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From the 4/30/2021 release of VAERS data:

This is VAERS ID 812329



Case Details

VAERS ID: 812329 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2018-10-23
Onset:2018-12-27
   Days after vaccination:65
Submitted: 0000-00-00
Entered: 2019-05-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (QIV DRESDEN) / GLAXOSMITHKLINE BIOLOGICALS AFLBA322CA / UNK - / OT

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Cough, Death, Dependence on respirator, Influenza, Influenza A virus test positive, Polymerase chain reaction positive, Pyrexia, Respiratory disorder, Respiratory distress, Vaccination failure
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2019-01-16
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: PCR; Result Unstructured Data: Test Result: Influenza A NA, Test Result Unit: unknown
CDC Split Type: DEGLAXOSMITHKLINEDE201907

Write-up: ARDS; respiratory disorder requiring ventilation; respiratory disorder requiring ventilation; Influenza A; Respiratory distress; fever; Dry cough; Vaccination failure; This case was reported by a physician via regulatory authority and described the occurrence of ards in a 72-year-old female patient who received Flu Seasonal QIV Dresden (Influsplit Tetra 2018/2019) (batch number AFLBA322CA, expiry date unknown) for prophylaxis. On 23rd October 2018, the patient received Influsplit Tetra 2018/2019 (intramuscular). On 27th December 2018, 65 days after receiving Influsplit Tetra 2018/2019, the patient experienced influenza a virus infection, vaccination failure (serious criteria GSK medically significant), respiratory distress (serious criteria GSK medically significant), fever and dry cough. On an unknown date, the patient experienced ards (serious criteria death and GSK medically significant), respiratory disorder nos (serious criteria death) and dependence on ventilator (serious criteria death and GSK medically significant). On 16th January 2019, the outcome of the ards, respiratory disorder nos and dependence on ventilator were fatal. On an unknown date, the outcome of the influenza a virus infection, vaccination failure, respiratory distress, fever and dry cough were unknown. The patient died on 16th January 2019. The reported cause of death was respiratory disorder, acute respiratory distress syndrome and dependence on ventilator. It was unknown if the reporter considered the ards, respiratory disorder nos, dependence on ventilator, influenza a virus infection, vaccination failure, respiratory distress, fever and dry cough to be related to Influsplit Tetra 2018/2019. Additional details: Age at vaccination was not reported however patient could be 71 or 72 years old at time of vaccination. On an unknown date, PCR was performed with results Influenza A NA. PEI assessment of causality was reported as Unclassifiable. Batch number for Influsplit Tetra 2018/2019 was reported as ASLBA322CA however on batch number review it was corrected to AFLBA322CA. Initial information was reported by a physician via regulatory authority on 30th April 2019. ARDS , espiratory disorder nos, Dependence on ventilator,influenza a virus infection, vaccination failure, respiratory distress, fever and dry cough. Lab Comments: On an unknown date PCR was performed with result Influenza A NA.; Reported Cause(s) of Death: Respiratory disorder; Acute respiratory distress syndrome; Dependence on ventilator


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