|
| VAERS ID: |
942085 (history) |
| Form: |
Version 2.0 |
| Age: |
62.0 |
| Sex: |
Female |
| Location: |
Kansas |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
FL0142 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Dyspnoea,
Livedo reticularis,
Pain,
Pulse absent,
Tremor,
Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
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: Ativen, Butrans Patch, Tylenol, Potassium Citrate-Citric Acid
Current Illness: Medical diagnosis: quadriplegia, Atherosclerotic heart disease
Preexisting Conditions: see #11.
Allergies: Amoxicillin, Clavulanic Acid, Codeine, Morphine, Pencillin
Diagnostic Lab Data:
CDC Split Type:
Write-up: No adverse effects from vaccination seen on 1/2/21. On 1/6/21 resident was seen by Dr and her baclofen pump was refilled with 20 ml Baclofen 4,000mcg/ml. ITB Rate increased by 6% to 455.5 mcg/day simple continuous rate over 3 days. On 1/8/21 at 0615 resident was shaking, lower extremities mottled, Sa02 70%, pulse 45. Oxygen started at 2 L/m per NC. At 0715 her primary physician was notified as well as her daughter. Oxygen increased to 4 L/min, sats at 83%. SOA noted, reported all over pain. At 0850 when they attempted to reposition the resident, she was not responsive. Licensed nurse assessed her and no heartbeat heard or pulse found. |
|
| VAERS ID: |
942106 (history) |
| Form: |
Version 2.0 |
| Age: |
54.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
UNKNOWN / UNK |
- / - |
Administered by: Private Purchased by: ?
Symptoms: Abdominal pain,
Cardiac arrest,
Chest pain,
Pain,
Pulse absent,
Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-09
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: 54 y/o M with PMH of HTN, HLD, Alcoholic Cirrhosis, Aortic Valve Stenosis, and angina BIBA as a Medical Alert for cardiac arrest noted PTA. Per EMS, the patient called because he was having constant, diffuse abdominal pain x 1 day that radiated to his chest. On scene, the patient had a witnessed arrest with EMS starting CPR. He was given 3 rounds of epi without ROSC. Pt had no associated shockable rhythm. Of note, pt''s wife, had noted pt had received covid vaccine the prior day. |
|
| VAERS ID: |
942290 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2021-01-04 |
| Onset: | 2021-01-06 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Asthenia,
Crepitations,
Death,
Decreased appetite,
Dizziness,
Dyspnoea,
Fall,
Hospice care,
Hyperhidrosis,
Lethargy,
Leukaemia,
Nausea,
Pyrexia,
SARS-CoV-2 test negative,
Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Haematological malignant tumours (narrow), Infective pneumonia (broad), COVID-19 (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-11
Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Influenza Virus Vaccines - Unknown date/type or brand
Other Medications: Tylenol, tylenol with codeine, Artificial Tears, ASA, Cal-Mag-Zinc, Claritin, Sertraline, Melatonin, MOM, Latuda, Estradiol, Gabapentin, Alendronate, Atorvastatin, Multi-Vit
Current Illness:
Preexisting Conditions: Glaucoma, Low back pain, restless leg syndrome, Osteoporosis, Compression Fx-Lumbar
Allergies: Dilaudid; Morphine Sulfate; Sulfonamides; Influenza Virus Vaccines
Diagnostic Lab Data: Resident has allergy to Influenza Virus Vaccines, pharmacists were informed of this prior to resident receiving the vaccine and both pharmacists stated that was not a risk factor.
CDC Split Type:
Write-up: Resident received 1st dose on 1/4/2021. On 1/6/2021 resident having SOB, increased weakness with O2 sats at 91% RA. On 8th resident sustained a fall, O2 sats 88-92, dizzy, weakness. Rapid COVID test performed with negative results. Evening of 8th resident was lethargic and diaphoretic with fever of 99.9. Resident transferred to ER, on 5lt of oxygen. Resident returned from the ER on 1/9/2021 with new diagnosis of Leukemia and orders for hospice. Continued with fever, crackles and N/V and loss of appetite from the 9th and 10th of January. Resident expired at 820am on 1/11/2021. |
|
| VAERS ID: |
943266 (history) |
| Form: |
Version 2.0 |
| Age: |
88.0 |
| Sex: |
Female |
| Location: |
Arizona |
| Vaccinated: | 2021-01-12 |
| Onset: | 2021-01-12 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL3249 / 1 |
LA / SYR |
Administered by: Other Purchased by: ?
Symptoms: Cerebral haemorrhage,
Coma,
Craniotomy,
Death,
Endotracheal intubation,
Headache,
Intracranial aneurysm,
Magnetic resonance imaging brain abnormal,
Vomiting
SMQs:, Acute pancreatitis (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Respiratory failure (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-13
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Losartan, Levothyroxine, Carvedilol
Current Illness:
Preexisting Conditions: Arthritis, high blood pressure
Allergies: Penicillin, Sulfa, Gluten
Diagnostic Lab Data:
CDC Split Type:
Write-up: Initial pain in back of head and extreme headache. Some vomiting. At emergency, went into coma and was intubated. Hole drilled in skull to relieve pressure. MRI taken. Lot of bleeding in brain - anuerism lead to death approximately 14 hours after initial symptoms. |
|
| VAERS ID: |
943362 (history) |
| Form: |
Version 2.0 |
| Age: |
73.0 |
| Sex: |
Female |
| Location: |
Michigan |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-13 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
RA / IM |
Administered by: Public Purchased by: ?
Symptoms: Autopsy,
Death,
Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-13
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: unknown none reported
Current Illness: none known
Preexisting Conditions: none
Allergies: none reported
Diagnostic Lab Data: currently undergoing preliminary autopsy
CDC Split Type:
Write-up: Pt collapsed at home approx 5:30 pm and died |
|
| VAERS ID: |
943397 (history) |
| Form: |
Version 2.0 |
| Age: |
28.0 |
| Sex: |
Male |
| Location: |
New Jersey |
| Vaccinated: | 2020-12-23 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 19 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1862 / UNK |
- / IM |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Cardioversion,
Endotracheal intubation,
Pupil fixed,
Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-11
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: Ceclor, Penicillin, Sulfa
Diagnostic Lab Data: No labs or tests.
CDC Split Type:
Write-up: On day due for 2nd dose, Patient was found unresponsive at work in the hospital. Patient pupils were fixed and dilated. Full ACLS was initiated for 55 minutes with multiple rounds of bicarb, calcium chloride, magnesium, and epinephrine. Patient was intubated. Patient continued into V. Fib arrest and was shocked multiple times. |
|
| VAERS ID: |
943442 (history) |
| Form: |
Version 2.0 |
| Age: |
68.0 |
| Sex: |
Male |
| Location: |
Georgia |
| Vaccinated: | 2020-12-30 |
| Onset: | 2020-12-31 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1686 / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
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: nka
Diagnostic Lab Data:
CDC Split Type:
Write-up: Systemic: reported by staff patient expired under suspicious circumstnces after receiving vaccine. Patient was on hospice, reported not expected to pass this soon; symptoms lasted 0 days |
|
| VAERS ID: |
943889 (history) |
| Form: |
Version 2.0 |
| Age: |
75.0 |
| Sex: |
Male |
| Location: |
Virginia |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
RA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death,
Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 0000-00-00
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alvesco, Amiodarone, Lipitor, Atrovent, Coreg, Cymbalta, Guaifenesin, Keppra, Levothroid, Megace, Protonix, Potassium, Prednisone, Rifampin, Carafate, Bactrim, Flomax
Current Illness: Rigth femur fracture, GI bleed
Preexisting Conditions: Hypertension, seizure, hypothyroidism, CHF
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:
Write-up: No adverse reactions observed after administration of medication. Patient starting complaining of shortness of breath around 0500 the following morning. SP02 checked in the 80s. Patient expired 01/09/2021; |
|
| VAERS ID: |
944282 (history) |
| Form: |
Version 2.0 |
| Age: |
70.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
LA / OT |
Administered by: Other Purchased by: ?
Symptoms: Cardio-respiratory 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), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-09
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: Medical History/Concurrent Conditions: Congestive heart failure; Heart failure; Open wound; Type 2 diabetes mellitus; Wound infection
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021016129
Write-up: resident coded on 09Jan at 8am and expired; This is a spontaneous report from a contactable Other Health Professional. A 70-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Batch/lot number: EL0140), intramuscularly in left arm on 05Jan2021 15:15 at single dose for COVID-19 immunization. Medical history included DM2(Type two diabetes mellitus), CHF(congestive heart failure), open wound, wound infection, heart failure. Allergies to medications, food, or other products: none. Concomitant medications included unspecified products (List of any other medications the patient received within 2 weeks of vaccination: yes). If the patient received any other vaccines within 4 weeks prior to the COVID vaccine: Unknown. Facility where the most recent COVID-19 vaccine was administered: Nursing Home/Senior Living Facility. The resident coded on 09Jan2021 at 8 AM and expired. The patient died on 09Jan2021. An autopsy was not performed. AE resulted in: patient died. Death cause: unknown at this time. Was treatment received for the adverse event: Unknown. Prior to vaccination, was the patient diagnosed with COVID-19: No. Since the vaccination, has the patient been tested for COVID-19: No. Serious: Yes. Seriousness criteria-Results in death: Yes. Seriousness criteria-Life threatening: No. Seriousness criteria-Caused/prolonged hospitalization: No. Seriousness criteria-Disabling/Incapacitating: No. Seriousness criteria-Congenital anomaly/birth defect: No.; Sender''s Comments: The old patient had diabetes mellitus, congestive heart failure, open wound complicated by infection, all these pre-existing medical conditions contribute to the patient death. More information including complete medical history, concomitant medications and event term details especially death cause and autopsy results are needed for a full assessment of the case. The impact of this report on the benefit/risk profile of the Pfizer product is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to Regulatory Authorities, Ethics Committees and Investigators, as appropriate; Reported Cause(s) of Death: resident coded on 09Jan at 8am and expired |
|
| VAERS ID: |
944365 (history) |
| Form: |
Version 2.0 |
| Age: |
76.0 |
| Sex: |
Male |
| Location: |
Kentucky |
| Vaccinated: | 2020-12-26 |
| Onset: | 2020-12-30 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
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), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-30
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: Diazepam, Levothyroxine, Magnesium Oxide, Olanzapine, Omeprazole, Sertraline, and Vitamin D3
Current Illness: None
Preexisting Conditions: Schziophrenia
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:
Write-up: Resident expired on 12/30/20, dx cardiac arrest. |
|
