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This is VAERS ID 1771021

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1771021
VAERS Form:2
Age:14.0
Sex:Male
Location:Foreign
Vaccinated:2021-09-27
Onset:2021-09-27
Submitted:0000-00-00
Entered:2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Dizziness, Influenza, Rash, Oropharyngeal pain, SARS-CoV-2 test

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:
Current Illness: Asthma; Suspected COVID-19
Preexisting Conditions: Medical History/Concurrent Conditions: Immunodeficiency (Has an illness or condition, not listed above, which reduces the immune response (e.g. immunodef...)
Allergies:
Diagnostic Lab Data: Test Name: COVID-19 virus test; Test Result: Inconclusive ; Result Unstructured Data: Inconclusive test
CDC 'Split Type': GBMODERNATX, INC.MOD20213

Write-up: sore throat; dizzy; flu; Rash; This case was received via regulatory authority (Reference number: GB-MHRA-ADR 26008838) on 30-Sep-2021 and was forwarded to Moderna on 30-Sep-2021. This regulatory authority case was reported by a consumer and describes the occurrence of RASH (Rash), OROPHARYNGEAL PAIN (sore throat), DIZZINESS (dizzy) and INFLUENZA (flu) in a 14-year-old male patient who received mRNA-1273 (Moderna CoviD-19 Vaccine) for COVID-19 vaccination. The patient''s past medical history included Immunodeficiency (Has an illness or condition, not listed above, which reduces the immune response (e.g. immunodef...). Concurrent medical conditions included Asthma and Suspected COVID-19 since 27-Sep-2021. On 27-Sep-2021, the patient received first dose of mRNA-1273 (Moderna CoviD-19 Vaccine) (unknown route) 1 dosage form. On 27-Sep-2021, the patient experienced RASH (Rash) (seriousness criterion medically significant). On an unknown date, the patient experienced OROPHARYNGEAL PAIN (sore throat) (seriousness criterion medically significant), DIZZINESS (dizzy) (seriousness criterion medically significant) and INFLUENZA (flu) (seriousness criterion medically significant). On 29-Sep-2021, RASH (Rash) had not resolved. At the time of the report, OROPHARYNGEAL PAIN (sore throat), DIZZINESS (dizzy) and INFLUENZA (flu) had resolved. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, SARS-CoV-2 test: not provided (Inconclusive) Inconclusive test. The action taken with mRNA-1273 (Moderna CoviD-19 Vaccine) (Unknown) was unknown. Patient waiting on PCR as sons has asthma and I has to multi-dose him as coughing non stop, rash spreading daily, sore throat, flu, dizzy etc was fit n well before 1st vaccine n a complete state. Company comment: This case concerns a 14 year-old male patient with history of asthma, suspected COVID-19, and immunodeficiency, who experienced the unexpected serious events of Oropharyngeal pain, Dizziness, Influenza, and Rash. The events occurred an unknown number of days after the first dose of mRNA-1273 vaccine. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report. The history of asthma, suspected COVID-19 and immunodeficiency may have contributed to the events. Seriousness criteria of Medically significant maintained for events for consistency with RA report, however the source document does not include information that supports seriousness criteria.; Sender''s Comments: This case concerns a 14 year-old male patient with history of asthma, suspected COVID-19, and immunodeficiency, who experienced the unexpected serious events of Oropharyngeal pain, Dizziness, Influenza, and Rash. The events occurred an unknown number of days after the first dose of mRNA-1273 vaccine. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report. The history of asthma, suspected COVID-19 and immunodeficiency may have contributed to the events. Seriousness criteria of Medically significant maintained for events for consistency with RA report, however the source document does not include information that supports seriousness criteria.

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