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

This is VAERS ID 1042049



Case Details

VAERS ID: 1042049 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-16
Onset:2021-01-19
   Days after vaccination:3
Submitted: 0000-00-00
Entered: 2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / OT

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

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; Dementia; Stroke
Allergies:
Diagnostic Lab Data: Test Date: 20210119; Test Name: covid-19 virus test; Result Unstructured Data: Test Result:covid-19
CDC Split Type: DEPFIZER INC2021113667

Write-up: Respiratory failure; Pneumonia; covid-19; This is a spontaneous report from a non-contactable physician downloaded from the Medicines Agency (MA) Regulatory Authority-WEB. The regulatory authority report number is DE-PEI-PEI2021001974. An 86-year-old female patient received BNT162B2 (COMIRNATY, PFIZER-BIONTECH COVID-19 VACCINE), intramuscular on 16Jan2021 at single dose for covid-19 immunization. Medical history included dementia, stroke, and atrial fibrillation from an unknown date and unknown if ongoing. The patient''s concomitant medications were not reported. The patient experienced covid-19 on 19Jan2021; the patient also experienced respiratory failure and pneumonia on an unspecified date, which were serious as they were life threatening, and lead to death. Details were as follows: covid-19 on 19Jan2021 was noted. Also reported unknown after vaccination, the patient developed respiratory failure and pneumonia, reported as lasting until 29Jan2021. The patient was dead and condition was reported as life threatening. Death cause was reported as respiratory failure and pneumonia. The patient died on 29Jan2021. It was not reported if an autopsy was performed. The patient under lab test include covid-19 virus test: covid-19 on 19Jan2021. The batch/lot number for the vaccine, BNT162B2, was not provided and will be requested during follow-up. Follow-up (15Feb2021): This follow-up is being submitted to notify that the batch number is not available, follow-up activities not applicable, information about lot/batch number cannot be obtained. Further follow-up information will be provided automatically upon availability via MA.; Reported Cause(s) of Death: pneumonia; respiratory failure


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