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From the 5/7/2021 release of VAERS data:

Found 4,057 cases where Vaccine is COVID19 and Patient Died



Case Details (Reverse Sorted by Onset Date)

This is page 9 out of 41

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VAERS ID: 1287846 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-23
Onset:2021-03-28
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-05-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046AZIA / 2 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Malaise, Mechanical ventilation
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Digoxin, Pradaxa, Amidarone, Metoprolol, Omprazole, Amiodarone, Hydroxychloroquin, Tamsulosin
Current Illness: A Fib,
Preexisting Conditions: diabetic
Allergies: Pork
Diagnostic Lab Data:
CDC Split Type:

Write-up: The person who received the vaccine got very sick 5 days after the receiving the vaccine. The patient was talking at 2:00 pm on the 28th and he was on a ventilator a few hours later. The doctors were never able to determine why he got so sick suddenly. He passed away on April 6th.


VAERS ID: 1289390 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-02-19
Onset:2021-03-28
   Days after vaccination:37
Submitted: 0000-00-00
Entered: 2021-05-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9267 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-02
   Days after onset: 35
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: COVID-19 PCR positive test on 3/28/2021
CDC Split Type:

Write-up: Patient hospitalized and died of pneumonia caused by COVID-19 after being fully vaccinated.


VAERS ID: 1139971 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-02-01
Onset:2021-03-27
   Days after vaccination:54
Submitted: 0000-00-00
Entered: 2021-03-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNSURE / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Electroencephalogram, Encephalopathy, Hallucination
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), 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: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Arimidex Synthroid Cozaar Mobic Pravachol
Current Illness: HTN HYPOTHYROIDISM
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data: Electroencephalogram 2/9/2021 ?... toxic/metabolic, or physiologic ideology.?
CDC Split Type:

Write-up: Per pts husband, pt had been ? normal,? coking and even mowing the grass prior to receiving the covid vaccine. She started to hallucinate and eventually was admitted to our facility and diagnosed with acute encephalopathy. The pt went home on hospice and has since passed Husband reports no one will listen to him regarding the events that took place.


VAERS ID: 1140258 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 59267-100-01 / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Dyspnoea, Malaise
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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
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: unknown
Current Illness: Obesity, and other co-morbidities
Preexisting Conditions: Obesity
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient contacted 911 complaining of not feeling well and difficulty breathing. Upon arrival patient was found by EMS in cardiac arrest. EMS was unable to get return of spontaneous circulation.


VAERS ID: 1140716 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8727 / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Zyprexa, docusate, Razadyne, Amaryl, Lipitor (list not confirmed)
Current Illness: No new illnesses recently
Preexisting Conditions: Dementia, diabetes, hyperlipidemia
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Approximately 30 minutes after vaccination the patient experienced a cardiac arrest. He was brought to the hospital where resuscitation efforts were continued but ultimately proved to be unsuccessful. The patient was pronounced deceased.


VAERS ID: 1140864 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 047AZIA / 2 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin, Olmesartan, Metoprolol, risperidone, asprin
Current Illness: None
Preexisting Conditions: type 2 diabetes and high blood pressure -- all under control and regularly monitored by a physician
Allergies: none that were known of
Diagnostic Lab Data: Not after her physician advised that if a heart attack was responsible in addition to the adverse effects from the covid vaccination, it would be impossible to deem the covid shot as the cause. This cannot be a coincidence.
CDC Split Type:

Write-up: My mom received her second covid shot at 10:05 AM on 3/26 and experienced no adverse symptoms. At around 6 am the following day, on the morning of 3/27 she was found on the floor, and presumably suffered from a heart attack. After devastation to our family, we called her physician and he himself was also surprised. Although she is a type 2 diabetic with high blood pressure she has maintained great health and kept her conditions under control with her medications. This, unfortunately, seems too coincidental to not have been in some way or completely caused by the second dose of the shot.


VAERS ID: 1144617 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808978 / UNK RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: allopurinol (ZYLOPRIM) 100 MG tablet Take 1 tablet by mouth daily. lisinopril (ZESTRIL) 10 MG tablet Take 1 tablet by mouth daily. metFORMIN (GLUCOPHAGE) 1000 MG tablet Take 1 tablet by mouth 2 times daily with meals. pravastatin (PRAVACHOL
Current Illness: None per chart
Preexisting Conditions: Hypertension High cholesterol Diabetes (CMS/HCC) Gout Obesity BMI 34.0-34.9,adult
Allergies: Codeine - Unknown Atorvastatin - Nausea Only Simvastatin - Nausea Only
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found deceased in her home by her daughter 9+ hours after receiving the vaccine. The was no indication of how long the patient had been deceased prior to being discovered.


VAERS ID: 1145219 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-25
Onset:2021-03-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acidosis, Anaemia, Computerised tomogram head normal, Computerised tomogram thorax abnormal, Death, Dysarthria, Effusion, Electrocardiogram abnormal, Hemiparesis, Hyporesponsive to stimuli, Hypotension, Muscular weakness, Myocardial ischaemia, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Lactic acidosis (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (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), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: ammonium lactate topical cream, aspirin 81 mg, Colace, diclofenac sodium, finasteride, indomethacin, ketoconazole, lisinopril, loratadine, Mapap, metoprolol succinate, omeprazole, magnesiumrosuvastatin
Current Illness: Treated for COVID pneumonia in January-February (hospitalization followed by rehab)
Preexisting Conditions: Anemia (mild, asymptomatic) Cerebral microangiopathy Coronary arteriosclerosis after coronary artery bypass grafting Hx of Heart attack (2019) Peripheral artery disease Hx of TIA Hypercholesteremia Hypertension Sleep apnea Aortic stenosis Atherosclerosis of aorta Mild cognitive impairment with memory loss
Allergies: NKA
Diagnostic Lab Data: Presented to ED on 3/27/21 around 8:30am complaining of weakness. EMTs had found left-sided weakness, slurred speech and EKG changes. Per hospital records, although he was exhibiting some markers of a stroke, it was unclear whether it was a true stroke as the overall acute picture of hypotension, diffuse cardiac ischemia and diffuse neurologic weakness pointed more towards anemia with heart failure. CT of head showed no stroke; CT of chest showed effusions with possible superimposed pneumonia (had recently recovered from COVID-19). At around 10:30am ppt was found to have severe acidosis; broad-spectrum antibiotics were ordered d/t sepsis concern. Renal failure was also found. By 11:14am, ppt was found to be less responsive and more hypotensive. Ppt was pronounced on 3/27/2021 at 3:48pm. UNSURE IF DEATH IS RELATED TO VACCINE.
CDC Split Type:

Write-up: Left-sided weakness, slurred speech


VAERS ID: 1145251 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-03-25
Onset:2021-03-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037A21B / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Computerised tomogram head abnormal, Death, Haemorrhage intracranial, Mental status changes, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg, ammonium lactate, Artificial Tears, Atorvastatin, Basaglar, KwikPen, Calcitriol, Clotrimazole, Colace, Diltiazem, Eliquis, escitalopram oxalate, fluticasone propionate, Furosemide, Lexapro, melatonin, Novolog, omeprazole, Sal
Current Illness: Saw PCP on 3/25/2021 d/t complaints of headache associated with high BP readings and to follow up after CHF exacerbation (improved at time of follow-up)
Preexisting Conditions: Hyperlipidemia Hypertensive kidney disease with chronic kidney disease due to diabetes mellitus Atherosclerosis of coronary artery of native heart with stable angina pectoris Pericarditis CHF with left ventricular diastolic dysfunction Hx of TIA Abdominal Aortic Aneurysm Anemia, iron deficiency Diabetic nephropathy Diabetic neuropathy Hypothyroidism, Acquired Osteopenia Polycystic kidney disease Chronic DVT Chronic pulmonary embolism Right bundle branch block Paroxysmal atrial fibrillation Right ventricular dysfunction Pericardial effusion Heme positive stool Ischemic cardiomyopathy COPD Angiopathy, diabetic
Allergies: NKDA
Diagnostic Lab Data: Intracranial hemorrhage (3/27/2021)
CDC Split Type:

Write-up: Ppt collapsed at home on 3/27/2021 late morning. Presented to ED on 3/27/21 from home around 11am with altered mental status. Was found to have a hyper acute stroke per CT head (intracranial hemorrhage). Ppt was pronounced on 3/28/2021 at 1:45pm. UNSURE IF DEATH RELATED TO VACCINE.


VAERS ID: 1145320 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8730 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cyanosis, Death, Pulse absent, Unresponsive to stimuli, Wheelchair user
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), 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: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vantin, trazadone, aricept, senna, ertapenem, vitamin D, heparin, risperidone,
Current Illness: Urosepsis with metabolic encephalopathy
Preexisting Conditions: Hyperlipidemia, right breast carcinoma, Alzheimer''s diease with dementia, atherosclerosis of aorta, right exudative age related macular degeneration.
Allergies:
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient reviewed vaccination at 1:20pm. She was observed for one hour per MD. At 5:18, she became unresponsive in her wheelchair and became blue with no palpable pulse. Patient had a DNR status and was not revived.


VAERS ID: 1145479 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 16B21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood gases, Coma scale abnormal, Computerised tomogram, Death, Endotracheal intubation, Extensor plantar response, Full blood count, Haemorrhagic stroke, Liver function test, Metabolic function test, Posturing, Respiratory distress, SARS-CoV-2 test, Tachycardia, Troponin, Unresponsive to stimuli, Urine analysis
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
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: Tylenol Calcitonin Calcium Acetate Vitamin B-12 Digestive Aids Mixture OR Multivitamin Preservision AREDS Omega 3 Systane Probiotic Tramadol Kenalog 0.1% Cream
Current Illness: none known
Preexisting Conditions: Hyperlipidemia GERD Osteoporosis Nontraumatic hemorrhage of right cerebral hemishere
Allergies: NKA
Diagnostic Lab Data: CT BMP Hemogram liver panel troponin UA COVID-19 swab Atrial Blood gas
CDC Split Type:

Write-up: Patient received vaccine at 10:18am and then went home with no reaction in the vaccination POD. EMS was called to the patients home shortly before 2:30 that afternoon. When EMS arrived patient was posturing with lower extremities extended in plantar flexion. Last seen normal 30 minutes prior. she was also tachycardic and in respiratory distress with sonorous respirations. Cranial nerve deficit present GCS 3.She was unresponsive and intubated. Airlifted after CT to hospital. She died at 1647 at Hospital from hemorrhagic stroke.


VAERS ID: 1146467 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-03
Onset:2021-03-27
   Days after vaccination:52
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9809 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Cardio-respiratory arrest, Death, Renal failure
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (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), Acute central respiratory depression (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA- patient refused second dose of vaccine - Patient condition at time of death Chronic Conditions Renal failure Advanced age 100 y/o Cardiopulmonary arrest secondary to Covid 19


VAERS ID: 1147326 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-24
Onset:2021-03-27
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Feeling hot
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: ESRD, DMII, HTN, Hypothyroidism
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received 1st vaccine on 3/24 with no issues reported. Patient returned on FRiday for routine treatment and was afebrile, BP within normal limits and no compliants. Left the unit stable post treatment. Patient passed away on Saturday morning. There was no hospitalization. Patient went straight from home to the funeral home. Daughter states that patient had been feeling warm since Wednesday.


VAERS ID: 1147591 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81mg daily Atorvastatin 80mg Daily Chondroitin/Glucosamine daily Mulitvitamin daily Metoprolol 25mg ER daily Ramipril 5mg Daily
Current Illness: None
Preexisting Conditions: Hx of anemia, Hyperlipidemia, Atherosclerosis, Type 2 diabetes, Hypertension and nicotine dependence
Allergies: No known allergies
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Patient received vaccine on 3/26/2021. Was found deceased on 03/27/2021


VAERS ID: 1149835 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-11
Onset:2021-03-27
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA VO1B21F / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: None.
Current Illness: None known.
Preexisting Conditions: According to her family, patient had no known medical history as she refused to go to the doctor. She had no primary physician and had never been hospitalized.
Allergies: None known.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received her first Moderna COVID-19 vaccination on 03/11/2021. She did not have any ill effects directly afterwards. However, starting on 03/27/2021, she began complaining of left arm pain in the area of the injection. She continued to complain of pain in the injection site on 03/28/2021. On 03/29/2021, her roommate found her deceased on her bed due to a probable cardiac event.


VAERS ID: 1150577 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014M20A / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Arthralgia, Blood chloride normal, Blood creatinine increased, Blood gases, Blood glucose increased, Blood lactic acid increased, Blood pH decreased, Blood potassium normal, Blood sodium normal, Blood urea normal, Calcium ionised decreased, Carbon dioxide decreased, Chills, Cold sweat, Dyspnoea, Fatigue, Feeling of body temperature change, Haematocrit normal, Metabolic function test, Nausea, Pain, Pain in extremity, Pallor, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Arthritis (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Benadryl, Vitamin D3 , Zinc, Tylenol
Current Illness: Lactose intolerance
Preexisting Conditions: Lactose intolerance
Allergies: No Known Drug Allergies
Diagnostic Lab Data: Test completed and resulted on 03-31-2021 0750AM COVID -19-NEGATIVE POC Chem 8 POC Blood Gas and Chemistries- sodium 139 Potassium- 4.1 Glucose- 421 Hematocrit- 42 Ionized Calcium- 1.18 Chloride- 104 BUN- 13 TCO2- 19 Creatinine- 1.4 PH Venous- 6.87 Lactate- 9.7
CDC Split Type:

Write-up: Got the shot Saturday patients arm was hurting Saturday and the people at shot clinic told the patient to take Tylenol for pain, Sunday the patient was extremely tired and clammy told the daughter his joints and body was hurting so badly. Sunday the patient woke up with allergy symptoms so patient was waiting it out to see dr until his appointment. The patient finally woke up on 3-31-21 around 5 am and the patient had cold chills and clammy the patient put on his robe then told his wife that he was too hot shortly after. The wife was leaving for work at 6am and the patient was curled around toilet stating he felt nauseous, wife left for work around 6am and then she stated about 15-20 minutes later the husband called her asking her to come back home she stated he sounded very short of breath and just not right, she turned around and got home around 645am and found her husband pale and in his recliner with his mouth open and unresponsive. The wife called 911 and she stated the told her pull him into floor and EMS arrived as soon as she got in the floor to start CPR.


VAERS ID: 1154639 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Penicillin
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient began having seizures about four hours post vaccine while at a friends house and passed away


VAERS ID: 1155893 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-22
Onset:2021-03-27
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808978 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Death, Myalgia, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   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: Tramadol HCl 50 Tablet Taking Lisinopril 40 MG Tablet Taking Allopurinol 100 Tablet Taking Atorvastatin Calcium 80 MG Tablet Taking Coumadin 7.5 MG Tablet Taking Desmopressin Acetate Spray Taking Atenolol 100 MG Tablet
Current Illness:
Preexisting Conditions: paroxysmal Atrial fib- stable, INR, 2.7, Last stress test normal (more than 10 mets no difficulty) Diabetes stable Hga1c 6.4% Pituitary adenoma
Allergies:
Diagnostic Lab Data: none. Last INR 2.7 Hga1c 6.4%
CDC Split Type:

Write-up: pt was at his normal baseline of health the Monday of vaccine. Per sister, he had a fever of 104F, chills and myalgias hte following Saturday. he was not heard from on Sunday therefore on Monday his sister did a forced entry and found him on the ground.


VAERS ID: 1156845 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-23
Onset:2021-03-27
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6207 / 1 LA / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: diprosone 0.05% cream, estradiol vaginal cream
Current Illness: none known
Preexisting Conditions: no info in chart
Allergies: none none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient received COVID vaccine 3/23/2021. The family called the vaccination clinic to inform that the patient died on 3/27/2021. Family believes the vaccine caused the death. I have no other information on this chart.


VAERS ID: 1159365 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebral haemorrhage, Death, Malaise, Unresponsive to stimuli
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (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: 2021-03-28
   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: many
Current Illness: no
Preexisting Conditions: High blood pressure, heart disease, depression
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: My father received his second dose of the moderna vaccine on 3/27/2021. Around 5PM he started to feel unwell and went to lay down. My mom found him unresponsive at 10PM and called an ambulance. She was told at the hospital that he had a massive brain bleed. He passed away the following morning around 10AM.


VAERS ID: 1160180 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-29
Onset:2021-03-27
   Days after vaccination:57
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Long term care patient death within 60 days of receiving a COVID vaccine


VAERS ID: 1160240 (history)  
Form: Version 2.0  
Age: 103.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-21
Onset:2021-03-27
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospice Patient death within 60 days of receiving the COVID vaccine series


VAERS ID: 1160839 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-21
Onset:2021-03-27
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-04-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hospice patient death within 60 days of receiving the COVID vaccine series


VAERS ID: 1197691 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-10
Onset:2021-03-27
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Balance disorder, Death, Dizziness, Fall, Lethargy, Loss of consciousness, Memory impairment
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Depression (excl suicide and self injury) (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan Metformin 500mg Low dose Aspirin
Current Illness: None
Preexisting Conditions: Hypertension
Allergies: No
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The weeks following vaccination, the patient felt lethargic, dizzy, unstable on his feet. Mental cognitive ability was unchanged, and he seemed to still be sharp. Up until the day of death, the patient was still active, able to drive, speak, make jokes, eat, and do everything normally. The morning of death, he had a bad fall, but couldn''t recall what happened. It''s assumed that a low blood pressure event, syncope, partial aneurysm, something of that nature causing temporary loss of consciousness occurred. We attended a funeral that afternoon, ate lunch, and dropped him off at his home. Sometime during that evening, he fell and died. The cause is unknown and still "undetermined" on the death certificate. (Heart attack or brain aneurysm is what I''m guessing)


VAERS ID: 1211110 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-03-13
Onset:2021-03-27
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 AR / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Thyroxine, estradiol, hctz, Klor-con er wax tabs, celecoxib, Flonase, omeprazole
Current Illness:
Preexisting Conditions: 1 kidney
Allergies: None
Diagnostic Lab Data: Cardiac Arrest
CDC Split Type:

Write-up: Death


VAERS ID: 1213287 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-03
Onset:2021-03-27
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Dyspnoea, Endotracheal intubation, Fluid overload, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death. Narrative: Patient received Moderna COVID vaccine #1 on 3/3/21. He is noted to be a dialysis patient. On 3/24/21, his wife took him to a facility ER due to intermittent shortness of breath over the previous week. He was admitted for fluid overload. On 3/27/21, he was found unresponsive and CPR was initiated and a code blue was called. He received defibrillation, epinephrine, IV calcium, sodium bicarb and amiodarone and was intubated; however he did not survive and time of death is recorded as 3/27/21 at 0138. No autopsy results available. 24 days from time of vaccine to date of death.


VAERS ID: 1219577 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood potassium increased, Blood urea increased, Condition aggravated, Dyspnoea, Full blood count, General physical health deterioration, Hypotension, International normalised ratio increased, Laboratory test abnormal, Metabolic function test, Unresponsive to stimuli, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   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: Atorvastatin 40, Cholecalciferol, MVI, Omeprazole, Polytehylene Glycol powder, Potassium Chloride ER 20 MEQ, Senna, Setraline, Spironoloctone, Torsemide, Warfarin 4mg, Colace.
Current Illness: 3/15 Adm with deconditioning, acute/chronic CHF, severe mitral valve stenosis, left atrial thrombus, A-fib. 3/25 Adm - ADL dysfunction, deconditioning, CHF, severe mitral valve stenosis.
Preexisting Conditions: Mitral valve disease, mitral valvuloplasty-1998. Tachycardia and Bradycardia, Pacemaker-2002. Pulmonary hypertension, Tircuspid valve regurgitation. GERD, Dyslipidemia, HTN, Insomia, Depression.
Allergies: Codeine, Hydrocodone, Morphine
Diagnostic Lab Data: 3/27/2021- CBC/BMP, INR. WBC- 15.93, BUN- 61, Crea- 1.95, K+ 5.2, INR 5.3. Sent to ER with hypotension and abnormal labs. 82/50mmHg, Pulse of 61.
CDC Split Type:

Write-up: 3/27/2021- @3 AM resident with increase in SOB with unresponsive episodes. Pt states she has history of unresponsive episodes related to cardiac issues, declined hospitalization.


VAERS ID: 1230079 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-19
Onset:2021-03-27
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol 50Mg once a day,losartan 50mg one a day,magnesium oxide 400 mg once a day, mirtazapine 7.5 mg one a day, multuvitamin, pantoprazole 40mg twice a day sertraline 50 mg one a day, sortaol 80mg half in the morning half at night, vitami
Current Illness: Was in the hospital on January 31 had a brain bleed. Was there for two weeks. From there he went into a nursing home for rehab. He got his first shot on February 19 2021 and the second one on March 19, 2021. He passed away on March 27,2021
Preexisting Conditions: mild copd,had a brain bleed almost 8 years before this last one.
Allergies: Penicillin, morphia,sulfur,codeine, chlorhexidine gluconate,sulfadiazine.
Diagnostic Lab Data: No, not sure it has anything ti do with his death, just reporting it.
CDC Split Type:

Write-up: My husband passed away two weeks and one day after getting his last vaccine


VAERS ID: 1231568 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac disorder, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril, simvastatin, levothyroxine, ropinirole, inhaler
Current Illness: None known
Preexisting Conditions: Hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, restless leg syndrome, obesity
Allergies: None known
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Unknown onset of adverse events. PT received second COVID vaccine on 3/26/21. She was found deceased in her residence (where she lives alone) by family on 3/28/21. She was found in bed, appropriately covered with blankets. Son last spoke with PT around 17:30 hours on 3/26 after receiving the vaccine, and reported the PT did not complain of any symptoms, did not sound short of breath, and did not complain of any breathing difficulty. Based on postmortem presentation, believed PT died late night of 3/26/early morning of 3/27. Suspect death is likely due to PT''s heart disease, Medical Examiner agreed with the assessment.I spoke with the clinic that administered the second dose, and was informed that the PT did not exhibit any signs/symptoms during the observation period immediately following the vaccine being given. PT''s PCP was contacted, and agreed to certify DC based on known medical history. PCP also agreed that the death did not sound related to the vaccine based on lack of symptoms as reported by the administering clinic and family.


VAERS ID: 1236405 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-04
Onset:2021-03-27
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was not previously COVID-19 positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there an ADR that occurred between the observation period and the date of death. Patient was 82 and had a PMH significant for parkinsonism w/ dementia, difficulty walking and performing daily tasks, CAD, afib, and osteomyelitis. Patient was authorized for home health aide on 3/18/21 after wife overwhelmed with his care. Listed cause of death on death certificate says "unknown-history of dementia and heart conditions"


VAERS ID: 1238342 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-20
Onset:2021-03-27
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Death, Dyspnoea, Hyponatraemia, Metastatic neoplasm, Pleural effusion, Pneumonia
SMQs:, Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Non-haematological malignant tumours (narrow), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-17
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 72 year old white male hospice patient received the Covid shot on 2/20/21 and went to the ED on 3/27/21 and was admitted on 3/27/21 with shortness of breath, pneumonia, hyponatremia, anemia, bilateral pleural effusion, metastatic cancer and died on 4/17/21. Please refer to the other details submitted within this report and contact the person who submitted this report via email for additional follow up details and investigation.


VAERS ID: 1241384 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-23
Onset:2021-03-27
   Days after vaccination:32
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient was 96 yr old, prostate cancer, peg tube placed, Died on Hospice service, No vaccine complication reported.


VAERS ID: 1243360 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / 2 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received first Moderna Vaccine on 02/26/2021 and second Moderna Vaccine on 03/26/2021. Health Department was notified of patients death on 03/27/2021, today 04/22/2021. Any further information is unknown by the health department for patients cause of death that occurred on 03/27/2021.


VAERS ID: 1250784 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: West Virginia  
Vaccinated:2021-03-25
Onset:2021-03-27
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-30
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My mother was found deceased in her home two days after receiving the first dose of Pfizer vaccine of unknown causes.


VAERS ID: 1251507 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-12
Onset:2021-03-27
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-04-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, Blindness, Cerebrovascular accident, Condition aggravated, Death, Dysphagia, Hemiplegia
SMQs:, Anticholinergic syndrome (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown at this time but was on palliative chemotherapy
Current Illness: Clear cell carcinoma. Other history unknown at this time.
Preexisting Conditions: CVA approximately 3 years ago. Other history unknown at this time.
Allergies: Heparin. Other allergies unknown at this time.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Department of Health received a call from her sister, in response to a call/letter/text sent out to all recipients of the Janssen vaccine. She stated that her sister received the J and J vaccine on 3/12/21 (confirmed in State vaccine system) at the hospital where she receives her oncology care. She reported the following: "She had a massive stroke on MARCH 27TH, 2021 leaving her paralyzed on the right side with the inability to speak, swallow, or see. She was initially diagnosed with Ovarian cancer approximately three and one half years ago. She was chosen for a study with Pharmaceuticals and her diagnosis was changed to a vary rare form of cancer called clear cell carcinoma which originates in the gynecological area. She did have a previous stroke approximately three years ago, (just after original diagnosis) but she was on a different course of treatment at that time...Oncologists have explained that this most recent stroke event would not be considered a side effect of her current treatment routine. She wanted to bring it to the attention of the health department in case it needs to be looked at more closely by the J&J research/scientific team. She passed away on 4/5/21. Her current treatment consisted of palliative chemo only. " Decedent was a resident but was vaccinated in another state. After the CVA she was brought to the hospital and subsequently transferred to the Medical Center where she died on 4/5/2021. Sister is willing to speak with any investigators if deemed necessary.


VAERS ID: 1271243 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-18
Onset:2021-03-27
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1802068 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, COVID-19, Chills, Confusional state, Death, Dizziness, Endotracheal intubation, Intensive care, Multiple organ dysfunction syndrome, Nausea, Pyrexia, SARS-CoV-2 test positive
SMQs:, Acute pancreatitis (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-18
   Days after onset: 22
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 23 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin (HALFPRIN) 81 MG tablet carvedilol (COREG) 25 MG tablet cilostazol (PLETAL) 100 MG tablet clopidogrel (PLAVIX) 75 MG tablet doxazosin (CARDURA) 2 MG tablet ferrous sulfate (FEOSOL, 65 FE,) 325 (65 FE) MG tablet Glucosamine 500 MG ca
Current Illness: None known
Preexisting Conditions: Hypertension associated with stage 3 chronic kidney disease due to type 2 diabetes mellitus (HCC) Stage 3b chronic kidney disease Proteinuria Non-insulin dependent type 2 diabetes mellitus (HCC) Multiple pulmonary nodules PAD (peripheral artery disease) (HCC) Hypertriglyceridemia Thrombocytopenia (HCC) Acute on chronic anemia Anemia in stage 3 chronic kidney disease Secondary hyperparathyroidism (HCC) Hyperkalemia Atherosclerosis of native artery of both lower extremities with intermittent claudication (HCC) Acute respiratory failure with hypoxia (HCC) Pneumonia due to COVID-19 virus Acute kidney injury superimposed on CKD (HCC) Essential hypertension Elevated liver enzymes Sepsis due to COVID-19 (HCC) Metabolic acidosis NSVT (nonsustained ventricular tachycardia) (HCC) Positive occult stool blood test
Allergies: None known
Diagnostic Lab Data: COVID-19 test positive on 3/27/21
CDC Split Type:

Write-up: Symptoms of fever, nausea, and weakness started 3 days following vaccination. Denies any exposure to COVID positive person. Presented to local emergency department on 3/27/21 with nausea, fever, chills, dizziness, and confusion. Due to patient''s condition, he was transferred to larger facility for further management. Patient was admitted to hospital and subsequently transferred to ICU on 4/17/21. He was intubated at that time. Patient went into multisystem organ failure and died on 4/18/21.


VAERS ID: 1272543 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-03-26
Onset:2021-03-27
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / UNK UN / SYR

Administered by: Other       Purchased by: ?
Symptoms: Abdominal exploration, Abdominal pain upper, Arthralgia, Back pain, Headache, Myocardial infarction, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Arthritis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: metformin, glipizide, lisinopril, atorvastatin
Current Illness: diabetic
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Went into hospital from ambulance, thought there was something wrong with his organs, so they cut him open to find out his organs were fine. Came to the conclusion he had a heart attack. The hospital suspected he had a heart attack from the initial adverse event that was mentioned along with the second event.
CDC Split Type:

Write-up: The following evening after the shot, he had severe pains in his back and shoulders, headache, nausea (vomited). 2 days later, felt severe pain in his stomach, along with pain in his shoulders and back, with a headache, also vomited.


VAERS ID: 1273671 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Mississippi  
Vaccinated:2021-03-21
Onset:2021-03-27
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805020 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   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: Her husband will provide information later.
Current Illness: Her husband will provide information later
Preexisting Conditions: Her husband will provide information later.
Allergies: There are no known allergies.
Diagnostic Lab Data: Husband will provide details later.
CDC Split Type:

Write-up: Husband stated that she died of an aneurysm on March 28, 2021. He will provide details later.


VAERS ID: 1281046 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Arthralgia, Blood chloride, Blood creatinine, Blood glucose, Blood lactic acid, Blood potassium, Blood sodium, Blood urea, Calcium ionised, Chills, Cold sweat, Dyspnoea, Fatigue, Feeling of body temperature change, Haematocrit, Nausea, Pain, Pain in extremity, Pallor, SARS-CoV-2 test, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: DIPHENHYDRAMINE; VITAMIN D3; ZINC
Current Illness: Lactose intolerance
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: Chloride; Test Result: Inconclusive ; Result Unstructured Data: 104; Test Name: Creatinine; Test Result: Inconclusive ; Result Unstructured Data: 1.4; Test Name: Glucose; Test Result: Inconclusive ; Result Unstructured Data: 421; Test Name: Lactate; Test Result: Inconclusive ; Result Unstructured Data: 9.7; Test Name: Potassium; Test Result: Inconclusive ; Result Unstructured Data: 4.1; Test Name: sodium; Test Result: Inconclusive ; Result Unstructured Data: 139; Test Name: BUN; Test Result: Inconclusive ; Result Unstructured Data: 13; Test Name: Ionized Calcium; Test Result: Inconclusive ; Result Unstructured Data: 1.18; Test Name: Hematocrit; Test Result: Inconclusive ; Result Unstructured Data: 42; Test Name: Covid-19 test; Test Result: Negative ; Result Unstructured Data: Negative
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Arthralgia; Chills; Cold sweat; Dyspnoea; Fatigue; Feeling of body temperature change; Nausea; Pain; Pain in extremity; Pallor; Unresponsive to stimuli; This case was received via FDA VAERS (Reference number: 1150577) on 27-Apr-2021 and was forwarded to Moderna on 27-Apr-2021. This regulatory authority case was reported by an other health care professional (subsequently medically confirmed) and describes the occurrence of ARTHRALGIA (Arthralgia), CHILLS (Chills), COLD SWEAT (Cold sweat), DYSPNOEA (Dyspnoea), FATIGUE (Fatigue), FEELING OF BODY TEMPERATURE CHANGE (Feeling of body temperature change), NAUSEA (Nausea), PAIN (Pain), PAIN IN EXTREMITY (Pain in extremity), PALLOR (Pallor) and UNRESPONSIVE TO STIMULI (Unresponsive to stimuli) in a 65-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 017B21A and 014M20A) for COVID-19 vaccination. Concurrent medical conditions included Lactose intolerance. Concomitant products included DIPHENHYDRAMINE, VITAMIN D3 and ZINC. On 27-Mar-2021, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 27-Mar-2021, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 27-Mar-2021, the patient experienced ARTHRALGIA (Arthralgia) (seriousness criterion death), CHILLS (Chills) (seriousness criterion death), COLD SWEAT (Cold sweat) (seriousness criterion death), DYSPNOEA (Dyspnoea) (seriousness criterion death), FATIGUE (Fatigue) (seriousness criterion death), NAUSEA (Nausea) (seriousness criterion death), PAIN (Pain) (seriousness criterion death), PAIN IN EXTREMITY (Pain in extremity) (seriousness criterion death), PALLOR (Pallor) (seriousness criterion death) and UNRESPONSIVE TO STIMULI (Unresponsive to stimuli) (seriousness criterion death). 27-Mar-2021, the patient experienced FEELING OF BODY TEMPERATURE CHANGE (Feeling of body temperature change) (seriousness criterion death). The patient was treated with PARACETAMOL (TYLENOL) at an unspecified dose and frequency. The patient died on 31-Mar-2021. The cause of death was not reported. It is unknown if an autopsy was performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Blood chloride: 104 (Inconclusive) 104. On an unknown date, Blood creatinine: 1.4 (Inconclusive) 1.4. On an unknown date, Blood glucose: 421 (Inconclusive) 421. On an unknown date, Blood lactic acid: 9.7 (Inconclusive) 9.7. On an unknown date, Blood potassium: 4.1 (Inconclusive) 4.1. On an unknown date, Blood sodium: 139 (Inconclusive) 139. On an unknown date, Blood urea: 13 (Inconclusive) 13. On an unknown date, Calcium ionised: 1.18 (Inconclusive) 1.18. On an unknown date, Haematocrit: 42 (Inconclusive) 42. On an unknown date, SARS-CoV-2 test: negative (Negative) Negative. For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter did not provide any causality assessments. Paracetamol was taken for the treatment of pain. Patient''s wife called 911 and she stated the told her pull him into floor and EMS arrived as soon as she got in the floor to start CPR. Action taken with the mRNA-1273 in response to the event is not applicable.; Sender''s Comments: Very limited information regarding these events has been provided at this time. The fatal outcome may be related to the patient''s pre-existing comorbidities. Further information required.; Reported Cause(s) of Death: Death


VAERS ID: 1292206 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-27
Onset:2021-03-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Pulmonary thrombosis, Thrombosis
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-31
   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: Pulmonary fibrosis
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Extreme blood clots in lungs and legs


VAERS ID: 1138403 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-01
   Days after onset: 24
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: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient showed no signs or symptoms after but was found deceased the following day.


VAERS ID: 1138695 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: expiration


VAERS ID: 1139653 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0012A / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: Per medical record: Carbidopa/Levodopa Ropinirole
Current Illness: Unknown: Patient was admitted to hospice care
Preexisting Conditions: Unknown: Patient was admitted to hospice care
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reported to hospital ER department the day following second vaccination. Patients issues at ER was: breathing difficulty, Respiratory arrest, Cardiac arrest, aspiration vomit. The patient died while in ER. It should be noted patient had been on hospice prior to vaccination.


VAERS ID: 1142674 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8732 / 2 AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Chills, Death, Fatigue, Feeling abnormal, Feeling cold, Hypersomnia, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 5 mg prednisone, apixaban, metoprol, simvastatin 20 mg, oxygen 3L
Current Illness: Covid (January 20-30th)
Preexisting Conditions: Heart Failure, COPD, Myositis, resolved pulmonary embolism, possible lung cancer - undetermined
Allergies: None
Diagnostic Lab Data: Her body is at the medical examiner''s for a partial autopsy
CDC Split Type:

Write-up: She developed chills she couldn''t control and fell asleep all afternoon, evening and through the night. I spoke with her twice and my uncle and aunt checked on her three times, all three she was freezing cold and too tired to get up. In the morning, she was dazed, cold and walked to the bathroom, where she collapsed to her death. Paramedics could not revive her. My mom died Saturday morning - within the 24-hour period of her vaccine. She was feeling so great leading up to it, active, stripping the guest bedroom sheets, bubbly, and excited for us to be able to finally visit her soon.


VAERS ID: 1142950 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-26
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Death, Mental status changes, Rhabdomyolysis, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: ALTERED MENTAL STATUS Bradycardia Elevated troponin Non-traumatic rhabdomyolysis Death


VAERS ID: 1142953 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-27
Onset:2021-03-26
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death


VAERS ID: 1144468 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN2613 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Diarrhoea, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NAUSEA, VOMITING AND DIARRHEA 48 HOURS AFTER VACCINE.


VAERS ID: 1145183 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Death, Resuscitation, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Previous COvid
Preexisting Conditions: Heart Disease- pacemaker installed Diabetes Had history of strokes Hyperlipidimia
Allergies: no allergies
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: 25 hours after receiving Covid vaccine, patient began seizing and went into cardiac arrest. Daughter began CPR and continued until EMS arrived. Patient subsequently passed away at Hospital.


VAERS ID: 1145423 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-12
Onset:2021-03-26
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Alanine aminotransferase normal, Albumin globulin ratio normal, Aspartate aminotransferase normal, Bacterial test positive, Basophil count normal, Basophil percentage, Bilirubin urine, Bladder catheterisation, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood chloride normal, Blood creatine increased, Blood glucose normal, Blood magnesium increased, Blood potassium normal, Blood sodium normal, Blood urea increased, Blood urine present, Brain natriuretic peptide, C-reactive protein normal, Carbon dioxide normal, Cardiomegaly, Chest X-ray abnormal, Chromaturia, Culture urine, Culture urine positive, Death, Differential white blood cell count abnormal, Eosinophil count normal, Eosinophil percentage decreased, Escherichia infection, Full blood count abnormal, Glomerular filtration rate decreased, Glucose urine absent, Haematocrit decreased, Haemoglobin decreased, Immature granulocyte count increased, Immature granulocyte percentage increased, International normalised ratio normal, Lymphocyte count, Lymphocyte percentage decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume increased, Mean platelet volume normal, Metabolic function test abnormal, Monocyte count increased, Monocyte percentage, Myocardial infarction, Neutrophil count increased, Neutrophil percentage increased, Nitrite urine present, Platelet count increased, Pleural effusion, Protein total normal, Protein urine present, Prothrombin time normal, Red blood cell count decreased, Red blood cell nucleated morphology, Red cell distribution width increased, SARS-CoV-2 test negative, Serum ferritin increased, Specific gravity urine normal, Troponin I increased, Urine ketone body absent, Urine leukocyte esterase positive, Urobilinogen urine, White blood cell count increased, White blood cells urine positive, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Tumour lysis syndrome (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: See VAERS Report #322299
Other Medications: Acetaminophen 500mg Oral EVERY 6 HOURS PRN amLODIPine Besylate 10 MG TAKE ONE (1) TABLET BY MOUTH ONCE DAILY Aspirin 81 mg Oral DAILY Blood Glucose Monitoring Suppl w/Device Use when testing blood sugars one time each day. Dx: E11.9 cl
Current Illness:
Preexisting Conditions:
Allergies: Ambien crestor macrodantin penicillin Plavix probenecid statins
Diagnostic Lab Data: Urine culture Collected: 03/26/21 1049 Order Status: Completed specimen: URINE,CLEAN CATCH (CCMS) Updated: 03/28/21 0840 Specimen Type CCMS Special Handling NONE Reflexed from F57974 Culture Result $g=100,000 COL/ML ESCHERICHIA COLI Specimen Status Report 03/28/2021 FINAL Organism Identification ESCHERICHIA COLI Susceptibility Escherichia coli MIC Amoxicillin/clavulanate Sensitive Ampicillin Resistant Ampicillin/sulbactam Resistant Aztreonam Sensitive Cefazolin Sensitive1 Cefepime Sensitive Cefoxitin Sensitive Ceftazidime Sensitive Ceftriaxone Sensitive Cefuroxime Sensitive Ciprofloxacin Resistant Ertapenem Sensitive Gentamicin Sensitive Imipenem Sensitive Levofloxacin Resistant Nitrofurantoin Sensitive Piperacillin/Tazob Sensitive Tetracycline Resistant TMP SULFA Resistant Tobramycin Sensitive 1 SUSCEPTIBL Linear View Susceptibility Comments Escherichia coli $g=100,000 COL/ML ESCHERICHIA COLI Ferritin [245923475] (Abnormal) Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/28/21 0200 Ferritin --High 18 - 340 ng/mL 585 (NOTE) High C-reactive protein [245923474] Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/27/21 1557 CRP -- 0.0 - 0.8 mg/dL 0.5 (NOTE) INTERPRETIVE INFORMATION: C-Reactive Protein Significantly decreased CRP values may result in specimens from patients treated with carboxypenicillins. NOVEL CORONAVIRUS SARS-COV-2 BY PCR [245923473] Collected: 03/26/21 1049 Order Status: Completed Specimen: Nasopharyngeal Updated: 03/27/21 1358 SARS-COV-2 Source NASOPHARYNGEAL SARS-COV-2 By PCR Not Detected Not Detected Comment: THIS TEST HAS BEEN VALIDATED BUT FDA''S INDEPENDENT REVIEW OF THE VALIDATION IS PENDING. THIS TEST IS PERFORMED AS A LABORATORY DEVELOPED TEST, INDEPENDENT REVIEW OF THE VALIDATION UNDER THE FDA''S EMERGENCY USE AUTHORIZATION (EUA) AUTHORITY WILL BE PERFORMED ACCORDING TO CURRENT GUIDANCE REQUIREMENTS. ********** WE WILL CONTINUE TO FOLLOW FEDERAL AND STATE REQUIREMENTS FOR BOTH NOTIFICATION OF RESULTS AND ANY CONFIRMATORY TESTING FHC COVID Antigen [245923485] Collected: 03/26/21 1050Order Status: Completed Specimen: NARES from NASAL Updated: 03/26/21 1114 FHC COV AG PRESUMPTIVE NEGATIVE Urinalysis with reflex to culture, if indicated [245923471] (Abnormal) Collected: 03/26/21 1049 Order Status: Completed Specimen: URINE, CATH IN AND OUT Updated: 03/26/21 1103 Glucose UA NEGATIVE NEGATIVE MG/D Protein UA TRACE Abnormal NEGATIVE MG/DL Bilirubin UA NEGATIVE NEGATIVE Urobilinogen UA 0.20.2 - 1.0 MG/DL pH UA 6.5 5.0 - 8.0 Blood UA TRACEAbnormal NEGATIVE Ketones UA NEGATIVE NEGATIVE MG/DL Nitrite UA POSITIVEAbnormal NEGATIVE Leukocyte Esterase UA 2+Abnormal NEGATIVE UR Appearance CLEAR CLEAR Specific Gravity UA 1.020 1.000 - 1.030 Color YELLOW YELLOW Site VOIDEDComment, Urine Culture IN PROGRESS WBC Urine 51 to 100 <5 /HPF Bacteria MODERATE Abnormal NONE /HPF Magnesium [245923468] Collected: 03/26/21 0907Order Status: Completed Specimen: Blood Updated: 03/26/21 095 Magnesium 2.2 1.8 - 2.4 MG/DLTroponin Series [245923470] (Abnormal) Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/26/21 0954 Troponin I 0.10High 0.00 - 0.06 ng/mL Comment: 0.1 to 0.5 ng/mL shows an increased risk of AMI. 0.6 to 1.5 or greater is suggestive of AMI. Comprehensive metabolic panel (Abnormal) Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/26/21 0953 Glucose 148High 65 - 100 MG/DL Blood Urea Nitrogen 40High 7 - 18 MG/DL Creatinine 2.4High 0.5 - 1.0 MG/DL Sodium 140 136 - 145 MMOL/L Potassium 4.0 3.5 - 5.1 MMOL/L Chloride 101 98 - 107 MMOL/L Co2 23 21 - 32 MMOL/L Calcium 9.7 8.5 - 10.1 MG/DL Protein Total 7.4 6.4 - 8.2 G/DL Albumin 3.8 3.4 - 5.0 G/DL A/G Ratio 1.1 0.8 - 2.0 Alkaline Phosphatase 44Low 46 - 116 U/L Alt (SGPT) 18 14 - 59 U/L AST(SGOT) 22 15 - 37 U/L Bilirubin, Total 0.4 0.2 - 1.0 MG/DL GFR Comment IF PATIENT IS AFRICAN AMERICAN, MULTIPLY RESULT BY 1.16 Est GFR 17Low $g90 ML/MIN/1.73sq.m APTT [245923463] Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/26/21 0951 APTT 29.3 25.4 - 38.4 SEC Protime (Prothrombin Time) [245923469] Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/26/21 0951 PROTIME 11.6 10.3 - 12.6 SEC INR 1.0 0.9 - 1.1 Comment: Recommended therapeutic ranges or oral anticoagulant is and INR of 2.0 to 3.0. An INR of 2.5 to 3.5 is recommended to prevent recurrent MI. Brain Natriuretic Peptide (BNP) (Abnormal) Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/26/21 0950 B-Type Natriuretic Peptide 1,210High Panic 0 - 100 PG/ML CBC w Auto Diff [245923465] (Abnormal) Collected: 03/26/21 0907 Order Status: Completed Specimen: Blood Updated: 03/26/21 0922 White Blood Cell Count 15.2High 4.3 - 10.5 THOUS/uL Red Blood Cell Count 3.70Low 3.93 - 5.07 MIL/uL Hemoglobin 11.5Low 11.8 - 14.8 GM/DL Hematocrit 35.9 35.6 - 45.0 % Mean Corpuscular Volume 97.0High 83.5 - 95.9 FL Mean Corpuscular Hemoglobin 31.1 27.4 - 32.0 PG Mean Corpuscular Hemoglobin Conc 32.0 31.5 - 34.7 G/DL Rdwcv 13.7 11.8 - 14.2 % Rdwsd 48.9High 37.2 - 47.8 FL Platelet Count 424High 167 - 402 THOUS/uL Mean Platelet Volume 10.0 8.8 - 12.0 FL Nucleated Red Blood Cells 0.0 0.0 /100 WBC''S Abs NRBC 0.0 0.0 THOUS/uL Differential Type AUTO Neutrophils 79.3High 34.0 - 67.9 % Lymphs 13.2Low 20.4 - 48.6 % Monocytes 5.1 5.0 - 11.5 % Eos 0.8Low 1.0 - 5.4 % Basos 0.7 0.2 - 1.3 % Neutrophils Absolute Count 12.1High 2.1 - 6.6 THOUS/uL Lymphocytes Absolute Count 2.0 1.2 - 3.9 THOUS/uL Monocytes Absolute Count 0.8 0.3 - 0.8 THOUS/uL Eosinophils Absolute Count 0.1 0.1 - 0.4 THOUS/uL Basophils Absolute Count 0.1 0.0 - 0.1 THOUS/uL Imm Gran 0.9High 0.1 - 0.7 % Abs Imm Gran 0.13High 0.0 - 0.1 THOUS/uL XR Chest Portable Collected: 03/26/21 0904 Order Status: Completed Updated: 03/26/21 0914 Narrative: EXAMINATION: Frontal view of the chest CLINICAL HISTORY: 88 years Female,chest pain/cough COMPARISON: 2/18/2021 FINDINGS: The heart is enlarged. There is bilateral hilar haziness and right perihilar infiltrate. Bilateral small effusions. IMPRESSION: Cardiomegaly with bilateral small effusions. Correlate for CHF. Right perihilar infiltrate.
CDC Split Type:

Write-up: 3/26/21 ER to Inpt Admission: Patient was admitted to the hospital for comfort measures after patient suffered MI and did not want any life-prolonging therapies. Patient was started on comfort medications and symptoms were monitored closely. The patient passed peacefully before she could be fully assessed


VAERS ID: 1145434 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 UN / UN

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: Unknown.
Current Illness:
Preexisting Conditions: Coronary Artery Disease, Congestive Heart Failure, Hypertension, Myocardial Infarction, Rheumatoid Arthritis, Osteoarthritis.
Allergies: Unknown.
Diagnostic Lab Data: Autopsy 3/29.
CDC Split Type:

Write-up: Acute onset shortness of breath approximately 11-12 hours post second dose of Moderna covid vaccine. EMS responded and briefly performed CPR before DNR was produced and life saving measures were discontinued. Patient subsequently expired.


VAERS ID: 1148215 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Alaska  
Vaccinated:2021-01-08
Onset:2021-03-26
   Days after vaccination:77
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: Morphine, Atropine, Lorazepam, Timolol,
Current Illness: Alzheimer''s, Glaucoma, Heart Disease, CVA,
Preexisting Conditions: Alzheimer''s, Glaucoma, Heart Disease, CVA,
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death


VAERS ID: 1157133 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: California  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: chronic uti''s
Preexisting Conditions: Chronic UTI''s Obesity BMI 39-39 Chronic neck pain hypertension hyperlipedemia hypothyroidism agoraphobia with panic disorder PTSD
Allergies: ace inhibitors sulfa azithromycin ciproflaxin metoclopramide opioids potassium clavulate
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt deceased approx 36 hours after vaccination


VAERS ID: 1167899 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-02-09
Onset:2021-03-26
   Days after vaccination:45
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1168352 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 UN / UN

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Confusional state, Diarrhoea, Flushing, Gait inability, Malaise, Muscle spasms, Nausea, SARS-CoV-2 test negative, Toxicologic test, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none other than eye drops
Current Illness: none
Preexisting Conditions: hypertension
Allergies: unknown
Diagnostic Lab Data: Autopsy including toxicology ( pending tax). COVID 19 test done at autopsy was negative.
CDC Split Type:

Write-up: Started feeling ill a few hours after vaccination. Became increasingly ill over the next few days with nausea and vomiting, severe diarrhea, leg cramps that progressed to where he was not able to ambulate, flushed, confused.


VAERS ID: 1169913 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-03-13
Onset:2021-03-26
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: pt had chest pain and SOB, taken to the hospital. had an acute MI secondary to Coronary Athersclerosis in the setting of ESRD and Metastatic Lung Cancer per Hospital notes
Allergies:
Diagnostic Lab Data: pt was placed in ICU with multiple tests done, blood given and pt arrested/died
CDC Split Type:

Write-up: none noted or reported after the injection


VAERS ID: 1171204 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 1 AR / ID

Administered by: Public       Purchased by: ?
Symptoms: Death, Dysarthria, Fall, Impaired driving ability, Posture abnormal, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantanoprost Ophthalmic Solution
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: Patient passed away in the Emergency Room at Hospital
CDC Split Type:

Write-up: Patient fell while on the job on Friday March 26th, slurred talking. Later slumped over in the car while driving and had to be taken to the Emergency room where he later passed away. Cause of death on the death certificate per the coroner is Pulmonary Embolus. Patient was just seen my his family physician in January and was in good health no medications taken other than eye drops.


VAERS ID: 1173746 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-20
Onset:2021-03-26
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 2 UN / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: Losartin 100 mg Aspirin 81 mg Duller a Asthma inhaler
Current Illness: Asthma Hypertension
Preexisting Conditions: Obesity Asthma
Allergies: NKDA
Diagnostic Lab Data: No autopsy
CDC Split Type:

Write-up: Received first dose 2/27/21 and received second dose 3/20/21 and died 3/26/21.


VAERS ID: 1176373 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-09
Onset:2021-03-26
   Days after vaccination:17
Submitted: 0000-00-00
Entered: 2021-04-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Metastatic neoplasm
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Narrative: Patient with gastric cancer received COVID-19 vaccine, first dose on 2/8/2021 and second dose on 3/9/2021. Chart note indicates that patient passed away on 3/26/2021 while on home hospice. Patient has never tested positive for COVID. Patient had metastatic cancer and was referred to hospice on 3/5/2021, note from provider indicates patient likely had only weeks to live. Patient had no documented reaction from COVID vaccine administration. Patient had no hospitalization around time of COVID vaccination. The patients most likely cause of death was the metastatic cancer, with date of death closely aligning with cancer providers'' estimations of remaining life span on 3/5.


VAERS ID: 1174338 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8727 / 1 RA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: SUBOXONE
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: None
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021338099

Write-up: Patient died 12-15hrs after vaccination.; This is a spontaneous report from a contactable Consumer. A 40-year-old male patient received bnt162b2 (BNT162B2), dose 1 via an unspecified route of administration, administered in Arm Right on 25Mar2021 12:45 (Batch/Lot Number: ER8727) at the age of 40-year-old as single dose for covid-19 immunisation. Medical history reported as none. Concomitant medication included buprenorphine hydrochloride, naloxone hydrochloride (SUBOXONE) taken for an unspecified indication, start and stop date were not reported. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient patient died 12-15 hours after vaccination. The patient died on 26Mar2021. An autopsy was not performed. No treatment received for the event. Prior to vaccination, the patient was not diagnosed with COVID-19 and since the vaccination, the patient was not been tested for COVID-19.; Reported Cause(s) of Death: Patient died 12-15hrs after vaccination.


VAERS ID: 1176806 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-03-19
Onset:2021-03-26
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP 6955 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal distension, Death, Dyspnoea, Logorrhoea, Mouth breathing, Protrusion tongue, Tongue discolouration
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Dyskinesia (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: tamsulosin, aflibercept DO, ranibizumab OS
Current Illness: CAD, BPH, AMD
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: OBJECTIVE: Patient found deceased on March 26, 2021, less than one week post vaccination with Pfizer-BioNTech COVID19 vaccine dose #1. Found by daughter who is also RN and caregiver. Patient found with black tongue protruding slightly from open mouth. Three days post vaccine date and for three days patient found mouth-breathing heavily. When patient?s attention was called to his breathing he immediately resumed normal breathing. Also three days post vaccine date and for three days patient had loosened waist belt and offered complaint of feeling full. Also, Patient was more talkative during the week following vaccination. SUBJECTIVE: Perhaps related to anxiety. OBJECTIVE: Patient had eaten only one avocado per day for his remaining two days of life. Patient had history of stoicism and was known to downplay or deny deviations in physical well-being.


VAERS ID: 1180145 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-03-04
Onset:2021-03-26
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood magnesium normal, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: 1/21/2021 Acute diarrhea negative for C.diff; 2/4/21 labs WBC 2.83, RDW-CV 15.3, Platelet Count 437, Neut # 1.50; Labs obtained from Hosiptal.
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Low Magnesium levels 2/24 Mag 1.5, 3/4 received 4gm Mag Sulfate, 3/8 Mag 1.6 (obtained from Hospital. Death within 30 days of vaccination


VAERS ID: 1180245 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-03-10
Onset:2021-03-26
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Echocardiogram abnormal, Endotracheal intubation, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: Unknown
Preexisting Conditions: Hyperlipidemia; htn; diabetes,
Allergies: NKA
Diagnostic Lab Data: Patient was helping to place lines on the football field when he had a sudden witnessed collapse, CPR was initiated and EMS was involved. Intubated in field with CPR following ACLS protocol during transport to ER. Asystole, confirmed in 2 leads and bedside echo showed no cardiac activity.
CDC Split Type:

Write-up: Death within 30 days of vaccination


VAERS ID: 1180291 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-02-03
Onset:2021-03-26
   Days after vaccination:51
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cough, Death, Dyspnoea, Enterobacter infection, Enterobacter test positive, Lethargy, Pneumonia, Urinary tract infection, Urine analysis abnormal
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: COVID + 11/10/2020; 12/18/20 GI Bleed; 12/29/20 Received 2 units Blood
Preexisting Conditions: COPD, Htn, Left breast, cervix and uterus cancer, s/p left mastectomy; bilateral pulmonary nodules suspicious for cancer.
Allergies: Lisinopril, macrobid, norco, symbicort, tetanus toxoid
Diagnostic Lab Data: 2/22/21 positive UTI Enterobacter cloacae and possible colitis; 3/17/21 admit for lethargy, sob with cough diagnosed with pneumonia.
CDC Split Type:

Write-up: Hospitalization x 2 within 30 days of vaccination; Death within 60 days of vaccination


VAERS ID: 1203159 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-11
Onset:2021-03-26
   Days after vaccination:43
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Lung cancer metastatic
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Metastatic Lung cancer


VAERS ID: 1204479 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-03-08
Onset:2021-03-26
   Days after vaccination:18
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN J&J 1805020 / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Back pain, Death, Fatigue, Musculoskeletal discomfort
SMQs:, Rhabdomyolysis/myopathy (broad), Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-27
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Adult low dose 81mg, aspirin, Alprazolam 0.5, Amitriptyline, Atenolol, duloxetine, furosemide, Norco, simvastatin, sumatriptan, Pre Natel Vitamins.
Current Illness: None other than osteoporosis.
Preexisting Conditions: Osteoporosis.
Allergies: None
Diagnostic Lab Data: None. Died in her sleep sometime the night of March 26 found at 5:30 AM morning of March 27
CDC Split Type:

Write-up: Initially 2 to 5 days just fatigue. Evening of March 26th unusual fatigue and lower back to middle back discomfort low pain level.


VAERS ID: 1205249 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   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: ATORVASTATIN; SPIRONOLACTONE; LISINOPRIL; COQ10 COMPLEX
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Heart disease, unspecified; Kidney disorder; Physical disability
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021372896

Write-up: Died from cardiac arrest; This is a spontaneous report from a contactable consumer. A 63-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection, Lot number was not reported), via an unspecified route of administration, administered in left arm on 24Mar2021 as single dose for COVID-19 immunization. Medical history included heart disease, kidney issues, and physical disability from an unknown date. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient has not been tested for COVID-19. Concomitant medication included atorvastatin; spironolactone; lisinopril; and ubidecarenone, vitamin e NOS (COQ10 COMPLEX) taken for an unspecified indication. The patient previously received the first dose of BNT162B2 on 03Mar2021 11:00 AM, on Left arm, for COVID-19 immunization. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. The patient was reported to have died from cardiac arrest on 26Mar2021. The reporter did not know if it was related to vaccine. The patient died on 26Mar2021. It was not reported if an autopsy was performed.; Reported Cause(s) of Death: It appears he died from cardiac arrest.


VAERS ID: 1209422 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Diabetes mellitus, Diabetic complication, Dyspnoea, Electrolyte imbalance, Impaired driving ability, Myocardial infarction, Nausea, Unresponsive to stimuli, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Insulin, albuterol, metoprolol, trazodone, duloxetine, cephdinir
Current Illness: Unknown
Preexisting Conditions: Asthma, obesity, insulin-dependent DM
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Per the patient''s husband, on 03/26/2021, the day after vaccination, the decedent complained of nausea with vomiting, and had difficulty driving. On 03/27/2021, her nausea continued and she complained of shortness of breath while walking. On 03/28/2021, she was short of breath before vomiting a small amount. She then became unresponsive. Death was pronounced a short time later. Per her treating physician who signed the death certificate, the cause of death is felt to be probable myocardial infarction due to electrolyte abnormalities due to complications of her diabetes mellitus.


VAERS ID: 1227977 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Laboratory test, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Colon cancer
Allergies:
Diagnostic Lab Data: Test Date: 2011; Test Name: lab work; Result Unstructured Data: Test Result:Good
CDC Split Type: USPFIZER INC2021406385

Write-up: Pulmonary embolism/ blood clot/ passed out; This is a spontaneous report from a contactable consumer (patient''s daughter). A male patient of an unspecified age received BNT162B2 (Pfizer COVID-19 vaccine), dose 1 via an unspecified route of administration, administered in arm, side unknown, on 24Mar2021 14:30 (Lot Number: EN6208) as single dose for COVID-19 immunisation. Vaccination facility type was clinic. Medical history included colon cancer in 2011. He had cancer in 2011 but resolved that year without chemotherapy or radiation. His lab work was good. There were no concomitant medications. No prior vaccinations (within 4 weeks). No family medical history relevant to AE. The patient experienced pulmonary embolism on 26Mar2021 with fatal outcome. The reporter was reporting on the Pfizer COVID vaccine that her father received. She stated he died from a blood clot after receiving the first dose. Stated she needs help because he had no health issues and he died. She just wanted this information to be out there and for people to be aware. This morning they had been reading on the news that the Johnson and Johnson vaccine is on hold. It seems to be put on the market without research. She felt like her father was a guinea pig. Her mother didn''t want to get her second dose. Stated there seems to be an issue with Pfizer too. Her father had no issues whatsoever. His death certificate stated the cause of death was a pulmonary embolism, but he had no history of blood clots. Passed away Friday 26Mar2021 at 11:33 am. The reporter stated when he went to Emergency Room they thought he was having a heart attack. All physicians were wondering what happened because he had no health issues. The event required a visit to the emergency room that day because he passed out at his job. The patient underwent lab tests and procedures which included lab work: good in 2011. The patient died on 26Mar2021. An autopsy was performed that revealed pulmonary embolism.; Reported Cause(s) of Death: Pulmonary embolism; Autopsy-determined Cause(s) of Death: Pulmonary embolism


VAERS ID: 1230230 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Biopsy soft tissue, Death, Dizziness, Fatigue, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-29
   Days after onset: 3
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: crevedol amiodorone metroprolol
Current Illness: None
Preexisting Conditions: Heart
Allergies: None
Diagnostic Lab Data: Tissue Biopsy
CDC Split Type:

Write-up: Fatigue, dizziness, heart attack and death


VAERS ID: 1237427 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / SYR

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Influenza like illness, Laboratory test abnormal, Pain in extremity
SMQs:, Retroperitoneal fibrosis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-05
   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: Humera, multi-vitamin, prednisone, iron
Current Illness:
Preexisting Conditions: COPD, Rheumatoid arthritis
Allergies: Adavan
Diagnostic Lab Data: Patient had just received positive lab results back from primary care physician visit prior to vaccine.
CDC Split Type:

Write-up: Arm soreness 1-3 days post vaccine flu like symptoms 4-7 days post vaccine Severe back pain 4-10 days post vaccine Death 11 days post vaccine


VAERS ID: 1242118 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-03-13
Onset:2021-03-26
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-04-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048A21A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Bacteraemia, COVID-19 pneumonia, Death, Endotracheal intubation, Gastrointestinal haemorrhage, Hyperkalaemia, Hypoxia, Oliguria, Renal replacement therapy, Sepsis, Shock, Therapeutic embolisation
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (broad), Retroperitoneal fibrosis (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), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Ischaemic colitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (narrow), Tumour lysis syndrome (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: aspirin EC 81 mg daily, metformin ER 500 mg BID, atorvastatin 40 mg daily
Current Illness: fall/trauma with rib fractures
Preexisting Conditions: CAD s/p CABG, dementia, diabetes, aortic valve replacement
Allergies: Iodine, penicillin (no reactions listed for either)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient presented after being found down next to toilet found to have COVID-pneumonia and sepsis needing intubation for ARDS and CRRT for hyperkalemia and oliguria. Hospitalization complicated by GIB s/p rectal artery embolization by IR and GNR bacteremia requiring cefepime. Due to worsening hypoxia and shock, patient was made comfort care/hospice by family and passed away on 4/9.


VAERS ID: 1249616 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: California  
Vaccinated:2021-03-26
Onset:2021-03-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 044A21A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Aorta problem
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: MY HUSBAND DIED WITHIN 24 HOURS OF RECEIVING THE VACCINE. I WANT TO CONFIRM THAT YOU KNOW ABOUT THIS. PLEASE CALL ME ON MY CELL PHONE , THANK YOU,


VAERS ID: 1262415 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-03-24
Onset:2021-03-26
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood test, Chest X-ray, Chills, Death, Dysstasia, Electrocardiogram, Muscular weakness, SARS-CoV-2 test, Skull X-ray, Syncope, Urine analysis
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-01
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol PRN; cholesterol medication, Blood pressure medication
Current Illness: denied
Preexisting Conditions: MDS, high cholesterol, high blood pressure.
Allergies: no known allergies
Diagnostic Lab Data: 3/31/2021: CXR; head x-ray, bloodwork, urine test, COVID-19 test, EKG
CDC Split Type:

Write-up: Information obtained from clients wife. patient received his first dose of Moderna 2/24/21 lot 024M20A with no reported issues except for a sore arm. patient received his second dose of Moderna on 3/24/21; Lot# 006B21A. No immediate effects from the vaccine. On day 2 post vaccination, patient became to have chills, per wife; did not check temperature and denied any symptoms such as flu-like symptoms. Day 3 post vaccination; patient began to have weakness in the legs. March 31st; patient was unable to stand and the rescue squad was called. patient was taken to the Hospital; where he was evaluated and released home. Pt collapsed at 1am 4/1/2021 and died 4/1/21.


VAERS ID: 1263575 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-03-25
Onset:2021-03-26
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN UNKNOWN / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Cold sweat, Nausea, Pulse absent, Resuscitation, Tremor, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had received the vaccine day prior to coming to ED. Presented to ED with family due to n/v/chills with shaking. She was able to dress self into gown and answer history questions. Then when she laid supine she became cold/clammy with loss of pulse. CPR was started with eventual decision by family to cease.


VAERS ID: 1268049 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-26
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-04-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Fall
SMQs:, Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-26
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fall Death


VAERS ID: 1134376 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-03-25
   Days after vaccination:49
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiogenic shock, Coronary artery bypass, Death
SMQs:, Cardiac failure (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   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: 05/04/2017 Glucagon Emergency Kit (human-recomb) 1 mg injection 05/19/2020 FreeStyle Freedom kit 05/19/2020 Novolog Flexpen U-100 Insulin aspart 100 unit/mL (3 mL) subcutaneous 05/19/2020 Glucophage XR 500 mg tablet,extended release 05/19/2
Current Illness: HFrEF, CAD, HTN, DM
Preexisting Conditions: CAD, HTN, HLD, DM, HF
Allergies: Ibuprofen
Diagnostic Lab Data: hospitalized, had multiple tests
CDC Split Type:

Write-up: Patient passed away from cardiogenic shock after a CABG


VAERS ID: 1135483 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-03-25
Onset:2021-03-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8732 / UNK - / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   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: insulin
Current Illness:
Preexisting Conditions: Diabetes
Allergies: Celebrex Atorvostatin
Diagnostic Lab Data: Code Blue
CDC Split Type:

Write-up: Patient got 2nd vaccine, waited 15 minutes for observation and collapsed when getting into car


VAERS ID: 1136004 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: New York  
Vaccinated:2021-03-15
Onset:2021-03-25
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-03-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known
Preexisting Conditions: Pulmonary Fibrosis, Atrial Fibrillation , Rheumatoid Arthritis
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patients representative notified pharmacy today to cancel patients second appointment as the patient had died this morning due to a staff infection in hospital. Representative did state they did not believe it was related to vaccination as patient has been having difficult time with underlying conditions (pulmonary fibrosis and atrial fibrillation).


VAERS ID: 1137579 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-03-16
Onset:2021-03-25
   Days after vaccination:9
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19, diagnosed with COVID bronchitis 3/22/2021, strep pharangitis
Preexisting Conditions: Carpal tunnel syndrome ? Depression ? Eczema ? Dysphagia ? Otalgia ? Gastroesophageal reflux disease ? Ganglion ? Headache ? Hemorrhoids ? Hypothyroidism ? Irritable bowel syndrome ? Right hip pain ? Pain in extremity ? Localized superficial swelling, mass, or lump ? Menopausal symptom ? Adiposity ? Open wound of lower leg ? Otitis media ? Raynaud''s phenomenon ? Ulnar neuropathy ? Urinary tract infection ? Candidiasis of vagina ? Family history of diabetes mellitus ? Anxiety
Allergies: Sulfa (Sulfonamide Antibiotics) Angioedema, Rash and Anaphylaxis
Diagnostic Lab Data:
CDC Split Type:

Write-up: ? Maderna vaccine #1 on 3/16 at clinic ? Provider visit 3/22 dx bronchitis due to COVID-19, z pak and steroids ? ED 3/25 syncopy, full arrest and patient expired patient states she had COVID in February


VAERS ID: 1138065 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-22
Onset:2021-03-25
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-03-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-26
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unk
Current Illness: UNK
Preexisting Conditions: UNK
Allergies: Hydroxyzine Hcl
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Pt came into Emergency Department with resuscitation efforts in progress. Patient spouse states no known health concerns but was feeling unwell after 2nd dose of vaccine on Monday.


VAERS ID: 1142078 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: New York  
Vaccinated:2021-03-05
Onset:2021-03-25
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-03-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature increased, Computerised tomogram abdomen abnormal, Computerised tomogram head abnormal, Computerised tomogram pelvis abnormal, Death, Influenza virus test negative, Lung infiltration, Lymphadenopathy, Malaise, Nausea, SARS-CoV-2 test negative, Sepsis, Splenomegaly, Subarachnoid haemorrhage, Unresponsive to stimuli, White blood cell count increased
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Zoloft, Xanax, levothyroxine, lovastatin, protonix
Current Illness: None
Preexisting Conditions: Chronic anemia Immune deficiency syndrome hx CLL- dx 1 yrs ago- was on no treatment Hypothyroidism Chronic stable thrombocytopenia with last known platelet count 95,000
Allergies: pyridium
Diagnostic Lab Data: please see narrative above
CDC Split Type:

Write-up: Patient was a high functioning 97-year-old female with a history of CLL diagnosed 1 year ago on no treatment prior to arrival, chronic stable thrombocytopenia, chronic kidney disease, past history of breast cancer and bladder cancer in remission, transfusion dependent anemia of chronic disease, covid 19 vaccination on 3/5/2021, who presented to the emergency room on 3/25/2021 unresponsive found by the family and emergency services was called. The paramedics found her temperature to be 101.6 and her room air sat was 87%. In the ER CT of the head revealed acute subarachnoid hemorrhage. There was no trauma. CT the abdomen and pelvis showed lymphadenopathy and splenomegaly consistent with her known CLL and new bilateral lung infiltrates. Patient''s white blood cell count was 124,000 consistent with her known CLL. Patient prior was high functioning and still drove herself to her doctor''s appointments. The day prior she told her son she was feeling slightly nauseous and ill and went to bed early. She was admitted with a subarachnoid hemorrhage which was felt to be spontaneous and not traumatic. She was not on any anticoagulation prior to arrival. She was also admitted with severe sepsis felt possibly due to aspiration pneumonia or pneumonia in general and she did have fever and bilateral infiltrates on imaging. covid 19 and influenza neg. The decision was made to place her on comfort care after discussion with family. She ultimately expired on 3/28 At 14:48 PM in the presence of her family


VAERS ID: 1142995 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-03-20
Onset:2021-03-25
   Days after vaccination:5
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER2613 / UNK RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1143266 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-19
Onset:2021-03-25
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-03-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death


VAERS ID: 1147418 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-03-19
Onset:2021-03-25
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006B21A / UNK LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 6 days after 2nd Moderna vaccine.


VAERS ID: 1147783 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-03-24
Onset:2021-03-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6203 / 1 UN / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6204 / 2 UN / SYR

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Had 2nd COVID shot died next day physician advised me to notify.


VAERS ID: 1149202 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-03-09
Onset:2021-03-25
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-03-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6199 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Feeling abnormal, Refusal of treatment by patient, Resuscitation, Syncope, 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), Dementia (broad), 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: 2021-03-25
   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:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per ED Provider Report, the patient collapsed while outside on 3/25/21. Ambulance was called to the scene where patient was found unresponsive. Patient was transferred to Hospital. Patient was in full cardiac arrest upon arrival. CPR was initiated. Patient deceased. Patient''s mother stated the patient had been feeling badly for 2-days, but refused to seek medical treatment.


VAERS ID: 1152421 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Vermont  
Vaccinated:2021-03-12
Onset:2021-03-25
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6198 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hospice patient - Malignant neoplasm upper lobe r bronchus or lung and Secondary neoplasm of brain
Preexisting Conditions: Hospice patient - Malignant neoplasm upper lobe r bronchus or lung and Secondary neoplasm of brain
Allergies:
Diagnostic Lab Data: none
CDC Split Type:

Write-up: hospice patietn passed away


VAERS ID: 1152759 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-03-17
Onset:2021-03-25
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Angiogram, Angiogram abnormal, Aspartate aminotransferase increased, Blood potassium decreased, Brain injury, Cardio-respiratory arrest, Chest X-ray abnormal, Computerised tomogram head normal, Death, Dyspnoea, Echocardiogram, Electroencephalogram abnormal, Endotracheal intubation, Fibrin D dimer increased, Hypoxia, Life support, Liver function test increased, Loss of consciousness, Magnetic resonance imaging head abnormal, Pulmonary embolism, Right ventricular dilatation, Right ventricular ejection fraction decreased, Right ventricular failure, Syncope, Ultrasound Doppler abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haemorrhage laboratory terms (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), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Hypokalaemia (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown at this time
Current Illness: unknown at this time
Preexisting Conditions: unknown at this time
Allergies: unknown at this time
Diagnostic Lab Data: Events on 3/25/2021: -AP Chest X-Ray, CT angiography proved bilateral pulmonary emboli, TTE showed severely dilated right ventricle with reduced EF at 60-65%. Arterial line and IJ central line placed for pressor support. Intubated on a vent. -Labs collected on this date: D_Dimer elevated at 5000, Potassium at 2.7, elevated LFT''s - AST = 439, ALT = 331. -Vasc doppler venous bilateral lower extremities showed no evidence of DVT in either leg. Venous flows in bilateral lower legs showed high pressure indicating right sided heart failure. -CT of head w/o contrast negative for intracranial hemorrhage, hydrocephalus, mass, or midline shift. Calvarium is intact. -MRI Brain w/o contrast negative for acute intracranial abnormalities. Event on 3/26/2021: EEG concerning for myoclonic seizures related to anoxic brain injury Event on 3/28/2021: MRI Brain w/o contrast showed new changes suggesting hypoxic/anoxic injury
CDC Split Type:

Write-up: 7 AM 3/25/2021 - Patient called out to husband from the bathroom where she experienced a syncopal event, then passed out. An ambulance was called and she was revived for a short period of time. She was taken to Hospital where she coded 3 times. She was then life-flighted to second Hospital. According to the hospital records, tests conducted over the course of several days determined that she had no neurological activity. Initial reports in the records indicate pulmonary embolism, cardiac and respiratory arrest. She was on life support for the remainder of her time. Organ donation is being pursued at present and results of this are pending at time of this report submission. Date of death is unknown until organ retrieval is accomplished. Family will be contacted in the next few days to ask further questions about any other kinds of vaccine-related reactions that may have happened more immediately to days after the vaccination on 3/17/2021. A co-worker thought that she had shortness of breath for 3-4 days before this critical event occurred on 3/25/2021.


VAERS ID: 1154465 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-26
Onset:2021-03-25
   Days after vaccination:27
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6202 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Angiopathy, Chronic obstructive pulmonary disease, Multiple sclerosis
SMQs:, Optic nerve disorders (broad), Demyelination (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA MS End Stage Vascular disease COPD


VAERS ID: 1155311 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-02-18
Onset:2021-03-25
   Days after vaccination:35
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6203 / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Lymphoma
SMQs:, Malignant lymphomas (narrow), Haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA Lymphoma - Hospice Care


VAERS ID: 1155785 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-03-25
   Days after vaccination:56
Submitted: 0000-00-00
Entered: 2021-04-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac failure, Peripheral vascular disorder, Respiratory failure
SMQs:, Cardiac failure (narrow), 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), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: NA Advanced age PVD, Heart failure ,respiratory failure


VAERS ID: 1167930 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-12
Onset:2021-03-25
   Days after vaccination:41
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1168198 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-02-19
Onset:2021-03-25
   Days after vaccination:34
Submitted: 0000-00-00
Entered: 2021-04-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized x 3 and died within 60 days of receiving a COVID vaccine series


VAERS ID: 1175952 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-04
Onset:2021-03-25
   Days after vaccination:49
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1176003 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-11
Onset:2021-03-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 1 - / -

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

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


VAERS ID: 1180533 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-03-11
Onset:2021-03-25
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-04-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: wife of the patient called came in for her COVID-19 vaccine appointment on 4/8/2021 and explained that her husband passed away in his sleep suddenly after a wonderful evening on 3/25/2021. She expressed that physician said it was not COVID related. Wife did not want to discuss the death of her husband at this time so the information is limited for this report.


VAERS ID: 1197557 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-01-28
Onset:2021-03-25
   Days after vaccination:56
Submitted: 0000-00-00
Entered: 2021-04-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   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: already reported VAER for hospitalization on 3/3; the patient subsequently died once transferred to SNF


VAERS ID: 1213290 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-03-03
Onset:2021-03-25
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 LA / IM

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

Write-up: Was informed at the time the client was to be seen for booster dose of COVID vaccine that he had recently passed away. Unable to contact family for more information.


VAERS ID: 1213571 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-01
Onset:2021-03-25
   Days after vaccination:24
Submitted: 0000-00-00
Entered: 2021-04-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012A21A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Cardio-respiratory arrest, Coronary artery bypass, Death, Dialysis, Oliguria, Pneumonia pseudomonal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (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), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Other ischaemic heart disease (narrow), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death. Narrative: Patient received Moderna COVID vaccine #1 on 3/1/21. On 3/17/21, he was admitted to a facility for a CABG. Per notes, after his CABG, he developed Pseudomonas pneumonia, AKI requiring dialysis and ultimately became oliguric. He required epinephrine, dobutamine, dopamine, amiodarone and went through two code blues prior to pronouncement of death on 3/25/21 at 2305. No autopsy reports available. 24 days from time of vaccine to date of death.


VAERS ID: 1222837 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-03-03
Onset:2021-03-25
   Days after vaccination:22
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiopulmonary failure, Death, Pyrexia, Secretion discharge, Urinary tract infection
SMQs:, Cardiac failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levetiracetam 500 mg, Depakote 250 mg, Lantus
Current Illness: None reported
Preexisting Conditions: Diabetes, Seizures, Aggressiveness
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type: PR-106-21

Write-up: On 3/25/2021 POC alleges that the resident begin to develop fever and urine infection. He was transferred to the hospital on 3/26/2021 where he had white secretions in his mouth. On 3/28/2021 he died in the hospital from respiratory cardio failure.


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