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This is VAERS ID 1440264

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First Appeared on 7/9/2021

VAERS ID: 1440264
VAERS Form:2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other      Purchased by: ??
Symptoms: Circulatory collapse, Malaise, Pyrexia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-06-16
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: Medical History/Concurrent Conditions: IDDM; Comments: IDDM
Diagnostic Lab Data:
CDC 'Split Type': ATJNJFOC20210655539

Write-up: UNOBSERVED CIRCULATORY ARREST, DEATH; SUBFEBRILE; FEELING SICK / FEELING UNWELL; This spontaneous report received from a physician via a Regulatory Authority (EMEA EVHUMAN NLP, AT-BASGAGES-2021-32463) concerned a 65 year old male of unspecified race and ethnic origin. The patient''s height, and weight were not reported. The patient''s past medical history included IDDM (Type 1 diabetes mellitus), and other pre-existing medical conditions included IDDM. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, intramuscular, batch number: XD986, expiry: unknown) 1 dosage forms, frequency 1 total dose administered on 10-JUN-2021 for covid-19 immunisation. No concomitant medications were reported. On 10-JUN-2021, the patient was subfebrile, feeling sick/feeling unwell. On 16-JUN-2021, the patient experienced unobserved circulatory arrest, and died. An autopsy was not performed. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The patient died of unobserved circulatory arrest, subfebrile and feeling sick/feeling unwell on 16-JUN-2021. This report was serious (Death).; Sender''s Comments: V0:20210655539-COVID-19 VACCINE AD26.COV2.S- Unobserved Circulatory arrest death , subfebrile , feeling sick/ feeling unwell . This event(s) is considered unassessable. The event(s) has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event(s).; Reported Cause(s) of Death: CIRCULATORY FAILURE; SUBFEBRILE; FEELING SICK/FEELING UNWEL

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