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This is VAERS ID 1316482

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History of Changes from the VAERS Wayback Machine

First Appeared on 7/9/2021

VAERS ID: 1316482
VAERS Form:2
Age:80.0
Sex:Male
Location:Foreign
Vaccinated:2021-04-20
Onset:2021-04-21
Submitted:0000-00-00
Entered:2021-05-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Hypotonia, Respiratory rate increased, Vomiting, General physical health deterioration

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-21
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': FIMODERNATX, INC.MOD20211

Write-up: Death; Breathing rate increased; Flaccidity; General physical health deterioration; Vomiting; This regulatory authority case was reported by a physician and describes the occurrence of DEATH (Death), RESPIRATORY RATE INCREASED (Breathing rate increased), HYPOTONIA (Flaccidity), GENERAL PHYSICAL HEALTH DETERIORATION (General physical health deterioration) and VOMITING (Vomiting) in an 80-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) for COVID-19 vaccination. No Medical History information was reported. On 20-Apr-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) 1 dosage form. On 21-Apr-2021, after starting mRNA-1273 (COVID 19 Vaccine Moderna), the patient experienced DEATH (Death) (seriousness criterion death), RESPIRATORY RATE INCREASED (Breathing rate increased) (seriousness criterion medically significant), HYPOTONIA (Flaccidity) (seriousness criterion medically significant), GENERAL PHYSICAL HEALTH DETERIORATION (General physical health deterioration) (seriousness criterion medically significant) and VOMITING (Vomiting) (seriousness criterion medically significant). On 21-Apr-2021, RESPIRATORY RATE INCREASED (Breathing rate increased), HYPOTONIA (Flaccidity), GENERAL PHYSICAL HEALTH DETERIORATION (General physical health deterioration) and VOMITING (Vomiting) outcome was unknown. The patient died on 21-Apr-2021. The cause of death was not reported. It is unknown if an autopsy was performed. For mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown), the reporter did not provide any causality assessments. Concomitant product use was not provided by the reporter. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. Company Comment: This is a case of death in a 80-year-old male subject with unknown medical history, who died one day after receiving the first dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Sender''s Comments: This is a case of death in a 80-year-old male subject with unknown medical history, who died one day after receiving the first dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: Unknown cause of death

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