary care physician who again did not examine her body or even know the details of her death.
CDC Split Type:

Write-up: Feb 8 states she had a cold. Feb 9 added stomach ache and nausea. Feb 9 visited urgent care facility for exam and Covid-19 test. Rapid test results were negative. Appeared tired but fine. Told to go home and rest. Feb 10 at 9:00 am found dead on the floor in pool of blood and aspirated. Excessive blood in toilet, pooled on floor and hallway rug.


VAERS ID: 1025472 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-10
Onset:2021-02-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dialysis, Fatigue, Peripheral coldness, Pulse absent, Unresponsive to stimuli
SMQs:, Acute renal failure (narrow), 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), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

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

Write-up: Patient received COVID19 vaccine at clinic at 11:52 am, discharge post treatment stable. Got home around 2:30 pm went to bed. He usually got tired post dialysis. He did not wake up at 6 pm. His wife went check on him. found patient cold and unresponsive. 911 pulseless PEA. ER Medical hospital. Pronounced death at 7:40 pm


VAERS ID: 1025079 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-09
Onset:2021-02-10
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol-ipratropium 2.5mg-0.5mg/3mL nebulizer QID amiodarone 100mg PO daily amlodipine 2.5mg PO daily PRN high blood pressure aspirin 81mg PO daily Symbicort 160mcg-4.5mcg/inh 2 puffs BID calcitriol 0.25mcg PO on M-W-F carvedilol 12.5m
Current Illness: None known
Preexisting Conditions: Aortic Stenosis Coronary Artery Disease asthma Hypertension cardiac pacemaker COPD Chronic kidney disease diastolic heart failure hyperlipidemia thrombocytopenia
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient found by family in his home deceased on the morning of 02/10/2021.


VAERS ID: 1025081 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-02-04
Onset:2021-02-06
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arteriosclerosis, Autopsy, Condition aggravated, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 5mg, asprin 81mg, atorvastin 10mg, cinacalet 120mg daily, sevelamer 800mg, Nephrocaps (MVT)
Current Illness:
Preexisting Conditions: ESRD on HD, HCV cirrhosis, refractory ascites, CAD, CHF (EF15%-20%), hyperparathyroidism
Allergies: Bactrin, NSAIDS
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reported adverse reactions from 1st or 2nd vaccine doses Patient died on 2/6/2021 at Correctional facility- autopsy was performed at medical examiner''s office. The COD was artherosclerotic cardiovascular disease


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