|
VAERS ID: |
920832 (history) |
Form: |
Version 2.0 |
Age: |
104.0 |
Sex: |
Female |
Location: |
New York |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-01 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 1 |
- / IM |
Administered by: Unknown Purchased by: ? Symptoms: COVID-19,
Death,
SARS-CoV-2 test positive SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
Days after onset: 3
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: Vaccine 12/30/2020 Screening PCR done 12/31/2020 Symptoms 1/1/2021 COVID test result came back positive 1/2/2021 Deceased 1/4/2021 |
|
VAERS ID: |
921175 (history) |
Form: |
Version 2.0 |
Age: |
77.0 |
Sex: |
Female |
Location: |
New Jersey |
Vaccinated: | 2021-01-03 |
Onset: | 2021-01-03 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1686 / 1 |
- / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Body temperature increased,
Dyspnoea SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
Days after onset: 2
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No Previous Vaccinations: Other Medications: Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea Preexisting Conditions: CHF, COPD, DM, heart failure, anemia, sleep apnea Allergies: NKA Diagnostic Lab Data: Epi pen 0.3mg given, sent to ER CDC Split Type:
Write-up: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4, |
|
VAERS ID: |
921481 (history) |
Form: |
Version 2.0 |
Age: |
88.0 |
Sex: |
Male |
Location: |
Ohio |
Vaccinated: | 2020-12-29 |
Onset: | 2021-01-01 |
Days after vaccination: | 3 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death,
Lethargy,
Rash,
Sluggishness SMQs:, Anaphylactic reaction (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
Days after onset: 3
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Vitamin D3 5000 units qd Furosemide 20mg qd Olanzapine 2.5mg bid Current Illness: Dementia Chronic PVD Preexisting Conditions: Dementia PVD Allergies: No known allergies Diagnostic Lab Data: n/a CDC Split Type:
Write-up: Vaccine given on 12/29/20 by Pharmacy. On 1/1/21, resident became lethargic and sluggish and developed a rash on forearms. He was a Hospice recipient and doctor and Hospice ordered no treatment, just to continue to monitor. When no improvement of codition reported, doctor and Hospice ordered comfort meds (Morphine, Ativan, Levsin). Resident expired on 1/4/2021 |
|
VAERS ID: |
921547 (history) |
Form: |
Version 2.0 |
Age: |
65.0 |
Sex: |
Male |
Location: |
Arkansas |
Vaccinated: | 2021-01-02 |
Onset: | 2021-01-04 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs:
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: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Pain. elevated Temp. Phone Active 05/08/2020 05/08/2020 AmLODIPine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYP Current Illness: CEREBRAL INFARCTION, UNSPECIFIED(I63.9), LONG TERM (CURRENT) USE OF ASPIRIN(Z79.82), VITAMIN DEFICIENCY, UNSPECIFIED(E56.9), ACUTE KIDNEY FAILURE, UNSPECIFIED(N17.9), HYPERKALEMIA(E87.5), ACUTE RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA(J96.00), PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED(E78.00), PAIN IN RIGHT FOOT(M79.671), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ACIDOSIS(E87.2), ABNORMAL LEVELS OF OTHER SERUM ENZYMES(R74.8), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), DISORDER OF THYROID, UNSPECIFIED(E07.9), GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS(K21.9), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, MULTIPLE SITES(M62.59), COGNITIVE COMMUNICATION DEFICIT(R41.841), UNSPECIFIED LACK OF COORDINATION(R27.9), OTHER DYSPHAGIA (R13.19), OTHER CHRONIC PAIN(G89.29), HYPOTHYROIDISM, UNSPECIFIED(E03.9), DRY EYE SYNDROME OF UNSPECIFIED LACRIMAL GLAND (H04.129), METABOLIC ENCEPHALOPATHY(G93.41), UNSPECIFIED CONVULSIONS(R56.9), POLYNEUROPATHY, UNSPECIFIED(G62.9), TYPE 1 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA(E10.319), NASAL CONGESTION(R09.81), BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC(J40), HYPOKALEMIA(E87.6), ELEVATED WHITE BLOOD CELL COUNT, UNSPECIFIED(D72. 829), OTHER MALAISE(R53.81), CELLULITIS OF RIGHT LOWER LIMB(L03.115), CELLULITIS OF LEFT LOWER LIMB(L03.116), EDEMA, UNSPECIFIED (R60.9), IRON DEFICIENCY ANEMIA, UNSPECIFIED(D50.9), CUTANEOUS ABSCESS, UNSPECIFIED(L02.91), COVID-19(U07.1) Preexisting Conditions: UNCONTROLLED DIABETES MELLITUS ON INSULIN Allergies: NKDA Diagnostic Lab Data: N/A CDC Split Type:
Write-up: DEATH ON 1/4/2021, RESIDENT RECIEVED VACCINE ON 1/2/20 |
|
VAERS ID: |
921572 (history) |
Form: |
Version 2.0 |
Age: |
87.0 |
Sex: |
Male |
Location: |
Wisconsin |
Vaccinated: | 2020-12-29 |
Onset: | 2020-12-30 |
Days after vaccination: | 1 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Chills,
Death,
Fall,
Hip fracture,
Oxygen saturation decreased,
Pain,
Unresponsive to stimuli SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-02
Days after onset: 3
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl Current Illness: Heart Failure Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease Allergies: Lisinopril, Losartan Diagnostic Lab Data: CDC Split Type:
Write-up: Resident had body aches, a low O2 sat and had chills starting on 12/30/20. He had stated that they had slightly improved. On 1/1/21 he sustained a fall with a diagnosis of a displaced hip fracture. On 1/2/21 during the NOC shift his O2 sat dropped again. He later went unresponsive and passed away. |
|
VAERS ID: |
921667 (history) |
Form: |
Version 2.0 |
Age: |
39.0 |
Sex: |
Female |
Location: |
Ohio |
Vaccinated: | 2020-12-29 |
Onset: | 2021-01-03 |
Days after vaccination: | 5 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Autopsy,
Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-03
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: LTCF Pfizer Vaccine clinic conducted 12/29/2020 Vaccine lead received a call indicating that a staff member deceased somewhere between 1/3/2021 and 1/4/2021. Cause of death is unknown, and an autopsy is being performed. |
|
VAERS ID: |
921768 (history) |
Form: |
Version 2.0 |
Age: |
58.0 |
Sex: |
Female |
Location: |
Washington |
Vaccinated: | 2021-01-04 |
Onset: | 2021-01-04 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0140 / 1 |
UN / IM |
Administered by: Private Purchased by: ? Symptoms: Cardiac arrest,
Death,
Dizziness,
Dyspnoea,
Fatigue,
Feeling hot,
Hot flush,
Lethargy,
Nausea,
Respiratory rate decreased,
Syncope SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Noninfectious myocarditis/pericarditis (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: None Known Diagnostic Lab Data: Autopsy scheduled for 01/07/2021 CDC Split Type:
Write-up: Vaccine received at about 0900 on 01/04/2021 at her place of work, Medical Center, where she was employed as a housekeeper. About one hour after receiving the vaccine she experienced a hot flash, nausea, and feeling like she was going to pass out after she had bent down. Later at about 1500 hours she appeared tired and lethargic, then a short time later, at about 1600 hours, upon arrival to a friends home she complained of feeling hot and having difficulty breathing. She then collapsed, then when medics arrived, she was still breathing slowly then went into cardiac arrest and was unable to be revived. |
|
VAERS ID: |
921880 (history) |
Form: |
Version 2.0 |
Age: |
96.0 |
Sex: |
Male |
Location: |
Virginia |
Vaccinated: | 2021-01-02 |
Onset: | 2021-01-02 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-05 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1284 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-02
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: Olanzapine, polyethylene glycol, ativan, morphine, senna Current Illness: was under hospice care Preexisting Conditions: alzheimers disease, ataxia, HTN, Kidney malignancy history, Prostate cancer history, GERD, sleep apnea, history falls Allergies: oxycodone Diagnostic Lab Data: CDC Split Type:
Write-up: The resident was found deceased a little less than 12 hours following COVID vaccination, and he had had some changes over the last 2 days. He was 96 and had been on hospice care for a little while. Noone noticed any side effects from vaccine after it was given |
|
VAERS ID: |
922977 (history) |
Form: |
Version 1.0 |
Age: |
71.0 |
Sex: |
Male |
Location: |
New York |
Vaccinated: | 2020-12-21 |
Onset: | 2020-12-27 |
Days after vaccination: | 6 |
Submitted: |
2020-12-28 |
Days after onset: | 1 |
Entered: |
2021-01-05 |
Days after submission: | 8 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 2 |
LA / - |
Administered by: Other Purchased by: Other Symptoms: Pyrexia,
Respiratory depression,
SARS-CoV-2 test positive SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-28
Days after onset: 1
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: Fever, RespDepression & COVID positive REMDESIVIR (EUA) 200 mg x1 then 100 mg daily |
|
VAERS ID: |
923993 (history) |
Form: |
Version 2.0 |
Age: |
62.0 |
Sex: |
Male |
Location: |
North Carolina |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-02 |
Days after vaccination: | 3 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-06 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 1 |
AR / IM |
Administered by: Private Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-02
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 Current Illness: No Preexisting Conditions: History of stage II (T3N0) appendiceal carcinoma - s/p resection Dec 2014. CAD s/p stenting Diabetes Mellitus Hyperlipidemia Hypertension Glaucoma Allergies: Hay fever Diagnostic Lab Data: CDC Split Type:
Write-up: Patient was vaccinated Dec 30, 2020. Prime dose of Moderna vaccine. Observed for full 15 minutes post-injection. No complaints when asked during observation. Released. Subsequently, vaccine clinic staff learned from the patient''s supervisor that on Jan 4, 2021 that the patient had expired on Jan 2, 2021. By report from the supervisor, the patient was found dead at his home. The patient''s primary care provider was unaware of his death when contacted by this reporter today (Jan 6, 2021). Electronic Medical Record without any information since the vaccination. |
|