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This is VAERS ID 1730639

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History of Changes from the VAERS Wayback Machine

First Appeared on 9/24/2021

VAERS ID: 1730639
VAERS Form:2
Age:12.0
Sex:Female
Location:Foreign
Vaccinated:2021-08-23
Onset:2021-08-23
Submitted:0000-00-00
Entered:2021-09-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 214018 / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Anaphylactic reaction

Life Threatening? No
Birth Defect? No
Died? No
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: VENTOLINE [SALBUTAMOL]
Current Illness: Allergic asthma
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': FRMODERNATX, INC.MOD20213

Write-up: Anaphylactic reaction; This case was received via regulatory authority (Reference number: BX20218022) on 16-Sep-2021 and was forwarded to Moderna on 16-Sep-2021. This regulatory authority case was reported by a physician and describes the occurrence of ANAPHYLACTIC REACTION (Anaphylactic reaction) in a 12-year-old female patient who received mRNA-1273 (Spikevax) (batch no. 214018) for COVID-19 vaccination. The patient''s past medical history included Allergic asthma since an unknown date. Concomitant products included SALBUTAMOL (VENTOLINE [SALBUTAMOL]) for an unknown indication. On 23-Aug-2021, the patient received first dose of mRNA-1273 (Spikevax) (Intramuscular) 1 dosage form. On 23-Aug-2021, the patient experienced ANAPHYLACTIC REACTION (Anaphylactic reaction) (seriousness criterion medically significant). At the time of the report, ANAPHYLACTIC REACTION (Anaphylactic reaction) had not resolved. For mRNA-1273 (Spikevax) (Intramuscular), the reporter did not provide any causality assessments. The treatment information was not provided. This case concerns a 12-year-old, female with a history of asthma , who experienced the expected event Anaphylactic reaction . The event occurred on the same day after the first dose of mRNA-1273 Moderna vaccine (Spikevax). The rechallenge was not applicable since this is the case for the first dose. The event is consistent with the current understanding of the mechanism of action of the study medication . The medical history of could be a potentially confounder. The benefit-risk relationship of mRNA-1273 Moderna vaccine in not affected by this report.; Sender''s Comments: This case concerns a 12-year-old, female with a history of asthma , who experienced the expected event Anaphylactic reaction . The event occurred on the same day after the first dose of mRNA-1273 Moderna vaccine (Spikevax). The rechallenge was not applicable since this is the case for the first dose. The event is consistent with the current understanding of the mechanism of action of the study medication . The medical history of could be a potentially confounder. The benefit-risk relationship of mRNA-1273 Moderna vaccine in not affected by this report.

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