National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 10/8/2021 release of VAERS data:

This is VAERS ID 963167



Case Details

VAERS ID: 963167 (history)  
Form: Version 1.0  
Age: 88.0  
Sex: Male  
Location: Delaware  
Vaccinated:2021-01-02
Onset:2021-01-04
   Days after vaccination:2
Submitted: 2021-01-08
   Days after onset:4
Entered: 2021-01-14
   Days after submission:6
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 0
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:
CDC Split Type:

Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=963167

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166