|
| VAERS ID: |
951519 (history) |
| Form: |
Version 1.0 |
| Age: |
78.0 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 0 |
| Submitted: |
2021-01-06 |
| Days after onset: | 1 |
| Entered: |
2021-01-09 |
| Days after submission: | 3 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EH9899 / 2 |
LA / - |
Administered by: Other Purchased by: Other
Symptoms: Palpitations,
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: 2021-01-05
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: Palpitations & Syncope Treatment: EPINEPHRINE 1 MG ONCE ,EPINEPHRINE 1 MG ONCE ,SODIUM BICARBONATE 50 ML ONCE |
|
| VAERS ID: |
956903 (history) |
| Form: |
Version 2.0 |
| Age: |
86.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-22 |
| Onset: | 2020-12-27 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
LA / IM |
Administered by: Other Purchased by: ?
Symptoms: Asymptomatic COVID-19,
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: 2020-12-27
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: mi Narrative: patient with asymptomatic covid 19, covid positive 12/10/2020. |
|
| VAERS ID: |
956966 (history) |
| Form: |
Version 2.0 |
| Age: |
86.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-25 |
| Onset: | 2020-12-25 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
LA / IM |
Administered by: Other Purchased by: ?
Symptoms: Body temperature increased,
Complication associated with device,
Cough,
Dyspnoea,
Hypoxia,
Secretion discharge
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-25
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: hypoxia, secretions,cough, dyspnea Narrative: ALS patient on hospice with ongoing history of aspiration pna, receiving tube feeds. Developed incr in secretions, hypoxeia, temp and with recently noted clogged feeding tube. |
|
| VAERS ID: |
964629 (history) |
| Form: |
Version 2.0 |
| Age: |
64.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-17 |
| Onset: | 2020-12-27 |
| Days after vaccination: | 10 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 1 |
LA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death,
Terminal state
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-27
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Death - Hospice patient with metastatic CA admitted to facility and received vaccine during stay. No adverse sequelae noted from vaccine administration, but reporting as required because pt died 7 days later. Narrative: Reporting this event because patient died 7 days after receiving vaccine in the facility where he was in hospice care for metastatic cancer. Vaccine was administered by protocol without complications. The patient had been asked and denied any prior severe reaction to this vaccine or its components and gave permission to receive it. No vaccine adverse sequelae were documented after the immunization as monitored for 15 minutes nor in facility notes for 7 days after the immunization. The patient''s death was felt to be due to underlying terminal illness. |
|
| VAERS ID: |
964636 (history) |
| Form: |
Version 2.0 |
| Age: |
81.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2020-12-17 |
| Onset: | 2020-12-22 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-09 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 1 |
RA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-22
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Pt on hospice in facility for severe cardiomyopathy unable to perform interventions received vaccine without adverse sequelae died 5 days later. Reporting as required. Narrative: Reporting as required patient death 5 days after immunization with Pfizer vaccine. However, no adverse sequelae were noted to the vaccine in the 15minute observation period, nor in the days following the immunization related to the vaccine. The patient denied any prior severe reaction to this vaccine or its components, and the patient gave verbal consent to receive the vaccine. Patient had been in the facility on hospice since 11/18/20 for severe decompensated HF and newly diagnosed cardiomyopathy, unable to perform interventions, also LE ischemic wounds with very poor potential to heal due to advanced PVD. |
|
| VAERS ID: |
932346 (history) |
| Form: |
Version 2.0 |
| Age: |
66.0 |
| Sex: |
Male |
| Location: |
North Carolina |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL3248 / 2 |
AR / SYR |
Administered by: Private Purchased by: ?
Symptoms: Death,
Dizziness,
Headache,
Pyrexia,
Respiratory arrest,
Resuscitation
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-10
Days after onset: 2
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: none known
Preexisting Conditions: hypertension, hyperlipidemia.
Allergies: Statin - muscle aches
Diagnostic Lab Data: autopsy pending
CDC Split Type:
Write-up: 1/7-21 - Received second dose of pfizer covid-19 vaccine 1/8/21 - Fever, dizziness, headache 1/10/21 0250 was found not breathing. EMS performed CPR and patient deceased |
|
| VAERS ID: |
932787 (history) |
| Form: |
Version 2.0 |
| Age: |
70.0 |
| Sex: |
Female |
| Location: |
Georgia |
| Vaccinated: | 2021-01-08 |
| Onset: | 2021-01-10 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
UN / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? Yes
Died? Yes
Date died: 2021-01-10
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: CRANBERRY, PROZAC, NEUROTIN PERCOCET, IMMODIUM, SYNTHROID, LINZESS, LIPITOR, MELATONIN METFORMIN, PROTONIX PLAVIX, PROAIR, ropinirole, PROAIR SYMBICORT, THIAMINE TYLENOL VIT C VOLTAREN. ZANAX, ZOFRAN
Current Illness: PNEUMONIA
Preexisting Conditions: DEPRESSION CHRONIC LUNG ANEMIA
Allergies: TRAMADOL, methocarbamol
Diagnostic Lab Data: NONE AT TIME OF REPORTING, TALK OF AN AUTOPSY
CDC Split Type:
Write-up: RECIEVED VACCINE 1/8/21 EXPIRED UNEXPECTED 1/10/21, NO ADVERSE REACTIONS NOTED |
|
| VAERS ID: |
932898 (history) |
| Form: |
Version 2.0 |
| Age: |
61.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2020-12-17 |
| Onset: | 2020-12-23 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Cardiac disorder,
Intensive care,
Withdrawal of life support
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: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Atorvastatin, Xarelto, Aspirin (These were medications listed with our office in 2019. Unknown if this patient was still taking at time of vaccination).
Current Illness:
Preexisting Conditions: High blood pressure. Congenital unicuspid aortic valve s/p aortic valve replacement 2001 & 2011. Pacemaker placement 2011. Melanoma
Allergies: None known.
Diagnostic Lab Data: Unknown.
CDC Split Type:
Write-up: The patient had an apparent cardiac arrest on 12/23/20 and was admitted to the ICU. He was taken off of life support on 12/30/20. He had known cardiac disease. |
|
| VAERS ID: |
933090 (history) |
| Form: |
Version 2.0 |
| Age: |
60.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-05 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 2 |
AR / SYR |
Administered by: Work Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-09
Days after onset: 4
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
CDC Split Type:
Write-up: Patient died, I have a copy of his vaccination card |
|
| VAERS ID: |
964653 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Male |
| Location: |
Unknown |
| Vaccinated: | 2021-01-06 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EH9899 / 2 |
LA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death,
Decreased appetite,
Fatigue,
General physical health deterioration,
Loss of consciousness,
Nausea,
Pneumonia aspiration,
Pyrexia,
Respiratory distress
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-07
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Patient''s temperature log: 12-15-20 08:38:00 97.6 O 12-15-20 16:38:00 97.8 O 12-16-20 08:43:00 97.9 O 12-16-20 11:25:00 98.3 O 12-16-20 16:50:18 98.2 12-17-20 06:22:47 98.1 12-17-20 08:27:00 98.1 O 12-17-20 14:20:00 98.4 O 12-17-20 16:34:00 97.5 O 12-18-20 06:14:00 97.3 Ax 12-18-20 08:05:00 97.5 O 12-18-20 17:30:00 97.5 O 12-19-20 05:35:00 98.1 O 12-19-20 08:21:00 98.4 O 12-19-20 16:32:00 98.4 O 12-20-20 08:27:00 98 O 12-20-20 16:58:39 97.6 12-21-20 08:20:00 98 O 12-21-20 16:34:00 98.8 O 12-22-20 05:44:00 98.2 O 12-22-20 08:58:00 97.7 O 12-22-20 16:39:00 97.5 O 12-23-20 08:12:00 97.5 O 12-23-20 16:56:26 98.1 12-24-20 08:18:00 98.2 O 12-24-20 16:37:00 98.4 O 12-25-20 05:35:00 98 O 12-25-20 08:17:00 97.6 O 12-26-20 05:54:00 98.2 O 12-26-20 08:30:01 97.7 12-26-20 16:16:00 97.5 O 12-27-20 06:23:34 97.9 12-27-20 08:40:37 97.6 O 12-27-20 16:23:00 97.4 O 12-28-20 07:52:00 98.3 O 12-28-20 17:57:31 97.7 12-29-20 05:23:14 98.3 12-29-20 08:43:00 98.4 O 12-29-20 16:44:00 98.6 O 12-30-20 05:54:15 97.4 12-30-20 08:24:00 97.6 O 12-30-20 21:16:00 98.3 O 12-31-20 06:04:02 97.9 12-31-20 08:26:00 97.5 Ax 12-31-20 19:00:00 97.9 O 01-01-21 06:22:09 98.3 01-01-21 08:04:00 98.7 O 01-01-21 16:15:00 99.1 O 01-01-21 17:01:00 97.1 O 01-02-21 06:19:09 98 01-02-21 08:22:00 98.3 O 01-02-21 16:05:00 98 O 01-03-21 06:11:00 97.2 O 01-03-21 08:20:00 98.2 O 01-03-21 16:03:00 97.7 O 01-04-21 05:42:00 97.8 O 01-04-21 08:25:00 98.1 O 01-04-21 18:04:00 97.9 O 01-05-21 05:27:21 98 01-05-21 08:50:00 98.4 O 01-05-21 08:53:22 98.4 01-05-21 16:53:01 98.6 01-06-21 06:03:04 98.1 01-06-21 08:13:00 97.8 O 01-06-21 16:59:00 98 O ***01-07-21 05:35:15 102.9*** 01-07-21 08:15:00 98.5
CDC Split Type:
Write-up: loss of consciousness; respiratory distress Narrative: Patient tolerated his 1st dose of the COVID-19 vaccine well, on 12/16/2020, and received his 2nd dose on 1/6/2021. Patient had some mild clinical decline the past few days prior to 2nd vaccination, with a decreased appetite and some increased fatigue per nursing report, but no significant changes. He experienced nausea on the evening of 1/6/21, which was effectively managed, but by early morning he spiked a fever of 102.9 with a sat of 86.1%. He continued to deteriorate from that point on and died 1/7/21 @13:20. Clinically, the presentation was most consistent with an aspiration pneumonia. |
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