|
| 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), 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:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Narrative: Symptoms: & Cardiac Arrest; Death Treatment: EPINEPHRINE |
|
| VAERS ID: |
967754 (history) |
| Form: |
Version 2.0 |
| Age: |
67.0 |
| Sex: |
Female |
| Location: |
Unknown |
| Vaccinated: | 2020-12-21 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 15 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1685 / 1 |
RA / IM |
Administered by: Other Purchased by: ?
Symptoms: Death
SMQs:
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: Death - unknown cause, no reported side effects Narrative: Unknown cause of death |
|
| VAERS ID: |
1349711 (history) |
| Form: |
Version 1.0 |
| Age: |
77.0 |
| Sex: |
Male |
| Location: |
Tennessee |
| Vaccinated: | 2020-12-22 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 16 |
| Submitted: |
2021-01-11 |
| Days after onset: | 4 |
| Entered: |
2021-01-14 |
| Days after submission: | 3 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
MOD039K20A / 2 |
RA / - |
Administered by: Other Purchased by: Other
Symptoms: Cardio-respiratory arrest
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: 2021-01-07
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Symptoms: & cardiopulmonary arrest Treatment: EPINEPHRINE 8 MG Unknown during code |
|
| VAERS ID: |
1349910 (history) |
| Form: |
Version 1.0 |
| Age: |
85.0 |
| Sex: |
Male |
| Location: |
Kansas |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 0 |
| Submitted: |
2021-01-08 |
| Days after onset: | 1 |
| Entered: |
2021-01-14 |
| Days after submission: | 6 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 2 |
LA / - |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 2 |
LA / - |
Administered by: Other Purchased by: Other
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
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: Symptoms: & Death |
|
| VAERS ID: |
946225 (history) |
| Form: |
Version 2.0 |
| Age: |
70.0 |
| Sex: |
Female |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL1283 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Cough,
Death,
Rash,
Respiratory tract congestion
SMQs:, Anaphylactic reaction (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
Days after onset: 1
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: CloZAPine 550 mg QD, Clozaril 150 mg QD, Ergocalciferol Capsule 1.25 MG (50000 UT) QD, MiraLax Powder 17 gram QD, Multivitamin QD, Remeron 45 MG QD, Sertraline HCl 200 mg QD, Simvastatin 20 MG QD, Synthroid Tablet 75 MCG QD, Tricor 14
Current Illness:
Preexisting Conditions: Dx with Covid-19 on 12/11/2020, PERIPHERAL VASCULAR DISEASES, SCHIZOAFFECTIVE DISORDER, BIPOLAR DISORDER, EPILEPSY, HYPERLIPIDEMIA, SECONDARY PARKINSONISM, MAJOR DEPRESSIVE DISORDER, ANXIETY DISORDER, HYPOTHYROIDISM, HYPERTENSION, OBESITY, and UNSPECIFIED CHRONIC BRONCHITIS,
Allergies: Lithium
Diagnostic Lab Data: No testes were done at the facility. Unsure what was performed in the ER.
CDC Split Type:
Write-up: At approximately 10:30pm on 1/14/2021, resident was noted to have a rash on her face, hands, arms, and chest. VS:100.2, 113, 20,108/59, 84% room air. applied nasal cannula at 4-L, telephoned Physician orders 6mg Decadron one time order, a second set of Vitals , reads 99.3, 110, 20, 106/60, 90% on 4-L N/C. On coming shift advised. At approximately 2:00am on 1/15/2021, resident congested and coughing. BP 151/70, pulse 124, temp 98.1 forehead, resp 20 and pulse oc 79% on 3L. At approximately 2:30am PRN cough syrup and breathing tx. Resident''s condition began to worsen with breathing tx. This LPN updated at 0248 doctor on resident''s condition. Doctor gave permission for resident to go to hospital. At 4:19am the Er called to say resident passed away. |
|
| VAERS ID: |
946293 (history) |
| Form: |
Version 2.0 |
| Age: |
51.0 |
| Sex: |
Male |
| Location: |
Virginia |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-07 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
RA / IM |
Administered by: Other Purchased by: ?
Symptoms: Acute respiratory failure,
Death,
Hypoxia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-12
Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Alvesco inh, Mepron susp, Coreg, Zetia, Tricor, Umeclidinum, Cellcept, Zyprexa, Prilosec, paxil, Miralax, prednisone, trazodone, xopenex inh
Current Illness: Pulmonary fibrosis on O2
Preexisting Conditions: COPD,Severe pulmonary fibrosis,HTN,GERD
Allergies: none
Diagnostic Lab Data:
CDC Split Type:
Write-up: 51 year old M with h/o O2 dependent COPD, Severe pulmonary fibrosis became increasingly hypoxic around 1800hours 1/7/2021. He was transported to hospital for acute on chronic hypoxia respiratory failure. On 1/12/2021 he decompensated further, and after discussing with family and palliative care, He was changed to comfort care. He expired on 1/12/2021@2325 at medical center. |
|
| VAERS ID: |
946959 (history) |
| Form: |
Version 2.0 |
| Age: |
83.0 |
| Sex: |
Male |
| Location: |
North Carolina |
| Vaccinated: | 2021-01-14 |
| Onset: | 2021-01-15 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL3249 / 1 |
LA / IM |
Administered by: Public Purchased by: ?
Symptoms: Autopsy,
Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-15
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: Post COVID-19 complications, A-fib, CHF
Preexisting Conditions: Diabetes,
Allergies: None
Diagnostic Lab Data: Unsure, autopsy pending
CDC Split Type:
Write-up: Sudden death 18 hours post vaccine . |
|
| VAERS ID: |
947129 (history) |
| Form: |
Version 2.0 |
| Age: |
101.0 |
| Sex: |
Female |
| Location: |
Georgia |
| Vaccinated: | 2020-12-23 |
| Onset: | 2020-12-25 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
026L20A / 1 |
AR / IM |
Administered by: Private Purchased by: ?
Symptoms: Cerebrovascular accident,
Death
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-01
Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Digoxin, Diltiazem CR, Namenda CR, Toprol XL, Acetaminophen, Vitamin D, Zyrtec
Current Illness: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Preexisting Conditions: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident received Moderna vaccine on 12/23/2020 around 5 pm. At approximately 3:35 am on 12/25/2020, resident had a CVA and died on 1/1/2021 at 3:00 am. |
|
| VAERS ID: |
947642 (history) |
| Form: |
Version 2.0 |
| Age: |
66.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 2 |
- / - |
Administered by: Unknown Purchased by: ?
Symptoms: Death,
Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-09
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: USPFIZER INC2021025817
Write-up: died two days after receiving the vaccine; Fever; This is a spontaneous report from a contactable consumer (patient''s stepchild). A 66-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, on 07Jan2021 (at the age of 66-years-old) as a single dose for COVID-19 immunization. The patient''s medical history was not reported. Concomitant medications included an unspecified statin. The patient experienced fever on 08Jan2021. The patient died two days after receiving the vaccine on 09Jan2021, which was reported as fatal. The clinical course was reported as follows: The patient had a fever the day after getting the vaccine and then he just died in the middle of night. It was reported that it was not clear what exactly happened, but they are looking into this. The clinical outcome of fever was unknown and of died two days after receiving the vaccine was fatal. The patient died on 09Jan2021. The cause of death was not reported. An autopsy was not performed (was reported to be taking place soon). The batch/lot number for the vaccine, BNT162B2, was not provided and has been requested during follow up.; Reported Cause(s) of Death: died two days after receiving the vaccine |
|
| VAERS ID: |
947662 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-01 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
General physical health deterioration,
Hypophagia,
Hyporesponsive to stimuli,
Somnolence
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (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: 2021-01-06
Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC Split Type:
Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death |
|
