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This is VAERS ID 1319043

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History of Changes from the VAERS Wayback Machine

First Appeared on 7/2/2021

VAERS ID: 1319043
VAERS Form:2
Age:
Sex:Male
Location:Foreign
Vaccinated:2021-05-02
Onset:2021-05-05
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: Unevaluable event

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-05-08
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': GBMODERNATX, INC.MOD20211

Write-up: Unevaluable event; This regulatory authority case was reported by a consumer and describes the occurrence of UNEVALUABLE EVENT (Unevaluable event) in a male patient of an unknown age who received mRNA-1273 (Moderna CoviD-19 Vaccine) for COVID-19 immunisation. No Medical History information was reported. On 02-May-2021, the patient received first dose of mRNA-1273 (Moderna CoviD-19 Vaccine) (Intramuscular) 1 dosage form. On 05-May-2021, the patient experienced UNEVALUABLE EVENT (Unevaluable event) (seriousness criterion death). The patient died on 08-May-2021. The cause of death was not reported. It is unknown if an autopsy was performed. No concomitant medication reported. No treatment information was provided. On unknown date, patient had a negative COVID-19 virus test. Company Comment: A male patient of an unknown age who received mRNA-1273 died 3 days after he received the first dose of vaccine. No medical conditions or concomitant products were provided. Very limited information has been reported at this time. Further information is not expected.; Sender''s Comments: A male patient of an unknown age who received mRNA-1273 died 3 days after he received the first dose of vaccine. No medical conditions or concomitant products were provided. Very limited information has been reported at this time. Further information is not expected.; Reported Cause(s) of Death: Unknown cause of death

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