|
| VAERS ID: |
936805 (history) |
| Form: |
Version 2.0 |
| Age: |
25.0 |
| Sex: |
Male |
| Location: |
Kentucky |
| Vaccinated: | 2020-12-22 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 20 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 1 |
RA / IM |
Administered by: Private Purchased by: ?
Symptoms: Death,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (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: See Continuation Field
Current Illness: Whiplash injury to neck. Sprain of ligaments of cervical spine
Preexisting Conditions: Septal defect (heart), chronic sinusitis
Allergies: Ceftriaxone
Diagnostic Lab Data: None associated.
CDC Split Type:
Write-up: Patient received the vaccine on 12/22/20 without complication. It was reported today that the patient was found unresponsive and subsequently expired at home on 1/11/21. |
|
| VAERS ID: |
937127 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Male |
| Location: |
Arkansas |
| Vaccinated: | 2020-12-22 |
| Onset: | 2020-12-28 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: 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: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Mirtazapine, Fentanyl Patch,
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: The facility had positive cases of COVID when we were able to begin vaccinating residents. Within about a week of vaccination, patient was tested positive for COVID. He was 91 years old and his immune system did not have the time to allow the vaccine to begin working before exposure. His age was a major contributing factor to his death. |
|
| VAERS ID: |
937152 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Female |
| Location: |
Arkansas |
| Vaccinated: | 2020-12-22 |
| Onset: | 2020-12-24 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: 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: 2021-01-11
Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol, Cephalexin, Brimonidine, Donepezil, Losartan, Latanoprost, Timolol
Current Illness: High blood pressure, pain, eye issues
Preexisting Conditions: Blood pressure, pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: The facility had positive cases for COVID 19 when the vaccine was received and administered to patient. With her advanced age and chronic conditions, she did not have time to build immunity between the time of vaccination and her testing positive. |
|
| VAERS ID: |
937186 (history) |
| Form: |
Version 2.0 |
| Age: |
87.0 |
| Sex: |
Female |
| Location: |
Arkansas |
| Vaccinated: | 2020-12-22 |
| Onset: | 2020-12-24 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: 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: 2021-01-10
Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrocodone-Acetamenaphin, Lidocaine, Cefritriaxone, Citalopram
Current Illness: Chronic pain
Preexisting Conditions: Pain
Allergies: None
Diagnostic Lab Data:
CDC Split Type:
Write-up: The facility had a number of positive COVID 19 cases prior to patients vaccination. Due to her advanced age, chronic condition, and exposure, patient did not have the time to build immunity after exposure before becoming positive. |
|
| VAERS ID: |
937434 (history) |
| Form: |
Version 2.0 |
| Age: |
70.0 |
| Sex: |
Male |
| Location: |
Montana |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 4 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20 / 1 |
- / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
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: None known
Preexisting Conditions: only had 1 lung
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt expired due to possible cardiac arrest. Unsure if this was vaccine related. |
|
| VAERS ID: |
937444 (history) |
| Form: |
Version 2.0 |
| Age: |
86.0 |
| Sex: |
Female |
| Location: |
Illinois |
| Vaccinated: | 2021-01-11 |
| Onset: | 2021-01-11 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL3246 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)
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:
Current Illness: Brain bleed, sleep apnea, htn
Preexisting Conditions: Brain bleed, sleep apnea, htn
Allergies:
Diagnostic Lab Data: The county coroner declared her death was related to a heart attack
CDC Split Type:
Write-up: Resident was found deceased at approximately 6pm in her apartment |
|
| VAERS ID: |
937527 (history) |
| Form: |
Version 2.0 |
| Age: |
44.0 |
| Sex: |
Female |
| Location: |
New Hampshire |
| Vaccinated: | 2020-12-23 |
| Onset: | 2021-01-04 |
| Days after vaccination: | 12 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| 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
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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown, not reported
CDC Split Type:
Write-up: unsure if related to vaccine, but was notified by her next of kin that she died on 1/4/2021. No reports of side effects or hospitalization were reported to the facility prior to the notification of death. |
|
| VAERS ID: |
937569 (history) |
| Form: |
Version 2.0 |
| Age: |
62.0 |
| Sex: |
Male |
| Location: |
Rhode Island |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
- / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
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: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:
Write-up: patient reported expired 1/7/2021 |
|
| VAERS ID: |
937773 (history) |
| Form: |
Version 2.0 |
| Age: |
85.0 |
| Sex: |
Male |
| Location: |
Kansas |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-02 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1686 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Haematuria
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-03
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID-19 positive on 11/30/2020
Preexisting Conditions: Parkinson''s Disease, Diabetes, Heart disease, A-fib, Hypothyroidism
Allergies: Baclofen, PCN, Ambien, Singulair
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient was sent to the ED due to significant hematuria. He was afebrile. |
|
| VAERS ID: |
937818 (history) |
| Form: |
Version 2.0 |
| Age: |
63.0 |
| Sex: |
Male |
| Location: |
Ohio |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-09 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-12 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
LA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
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: HTN CAD Stemi with stent placement BPH
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: This is being reported because of the incident occurring 2 days after the Moderna Covid-19 vaccination. It was reported that the patient expired on 1/9/21, 2 days after receiving the Moderna vaccine. Upon screening of patient prior to administration on 1/7/21, the patient completed paperwork answering NO to the following "Do you currently have any active infections or acute respiratory illness or fever." |
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