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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1718133

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Case Details

VAERS ID: 1718133 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-04-06
Onset:2021-09-07
   Days after vaccination:154
Submitted: 0000-00-00
Entered: 2021-09-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Drug ineffective, SARS-CoV-2 test
SMQs:, Lack of efficacy/effect (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension
Preexisting Conditions: Medical History/Concurrent Conditions: Overweight; Smoker (former smoker)
Allergies:
Diagnostic Lab Data: Test Date: 20210907; Test Name: COVID-19 virtus test; Test Result: Positive ; Result Unstructured Data: positive
CDC Split Type: USMODERNATX, INC.MOD20213

Write-up: Tested positive for COVID-19; Tested positive for COVID-19 on September 7th; This spontaneous case was reported by a consumer and describes the occurrence of COVID-19 (Tested positive for COVID-19) and DRUG INEFFECTIVE (Tested positive for COVID-19 on September 7th) in a 55-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included Overweight and Smoker (former smoker). Concurrent medical conditions included Hypertension. On 06-Apr-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 06-May-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 07-Sep-2021, the patient experienced COVID-19 (Tested positive for COVID-19) and DRUG INEFFECTIVE (Tested positive for COVID-19 on September 7th). At the time of the report, COVID-19 (Tested positive for COVID-19) had not resolved and DRUG INEFFECTIVE (Tested positive for COVID-19 on September 7th) outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 07-Sep-2021, SARS-CoV-2 test: positive (Positive) positive. Concomitant medication of the patient was not reported. No treatment information was provided by the reporter.; Sender''s Comments: This case concerns a 55-year-old female patient, former smoker, overweight and hypertensive, who experienced the unexpected event of COVID-19, vaccination failure was considered as an additional event. The event occurred approximately 4 months after the second dose of Spikevax. The event was considered related to the product per the reporter''s assessment. The rechallenge was not applicable. The benefit-risk relationship of Spikevax in not affected by this report.


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