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

This is VAERS ID 1112900



Case Details

VAERS ID: 1112900 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-01-26
Onset:2021-01-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / OT

Administered by: Other       Purchased by: ?
Symptoms: Death, Incorrect route of product administration, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Drug abuse and dependence (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: DEPFIZER INC2021266948

Write-up: Unknown cause of death; Respiratory distress; Patient received BNT162B2 (COMIRNATY) intravenous; This is a spontaneous report downloaded from the Agency Regulatory Authority-WEB, regulatory authority number: DE-PEI-CADR2021017187 and DE-PEI-2021007890. A non-contactable consumer reported that a 95 years old female patient received BNT162B2 (COMIRNATY) intravenous, on 26Jan2021, at single dose, on COVID-19 immunisation. Relevant medical history and concomitant medications were unknown. On 29Jan2021, the patient experienced respiratory distress. The patient died on 01Feb2021. It was unknown if autopsy was done. Unknown cause of death was reported. The patient did not recover from respiratory distress at time of patient''s death. Causality was provided by Regulatory Authority as Inconsistent causal association to immunization. No follow-up attempts are needed, information about lot number cannot be obtained. No follow-up attempts needed, follow-up automatically provided by Regulatory Authority.; Reported Cause(s) of Death: Unknown cause of death


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