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This is VAERS ID 1239867

History of Changes from the VAERS Wayback Machine

First Appeared on 7/2/2021

VAERS ID: 1239867
VAERS Form:2
Age:92.0
Sex:Male
Location:Foreign
Vaccinated:2021-02-09
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 300042460 / 1 LA / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Loss of consciousness, Vaccination complication

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-10
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ASPIRIN CARDIO; ATACAND; BELOC ZOK; FLUDEX [INDAPAMIDE]
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: No adverse event, Continue: [UNK], Comment: No significant Medical History
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': CHMODERNATX, INC.MOD20210

Write-up: Lost consciousness; Did not feel well; This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of LOSS OF CONSCIOUSNESS (Lost consciousness) and VACCINATION COMPLICATION (Did not feel well) in a 92-year-old male patient who received mRNA-1273 (Moderna CoviD-19 Vaccine) (batch no. 300042460) for COVID-19 vaccination. The patient''s past medical history included No adverse event (No significant Medical History). Concomitant products included ACETYLSALICYLIC ACID (ASPIRIN CARDIO), CANDESARTAN CILEXETIL (ATACAND), METOPROLOL SUCCINATE (BELOC ZOK) and INDAPAMIDE (FLUDEX [INDAPAMIDE]) for an unknown indication. On 09-Feb-2021, the patient received first dose of mRNA-1273 (Moderna CoviD-19 Vaccine) (Intramuscular) 1 dosage form. On 10-Feb-2021, the patient experienced LOSS OF CONSCIOUSNESS (Lost consciousness) (seriousness criterion death) and VACCINATION COMPLICATION (Did not feel well) (seriousness criterion death). The patient died on 10-Feb-2021. The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (Moderna CoviD-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. Resuscitation attempted after the patient lost consciousness was ineffective and the patient died approximately 3 hours after not feeling well. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. This is a 92 year-old, male patient who received mRNA-1273 Vaccine and experienced malaise and loss of consciousness with a fatal outcome, a day after receiving first dose of vaccine. No medical hx or conmeds were provided. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. No further information is expected. Reporter did not allow further contact; Sender''s Comments: This is a 92 year-old, male patient who received mRNA-1273 Vaccine and experienced malaise and loss of consciousness with a fatal outcome, a day after receiving first dose of vaccine. No medical hx or conmeds were provided. The fatal outcome may be related to the patient''s pre-existing comorbidities Very limited information has been reported at this time. No further information is expected.; Reported Cause(s) of Death: unknown cause of death

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