National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 11/19/2021 release of VAERS data:

This is VAERS ID 1304892

Government Disclaimer on use of this data

Case Details

VAERS ID: 1304892 (history)  
Form: Version 2.0  
Sex: Male  
Location: Foreign  
   Days after vaccination:48
Submitted: 0000-00-00
Entered: 2021-05-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: ?
Symptoms: Body temperature, C-reactive protein, COVID-19, Death, Drug ineffective, Exposure to SARS-CoV-2, Nausea, Oxygen saturation, SARS-CoV-2 test, Transient ischaemic attack, Vaccination failure
SMQs:, Acute pancreatitis (broad), Lack of efficacy/effect (narrow), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-11
   Days after onset: 27
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Chronic ischemic heart disease, unspecified; Hyperplasia of prostate; Living in nursing home; Uncomplicated hypertension
Diagnostic Lab Data: Test Date: 20210411; Test Name: Body temperature; Result Unstructured Data: Test Result:Normal; Comments: Normal (value not specified) on 11Apr2021 14: 30; Test Date: 20210411; Test Name: C-reactive protein; Result Unstructured Data: Test Result:6 mg/l; Comments: 14: 30; Test Date: 20210411; Test Name: Oxygen saturation; Test Result: 96 %; Comments: 14: 30; Test Date: 20210405; Test Name: SARS-CoV-2 RT-PCR test; Test Result: Positive ; Comments: Result: Positive. B.1.351 lineage. Low Ct value.
CDC Split Type: NOPFIZER INC2021496824

Write-up: NAUSEA; died/Cause of death was unknown; covid19 detected/vaccination failure; covid19 detected/lack of drug effect; covid19 detected/asymptomatic covid-19; exposure to covid-19/Infection exposed; TIA; This is a spontaneous report from a contactable physician downloaded from the Regulatory Authority (RA)-WEB, regulatory authority number NO-NOMAADVRE-FHI-2021-Uqwd1x. Safety Report Unique Identifier [NO-NOMAADVRE-E2B_00026428]. An 88-year-old male patient received bnt162b2 (COMIRNATY, Solution for injection), dose 2 intramuscular on 26Jan2021 14:15 (Lot Number: EJ6134) as single dose, dose 1 intramuscular on 05Jan2021 16:15 (Lot Number: EJ6795) as single dose, for covid-19 immunisation. Medical history included Living in nursing home; Chronic ischemic heart disease, unspecified; Hyperplasia of prostate; Uncomplicated hypertension. Concomitant medications included oxazepam (SOBRIL); tamsulosin hydrochloride (OMNIC); lercanidipine hydrochloride (ZANIDIP); metoprolol succinate (SELO-ZOK); rivastigmine (EXELON [RIVASTIGMINE]); apixaban (ELIQUIS). The patient experienced TIA (Transient ischaemic attack) on 15Mar2021, asymptomatic covid-19 on 05Apr2021; exposure to covid-19 from 27Mar2021 - 28Mar2021) (B.1.351 lineage); Infection exposed 27Mar2021-28Mar2021 - possibly also 01Apr2021-02Apr2021. On 05Apr2021, the patient developed vaccination failure, lack of drug effect, COVID-19. Relevant laboratory findings and investigations included in the report: SARS-COV-2 RT-PCR TEST on 05Apr2021, Result: Positive. B.1.351 lineage. Low Ct value). COVID-19 detected as part of infection tracing 05Apr2021 - asymptomatic at the time. Little affected in subsequent days. On 11Apr2021 at 14: 30, the patient developed a little nausea but otherwise in good shape. Relevant laboratory findings and investigations included in the report: C-reactive protein on 11Apr2021 14: 30: 6 mg/l; oxygen saturation on 11Apr2021 14: 30: 96%; body temperature on 11Apr2021 14: 30: Normal (value not specified). On the basis of findings stated above and after conversation with the hospital, the patient started treatment with prednisolone 40 mg. The patient was found dead in bed on 11Apr2021 just before midnight. An autopsy was not performed. The reporter suspected that the patient died with and not because of COVID-19. Cause of death was unknown to the reporter. The patient''s outcome was fatal. The case was considered to be Serious. The outcome of the event died/Cause of death was unknown was fatal, of exposure to covid-19/Infection exposed was recovered on 02Apr2021, of the other events was unknown. Health Authority Comment: Since the vaccine is new, it will be subject to special monitoring to identify any new safety information as soon as possible. It is especially important that serious and/or unusual side effects be reported. Your message is therefore important to expand knowledge about adverse reactions that were not discovered in the studies, and it is an important contribution to international cooperation to maintain safe vaccination worldwide. Causality assessment (Relatedness of drug to reaction(s)/event(s)): Vaccination failure: Source of assessment: Center. Result of Assessment: Possible; Drug ineffective: Source of assessment: Center. Result of Assessment: Possible; COVID-19: Source of assessment: Center. Result of Assessment: No relationship; Nausea: Source of assessment: Center. Result of Assessment: Possible.; Reported Cause(s) of Death: died/Cause of death was unknown

New Search

Link To This Search Result:

Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166