Author's Note: As of October 2023, information has been reported that there were 2 different methods used to "multiply" the Spike Protein for the COVID-19 Vaccine.  The first batches of COVID-19 mRNA Vaccines used PCR AMPLIFICATION, which is an accurate, expensive, and time consuming method for making more mRNA for the COVID-19 Vaccine.

The second method was reported to be faster and cheaper, and since the "vaccine" was EXPERIMENTAL, pharmaceutical companies knew they could not be held libel or be sued.  Pharmaceutical companies have a duty to their stockholders, not their customers, so they chose to use the second, cheaper method, which involved "growing" (multiplying) the COVID-19 virus in a bacteria, which produced excessively unwanted amounts of DNA.  To get rid of the DNA, a chemical was added to cause the DNA to break apart into many fragments, *BUT* these fragments carried a risk of sometimes inserting itself into Human DNA (Reverse Transcription), causing a NEW TYPE OF CANCER that could kill within days, weeks but typically 6 to 12 months, because of the extremely aggressive, never before seen forms of Breast, Colon, Lung, Blood, Lymphomas, and other types of Cancers.  This new type of cancer is called TURBO CANCER, AND IT IS REPORTED TO BE RESISTANT TO CURRENT CANCER TREATMENTS.  Information can be found on uncensored video websites such as RUMBLE.com, ODYSEE.com, and several others.  You can start here: https://rumble.com/v3fkwum-cancer-experts-drs.-risch-and-makis-discuss-vaxx-induced-turbo-cancer-likel.html  

DEL BIGTREE is at the top of BILL GATES' hit list.  BIGTREE sued the FDA twice, and forced them to hand over detailed COVID-19 Vaccine REACTION DATA collected on your cellphone.  This data appears on his website (click here)


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Search Results

From the 8/27/2021 release of VAERS data:

Found 13,911 cases where Vaccine targets COVID-19 (COVID19) and Patient Died

Table

   
Vaccine/Manufacturer Count Percent
COVID19 / JANSSEN 837 6.02%
COVID19 / MODERNA 3,695 26.56%
COVID19 / PFIZER/BIONTECH 10,130 72.82%
COVID19 / UNKNOWN MANUFACTURER 42 0.3%
FLU3 / GLAXOSMITHKLINE BIOLOGICALS 1 0.01%
FLU4 / SANOFI PASTEUR 1 0.01%
FLUX / UNKNOWN MANUFACTURER 2 0.01%
PPV / MERCK & CO. INC. 1 0.01%
PPV / UNKNOWN MANUFACTURER 1 0.01%
UNK / UNKNOWN MANUFACTURER 153 1.1%
VARZOS / GLAXOSMITHKLINE BIOLOGICALS 2 0.01%
TOTAL † 14,865 † 106.86%
† Because some cases have multiple vaccinations and symptoms, a single case can account for multiple entries in this table. This is the reason why the Total Count is greater than 13911 (the number of cases found), and the Total Percentage is greater than 100.



Case Details

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VAERS ID: 909095 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2020-12-23
Onset: 2020-12-25
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2020-12-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Foaming at mouth, Pain in extremity, Pallor, Pulse absent, Respiratory arrest, Somnolence, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tamsulosin 0.4mg, Lactobacillus tablet, Nephro-vite tablet 0.8mg, Allopurinol 100mg, ferrous gluconate 324mg, melatonin 6mg, lisinopril 2.5mg, colace 100mg, metamucil powder, aspirin 81mg, amidoarone 200mg, hydrooxyzine 25mg, cholestyramine
Current Illness: End stage renal disease with dependence on renal dialysis, COPD, cirrhosis of the liver, hypokalemia, gout, heart failure, hyperlipidemia, atrial fibrillation.
Preexisting Conditions: Refused dialysis frequently resulting in episodes of hypokalemia and hospitalization, resident dependent on supplemental oxygen. The resident refused to go to dialysis on 12/23/2020 and said he was feeling fine.
Allergies: alprazolam, Lorazepam
Diagnostic Lab Data: None
CDC Split Type:

Write-up: on 12/24/2020 the resident was sleepy and stayed in bed most of the shift. He stated he was doing okay but requested pain medication for his legs at 250PM. At 255AM on 12/25/2020 the resident was observed in bed lying still, pale, eyes half open and foam coming from mouth and unresponsive. He was not breathing and with no pulse
VAERS ID: 910363 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: California  
Vaccinated: 2020-12-23
Onset: 2020-12-26
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT 039K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypophagia, Hypotension, Somnolence
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   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: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.
VAERS ID: 913143 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Texas  
Vaccinated: 2020-12-29
Onset: 2020-12-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-29
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: 2020-12-29
   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: Gabapentin 100mg, Memantine 10mg
Current Illness:
Preexisting Conditions: dementia, aphasia, type 2 DM, iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, MDD
Allergies: codeine, phenobarbital, penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine administered with no immediate adverse reaction at 11:29am. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 1:30pm the resident passed away.
VAERS ID: 913733 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2020-12-29
Onset: 2020-12-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: My grandmother died a few hours after receiving the moderna covid vaccine booster 1. While I don?t expect that the events are related, the treating hospital did not acknowledge this and I wanted to be sure a report was made.
VAERS ID: 914604 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2020-12-16
Onset: 2020-12-20
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-20
   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: Spouse awoke 12/20 and found spouse dead. Client was not transferred to hospital.
VAERS ID: 914621 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2020-12-22
Onset: 2020-12-27
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J02A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dementia, Fatigue
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   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: None
Preexisting Conditions: Resident in long term care facility for 9+ years Coronary Artery Disease Dementia Hypothyroidism Hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident in our long term care facility who received first dose of Moderna COVID-19 Vaccine on 12/22/2020, only documented side effect was mild fatigue after receiving. She passed away on 12/27/2020 of natural causes per report. Has previously been in & out of hospice care, resided in nursing home for 9+ years, elderly with dementia. Due to proximity of vaccination we felt we should report the death, even though it is not believed to be related.
VAERS ID: 914690 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated: 2020-12-23
Onset: 2020-12-24
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Anxiety, Death, Pyrexia, Respiratory distress, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-26
   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: Contact facility for medical records. We think levothyroxine daily and ativan prn.
Current Illness: none known
Preexisting Conditions: COPD
Allergies: none known
Diagnostic Lab Data: We were told her last COVID test was negative
CDC Split Type:

Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020.
VAERS ID: 914805 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2020-12-28
Onset: 2020-12-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: Asa-81mg, Lisinopril 10mg daily, ferrous sulfate-325, MVI with min, zyprexia-20mg, Flomax-0.4, famotidine-20mg, vit C, carbamazepine-250mg bid, Depakote-750mg bid, metformin-1000 bid, sertraline-100 bid, albuterol,buspar-10mg TID, Fibercon-
Current Illness: none
Preexisting Conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gerd, hyperlipidemia, dipolar, rectal bleeding, HTN
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: RESIDENT CODED AND EXPIRED
VAERS ID: 914895 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2020-12-28
Onset: 2020-12-30
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2020-12-30
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: 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: Senna Plus, Loperamide, Ondansetron, Acetaminophen, Mucus & Chest Relief cough syrup, Oystershell Calcium Plus D, Vitamin D3, Escitalopram, Bupropion, Hydrocodone/Acetaminophen, Bisacodyl Suppositories
Current Illness: Alzheimer''s Disease, Encephalopathy, Hypertension,Acute Kidney failure, Urine Retention, Recent UTI
Preexisting Conditions: Alzheimer''s Disease, Encephalopathy, Hypertension
Allergies: No known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Injection given on 12/28/20 - no adverse events and no issues yesterday; Death today, 12/30/20, approx.. 2am today (unknown if related - Administrator marked as natural causes)
VAERS ID: 914917 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2020-12-19
Onset: 2020-12-23
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / UNK - / -

Administered by: Work       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: 2020-12-23
   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: Atenolol, Chlorthalidone, Tamsulosin
Current Illness: None
Preexisting Conditions: hypertension
Allergies: None
Diagnostic Lab Data: Death certificate
CDC Split Type:

Write-up: Death by massive heart attack. Pfizer-BioNTech COVID-19 Vaccine EUA
VAERS ID: 914961 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness: per nursing home staff over 14 days post covid
Preexisting Conditions:
Allergies: none listed
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt passed away with an hour to hour and 1/2 of receiving vaccine. per nursing home staff they did not expect pt to make it many more days. pt was unresponsive in room when shot was given. per nursing home staff pt was 14 + days post covid
VAERS ID: 914994 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 AR / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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: not known
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt was a nursing home pt. pt received first dose of covid vaccine. pt was monitored for 15 minutes after getting shot. staff reported that pt was 15 days post covid. Pt passed away with in 90 minutes of getting vaccine
VAERS ID: 915562 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (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:
Current Illness:
Preexisting Conditions:
Allergies: none listed
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt received vaccine at covid clinic on 12/30 at approximately 3:30, pt vomited 4 minutes after receiving shot--dark brown vomit, staff reported pt had vomited night before. Per staff report pt became short of breath between 6 and 7 pm that night. Pt had DNR on file. pt passed away at approximately 10pm. Staff reported pt was 14 + days post covid
VAERS ID: 915682 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Respiratory Disease, Essential Hypertension, Coronary Artery Disease, History of positive COVID 11/17/20
Allergies: No Known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received vaccine per pharmacy at the facility at 5 pm. Approximately 6:45 resident found unresponsive and EMS contacted. Upon EMS arrival at facility, resident went into cardiac arrest, code initiated by EMS and transported to hospital. Resident expired at hospital at approximately 8 pm
VAERS ID: 915880 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Montana  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: Refused anything PO for about one week prior to death.
Current Illness: Refused food for one week prior to death.
Preexisting Conditions:
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died within 12 hours of receiving the vaccine.
VAERS ID: 915920 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2020-12-28
Onset: 2020-12-28
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELO140 / UNK AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Tetanus toxoid
Other Medications: ASA 81, Vitamin D, Vitamin B12, Atorvastatin, Omeprazole, Tylenol, Donepezil, Amlodipine, Coreg, Remeron
Current Illness: Resident was living in an assisted living facility. She fell on 11/24/2020 and was seen in the ER. There, she tested positive for COVID 19. She was admitted to this facility for rehab. She showed a decline after admission and was referred to hospice.
Preexisting Conditions: Vitamin deficiency, hyperlipidemia, hypertension, anemia, dementia, chronic kidney disease III, osteoporosis, history of breast cancer/MI/pulmonary embolism, depression.
Allergies: Tetanus toxoid
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received vaccine in am and expired that afternoon.
VAERS ID: 917117 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Arkansas  
Vaccinated: 2020-12-22
Onset: 2020-12-28
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       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: 2021-01-01
   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: Quietapine, Mertazipine, Hydrocodone, Fentanyl
Current Illness: Yes
Preexisting Conditions: Yes
Allergies: None
Diagnostic Lab Data: COVID-19 positive test approximately one week after vaccination. There is no evidence to support that the vaccine caused his death in any way.
CDC Split Type:

Write-up: After vaccination, patient tested positive for COVID-19. Patient was very ill and had numerous chronic health issues prior to vaccination. Facility had a number of patients who had already tested positive for COVID-19. Vaccination continued in an effort to prevent this patient from contracting the virus or to mitigate his risk. This was unsuccessful and patient died.
VAERS ID: 917790 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2020-12-22
Onset: 2020-12-29
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, Exposure to SARS-CoV-2, 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: 2021-01-03
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Torsemide, Trazadone, Amitizide, Morphine Sulfate, Fentanyl, Carbidoba-Levodopa, Prednisone, Potassium Chloride, Escalitapram, Incruse Ellipta, Mirtazipane, Clonazepam, Levothyroxine
Current Illness: Patient was a resident of a long term care facility and had numerous chronic conditions prior to vaccination.
Preexisting Conditions: Thyroid disease, chronic elderly conditions.
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: At the time of vaccination, there was an outbreak of residents who had already tested positive for COVID 19 at the nursing home where patient was a resident. About a week later, patient tested positive for COVID 19. She had a number of chronic, underlying health conditions. The vaccine did not have enough time to prevent COVID 19. There is no evidence that the vaccination caused patient''s death. It simply didn''t have time to save her life.
VAERS ID: 917793 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2020-12-22
Onset: 2020-12-29
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       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: 2021-01-02
   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: Metoprolol-Tartrate, Latanoprost, Glipizide, Pravastatin, Metformin, Benaprezil, Potassium-Chloride, Levothyroxine
Current Illness: Diabetes, Thyroid disease
Preexisting Conditions: Diabetes, Thyroid Disease
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Prior to the administration of the COVID 19 vaccine, the nursing home had an outbreak of COVID-19. Patient was vaccinated and about a week later she tested positive for COVID-19. She had underlying thyroid and diabetes disease. She died as a result of COVID-19 and her underlying health conditions and not as a result of the vaccine.
VAERS ID: 918065 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: California  
Vaccinated: 2020-12-30
Onset: 2021-01-01
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 - / IM

Administered by: Other       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: 2021-01-01
   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: - Invega Trenza 546mg Q3months - Lithium 300mg BID - Oxybutynin 5mg QID - lipitor 20mg QHS - cogentin 2mg BID - Norvasc 5mg QD - Dyazide Capsule 37.5-25 MG (Triamterene-HCTZ) QD
Current Illness: - covid-19
Preexisting Conditions: - SCHIZOPHRENIA, UNSPECIFIED - ANEMIA, UNSPECIFIED - OVERWEIGHT - OVERACTIVE BLADDER - ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS - HYPOTHYROIDISM DUE TO MEDICAMENTS AND OTHER EXOGENOUS SUBSTANCES - NICOTINE DEPENDENCE, UNSPECIFIED, UNCOMPLICATED - CHRONIC VIRAL HEPATITIS C - UNSPECIFIED AGE-RELATED CATARACT - ESSENTIAL (PRIMARY) HYPERTENSION - CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED - UNSPECIFIED CONVULSIONS - INHALANT ABUSE, UNCOMPLICATED - OTHER SEIZURES
Allergies: - Clozaril - Tegretol
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: 1/1/2020: Residents was found unresponsive. Pronounced deceased at 6:02pm
VAERS ID: 918388 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Florida  
Vaccinated: 2020-12-30
Onset: 2021-01-01
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-04
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, Pulse absent, Respiratory arrest, Resuscitation, 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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Albuteral Sulfate Amlodipine Carvedilol Ipratropium Levetiracetam Olanzapine Sodium Chloride Symbicort Valproic Acid
Current Illness: No acute illness at time of vaccination. History of: CVA SCPT Dementia Seizure Disorder HTN COPD
Preexisting Conditions: As noted above
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident found unresponsive without pulse, respirations at 04:30 CPR performed, expired at 04:52 by Rescue
VAERS ID: 918418 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-30
Onset: 2021-01-01
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Dyspnoea, Hospice care, Hypoxia, Oxygen saturation decreased, Pulse absent, Respiratory arrest, Respiratory tract congestion
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   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: Mucomyst ASA Benadryl Periactin Colace Ferrous Sulfate Folic Acid Gabapentin Sennosides Albuterol Ipratropium Melatonin MVI Oxycodone Polyethylene Glycol Seroquel Rosuvastatin Valproic Acid Venlafaxine Vitamin C
Current Illness: Hypoxia started on 1/1/2021. History of: Osteomyelitis CVA Pain Pressure Ulcers PVD Hepatitis C COPD HTN HLD Constipation SCPT Anemia Seizure disorder Depression AKA
Preexisting Conditions: As noted above
Allergies: NKA
Diagnostic Lab Data: low oxygen saturation
CDC Split Type:

Write-up: Resident became SOB, congested and hypoxic requiring oxygen, respiratory treatments and suctioning. Stabilized after treatment and for the next 72 hours with oxygen saturations in the 90s. On 1/3/2021 was found without pulse and respirations. Resident was a DNR on Hospice.
VAERS ID: 918487 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2020-01-02
Onset: 2021-01-04
   Days after vaccination: 368
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L2OA / 1 RA / 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)

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: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Two days post vaccine patient went into cardiac arrest and passed away.
VAERS ID: 918518 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Nebraska  
Vaccinated: 2020-12-31
Onset: 2020-12-31
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Cardio-respiratory arrest, Death, Resuscitation, Syncope
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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: To be determined
Current Illness: To be determined
Preexisting Conditions: To be determined
Allergies: To be determined
Diagnostic Lab Data: Autopsy being performed
CDC Split Type:

Write-up: syncopal episode - arrested - CPR - death
VAERS ID: 919108 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: New York  
Vaccinated: 2020-12-22
Onset: 2020-12-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH F10140 / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood culture, Culture urine, Full blood count, Malaise, Pyrexia, Urine analysis
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: 2021-01-03
   Days after onset: 11
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: UA. C&S, CBC/Blood culture 1/2/2021
CDC Split Type:

Write-up: Fever, Malaise
VAERS ID: 919537 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-03
Onset: 2021-01-03
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

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: Robitussin Cough+Chest Cong DM Liquid 5-100 MG/5ML (Dextromethorphan-guaiFENesin) Tylenol Extra Strength Tablet (Acetaminophen) amLODIPine Besylate Tablet 5 MG Morphine Solu Tab 2.5MG Capsaicin Cream 0.025 % Leflunomide Tablet 10 MG Levothy
Current Illness: Resident had suspected vasovagal episode with drop in O2 saturation.
Preexisting Conditions: ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE RHEUMATOID ARTHRITIS, UNSPECIFIED ANEMIA, UNSPECIFIED HYPOTHYROIDISM, UNSPECIFIED CACHEXIA ESSENTIAL (PRIMARY) HYPERTENSION DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE AGE-RELATED PHYSICAL DEBILITY OTHER CHRONIC PAIN DILATED CARDIOMYOPATHY ERYTHEMATOUS CONDITION, UNSPECIFIED UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE PRIMARY GENERALIZED (OSTEO)ARTHRITIS OTHER SPONDYLOSIS WITH RADICULOPATHY, LUMBAR REGION HYPERKALEMIA OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE CERVICALGIA OTHER BIOMECHANICAL LESIONS OF LUMBAR REGION ??? BILATERAL PRIMARY OSTEOARTHRITIS OF KNEE LOCALIZED EDEMA HYPO-OSMOLALITY AND HYPONATREMIA OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE HISTORY OF FALLING WEAKNESS
Allergies: Celebrex and Tramadol
Diagnostic Lab Data: N/A.
CDC Split Type:

Write-up: Resident exhibited no adverse events during 30 minute monitoring following vaccine administration. Resident found without pulse at 1900.
VAERS ID: 920326 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Indiana  
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 026L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Erythema, Hospice care, Localised oedema, Skin warm
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Cetirizine, Lactaid
Current Illness: G30.1 Alzheimer''s disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension
Preexisting Conditions: G30.1 Alzheimer''s disease with late onset (Primary) M19.90 Unspecified osteoarthritis, unspecified site J44.9 Chronic obstructive pulmonary disease, unspecified I95.1 Orthostatic hypotension J45.909 Unspecified asthma, uncomplicated R13.12 Dysphagia, oropharyngeal phase M15.0 Primary generalized (osteo)arthritis M85.80 Other specified disorders of bone density and structure, unspecified site Note: Osteopenia J30.9 Allergic rhinitis, unspecified F41.1 Generalized anxiety disorder M24.511 Contracture, right shoulder M24.512 Contracture, left shoulder M24.521 Contracture, right elbow R29.3 Abnormal posture M17.4 Other bilateral secondary osteoarthritis of knee M25.561 Pain in right knee R26.89 Other abnormalities of gait and mobility Z74.1 Need for assistance with personal care Z91.81 History of falling M62.81 Muscle weakness (generalized) R29.6 Repeated falls R27.8 Other lack of coordination R63.3 Feeding difficulties E73.8 Other lactose intolerance R53.1 Weakness I95.89 Other hypotension
Allergies: Lactose
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Redness and warmth with edema to right side of neck and under chin. Resident was on Hospice services and expired on 1.1.21
VAERS ID: 920368 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Indiana  
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 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Body temperature increased, Chest X-ray abnormal, Decreased appetite, Dyspnoea, Erythema, Full blood count, Hospice care, Influenza virus test negative, Lung infiltration, Metabolic function test, Respiratory rate increased, Vital functions abnormal, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Acetaminophen, Atenolol, Colace, Lisinopril, Mirtazapine, Omeprazole, Simvastatin, Vitamin D3
Current Illness: F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Preexisting Conditions: U07.1 2019-nCoV acute respiratory disease (Primary) F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Allergies: quinine sulfate
Diagnostic Lab Data: Influenza Swab: 12/30/20-Negative Results CBC: 12/30/20 showed WBC of 14.1 (H) CMP: 12/30/20 showed BUN: 113 (H); Creatinine 2.7 (H) CXR: 12/30/20 showed: Conclusion: A mild left lower lung infiltrate
CDC Split Type:

Write-up: 12/30/2020 07:02 AM Resident noted to have some redness in face and respiration were fast. Resident vital signs were abnormal except blood pressure. Temp at the time was 102.0 F taken temporal. Resident respirations were 22 labored at times. Pulse is 105 and pulse ox 94% on room air. Resident is made comfortable in bed. Notified triage of change in condition also made triage aware of resident receiving Covid vaccination yesterday morning. Resident appetite and fluid consumption has been poor for few days. 12/30/2020 07:32 AM Received order from agency to administer Acetaminophen 650mg suppos rectally due to resident not wanting to swallow anything including fluids, medications and food. This writer administered medication as NP ordered. Will monitor for effectiveness and adverse effects if any. 12/30/2020 08:41 AM Received new orders to obtain Flu swab, obtain CBC and BMP, and Chest Xray all to be obtained today. Notified family of resident having temperature and vital signs excluding b/p that was abnormal. Family was thankful for call and inierated to nurse that family does not want resident sent to hospital. Did educate family on benefits of Hospice services, but family persistant on continued daily care provided by nursing staff. Requests visits if decline continues. Family assured if resident continues to decline, facility will accomandate resident family to be able to be at bedside when time comes to do so. NP ordered IVF and IV Levaquin on 12/31/20. Family chose at that time to sign for Hospice services and not have resident provided with IVF or IV Antibiotics
VAERS ID: 920545 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: South Dakota  
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 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abnormal behaviour, Blood pressure abnormal, Fatigue, Limb discomfort, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Hypertension (broad), Hypersensitivity (broad), Respiratory failure (narrow)

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: Ferrex 150 mg, Folic Acid 1 mg, Furosemide 20 mg, Isosorbide Mononoitrate ER 30 mg, Lactulose 15 mL, Omeprazole 40 mg, Potassium Chloride ER 20 MEQ, Metoprolol 12.5 mg, PreserVision AREDS 2 one capsule, Ranolazine ER 1,000 mg, and Sucralf
Current Illness:
Preexisting Conditions: ACUTE POSTHEMORRHAGIC ANEMIA, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH OTHER FORMS OF ANGINA PECTORIS, CARDIAC MURMUR, UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE 2, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, EMPHYSEMA, ESSENTIAL (PRIMARY) HYPERTENSION, FRACTURE OF NASAL BONES, INITIAL ENCOUNTER FOR CLOSED FRACTURE, HYPOXEMIA, PAROXYSMAL ATRIAL FIBRILLATION, PRESENCE OF CARDIAC PACEMAKER, THROMBOCYTOPENIA, UNSPECIFIED CIRRHOSIS OF LIVER, and UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: The resident received is vaccine around 11:00 am and tolerated it without any difficulty or immediate adverse effects. He was at therapy from 12:36 pm until 1:22 pm when he stated he was too tired and could not do anymore. The therapist took him back to his room at that time and he got into bed himself but stated his legs felt heavy. At 1:50 pm the CNA answered his call light and found he had taken himself to the bathroom. She stated that when he went to get back into the bed it was "abnormal" how he was getting into it so she assisted him. At that time he quit breathing and she called a RN into the room immediately. He was found without a pulse, respirations, or blood pressure at 1:54 pm. He was a DNR.
VAERS ID: 920815 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-30
Onset: 2021-01-04
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       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: Per employee health records HTN, DM, Breast CA 2016 with radiation, obesity, gastric sleeve 10 years ago, arthritis, plantar fasciitis, ankle tendonitis, DeQuarvains, carpal tunnel, anxiety
Allergies: Lisinpril, Codeine, Latex , environmental (hay fever)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found deceased in her home, unknown cause, 6 days after vaccine.
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)

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.
VAERS ID: 924126 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2020-12-30
Onset: 2021-01-01
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Singulair, lopressor, pepcid, omeprazole, lasix, albuterol, azelastine eye gtts, calcium, eliquis, prozac, terazosin, magnesium oxide, potassium
Current Illness: Low blood pressure requiring medication changes. Sent to ER on 1/1 with low b/p sent back same day, heart failure. Family requests comfort measures only.
Preexisting Conditions: CHF, Heart Failure, hypertension, Atrial-fibrillation, Crohns disease.
Allergies: Asa, Cardizem, delsyn, doxycycline, levaquin, motrin, prevacid, vicodin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: resident expired 1/1/2021
VAERS ID: 924186 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2020-12-30
Onset: 2021-01-03
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: aldactone, lasix, aspirin, tylenol, potassium, spiriva
Current Illness: Covid positive previous with no s/s poor appetite Chronic wound right leg
Preexisting Conditions: alzheimers dementia, COPD , DM- type 2
Allergies: Codeine, Penicillin, Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired 1/3/21
VAERS ID: 924456 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pupil fixed, Regurgitation, Respiratory arrest, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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: Lexapro, famotidine, Namenda, Seroquel, simvastatin, Trazodone; Tamsulosin; Docusate sodium; Polyethylene glycol; Celebrex; Acetaminophen
Current Illness: COVID-19 detected after vaccination; asymptomatic
Preexisting Conditions: Hyperlipidemia; Alzheimer''s disease; Atherosclerotic heart disease of native coronary artery w/o angina pectoris; Osteoarthritis; Major depressive disorder, single episode, unspecified; unspecified severe protein-calorie malnutrition
Allergies: No known allergies
Diagnostic Lab Data: OVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19
CDC Split Type:

Write-up: Patient did not display any obvious signs or symptoms; the vaccination was administered at approximately 10:00 AM and the patient continued throughout her day without any complaints or signs of adverse reaction. Patient was helped to bed by the nursing assistant estimated at around 9:00 PM. The facility received notification from the lab around 11:00 PM that the patient''s COVID-19 specimen collection from Sunday, 1/3/21, detected COVID-19. When the nursing staff went to the room to check on the resident and prepare her to move to a COVID-19 care area the patient was found unresponsive, no movement, no chest rises, noted regurgitated small amount of food to mouth left side, lying on left side. Pupils non reactive.
VAERS ID: 924464 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-01-05
Onset: 2021-01-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Condition aggravated, Haemoptysis, Lung neoplasm malignant
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), 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), Non-haematological malignant tumours (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: COPD, lung cancer
Preexisting Conditions: COPD, lung cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: coughing up blood, significant hemoptysis -- $g cardiac arrest. started day after vaccine but likely related to ongoing progression of lung cancer
VAERS ID: 924664 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Hawaii  
Vaccinated: 2021-01-02
Onset: 2021-01-05
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O11L20A / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram abnormal, Death, Intracranial aneurysm, Pulmonary oedema, Unresponsive to stimuli, X-ray abnormal
SMQs:, Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Metoprolol succ ER 50mg 1 tab PO daily Omeprazole DR 20mg 1 cap PO daily Amlodipine besylate 5mg 1 tab PO daily Aspirin 81mg 1 tab PO daily Carbamazepine ER 100mg 1 tab PO TID Docusate 100mg 1 cap PO daily Multivitamin 1 tab PO daily Olmesa
Current Illness: none
Preexisting Conditions: history of stroke, hyperlipidemia, dementia, GERD, and macular degeneration
Allergies: Hydrochlorothiazide
Diagnostic Lab Data: CT scan, X ray 1/5/2021
CDC Split Type:

Write-up: At approximately, 1855, I was alerted by caregiver, resident was not responding. Per caregiver, she was doing her rounds and found resident in bed, unresponsive, mouth open, observed gurgling noises and tongue hanging out of mouth. This primary caregiver observed resident at baseline and ambulating after dinner at approximately, 1800 less than an hour prior to incident. This PCG called 911 for EMS and gave report of incident. Resident was taken to Medical Center Emergency Department. At ER, CT scan and X-ray was performed. Per report from ER RN, CT scan and x-ray revealed an intracranial aneurysm and fluid in the lungs. Per RN, resident was still unresponsive and was admitted to Medical Center for observation and comfort measures. This primary caregiver reported to RN, resident recently received the first dose of COVID-19 vaccine on 1/2/21. Primary caregiver received a call from Castle RN at 0700, resident expired at 0615.
VAERS ID: 925154 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-03
Onset: 2021-01-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Public       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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Avorstatin Aspirin Oxycodone
Current Illness: NONE
Preexisting Conditions: COPD
Allergies: None
Diagnostic Lab Data: Hospital
CDC Split Type:

Write-up: Deceased
VAERS ID: 925264 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Oklahoma  
Vaccinated: 2020-12-31
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Norco 5/325 1 tablet every 6 hours as needed. Warfarin 4mg , 2 tablets orally Monday and Friday Torsemide 100mg, 1/2 tablet orally once a day Sabcubitril-Valsartan 24/26mg 1/4 tablet orally twice a day Gabapentin 300mg, tablet once daily Ca
Current Illness: CHF HTN DM 2 CKD Obesity DDD
Preexisting Conditions: CHF HTN DM 2 CKD Obesity DDD
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: PT was found deceased in his home on 1/5/2021
VAERS ID: 925556 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-30
Onset: 2021-01-06
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Acute on chronic heart failure, sepsis
Preexisting Conditions: CAD, CKD, DM type 2, CHF, Hx TIA, Atrial fibrillation
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Expired 1/05/2021
VAERS ID: 926269 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Maryland  
Vaccinated: 2021-01-04
Onset: 2021-01-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Death, Pulse absent, Respiratory arrest, Resuscitation, 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), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), 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: Acetaminophen Tablet 325 MG, Enulose Solution 10 GM/15ML (Lactulose Encephalopathy), HYDROcodone-Acetaminophen Tablet 5-325 MG, Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide, Potassium Chloride ER Tablet Extended Release 20 ME
Current Illness: Fracture of right superior and inferior pubic rami, fracture of the right sacral alla, and fracture of the L3 vertebral body. UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
Preexisting Conditions: Abdominal aortic aneurysm CHRONIC OBSTRUCTIVE PULMONARY DISEASE tobacco abuse, EtOH abuse Ambulatory dysfunction, debility, high risk for falls, deconditioning, ambulatory dysfunction/debility/deconditioning/high fall risk/generalized weakness MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED PERSONAL HISTORY OF MALARIA
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt last seen at 1200 by nurse for ID band check. No visible signs of distress noted. Pt states "I just want to be left alone". 1230 nurse was called to pt room. Pt was noted unresponsive, no pulse and respiration noted. CPR started immediately, at 1239 first shock given. 1245 EMT took over, at 1319 EMT called time of death
VAERS ID: 926462 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-28
Onset: 2021-01-04
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Absence of immediate treatment response, Death, Hypoxia
SMQs:, Asthma/bronchospasm (broad), Lack of efficacy/effect (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   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: Lorazepam, pantoprazole, miralax, senna plus, carbodopa-levodopa, metoprolol, mirtazipine, quetiapine
Current Illness: dementia, Upper gastrointestinal bleed
Preexisting Conditions: Advanced dementia, Parkinson''s'' disease ,chronic kidney disease, sciatica, hyperlipidemia
Allergies: no known food or medication allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed hypoxia on 1/4/2021 and did not respond to maximal treatment and passed way on 1/5/2021
VAERS ID: 926568 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-28
Onset: 2020-12-30
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1042 / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Absence of immediate treatment response, Death
SMQs:, Lack of efficacy/effect (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 5
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: alprazolam, amlodipine, ASA, cilostazol, advair, lamotrigine, ,losartan, metoprolol,omprazole,simvastatin
Current Illness: chronic medical problems as noted below
Preexisting Conditions: dementia, peripheral vascular disease, COPD, hypertension, GERD, S/P CVA with stent of left carotid ,right common iliac and right external iliac arteries, CDK,diabetes
Allergies: clopidigrel, sulfa, vicodin
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient declined 12/30/2020 and was transferred to hospital where he did not respond to treatment and passed away 1/4/2020
VAERS ID: 926600 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-04
Onset: 2021-01-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 37K20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Diabetes, renal insufficiency
Preexisting Conditions: Diabetes, renal insufficiency
Allergies: Penicillin, ibuprofen
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient did not report any signs or symptoms of adverse reaction to vaccine. Patient suffered from several comorbidities (diabetes and renal insufficiency). Patient reported not feeling well 01/06/2021 and passed away that day.
VAERS ID: 926797 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: South Dakota  
Vaccinated: 2020-12-31
Onset: 2021-01-01
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: This is a 93 year old with significant heart issues?EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine
Preexisting Conditions: Heart disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: had a vaccination on 12/31/2020 late morning passed away early morning 01/01/2020. This is a 93 year old with significant heart issues. EF of 20% among other comorbidities. He died suddenly approximately 0430, it is unlikely it was related to receiving the vaccine.
VAERS ID: 927189 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-07
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / SYR

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: stroke
Preexisting Conditions: hypertension, atrial fibrillation, atherosclerosis,
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated at 11am and was found at the facility in his room deceased at approximately 3:00pm. Nurse did not have cause of death
VAERS ID: 927260 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2020-12-28
Onset: 2021-01-06
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid increased, Bradycardia, Cardiac arrest, Computerised tomogram head normal, Death, Heart sounds abnormal, Pulse absent, Respiration abnormal, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (narrow), 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), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met
Current Illness: Digestive Surgery for bowel obstruction
Preexisting Conditions: HTN, AAA, Chronic Diastolic Heart Failure, Diabetes Type 2, Paroxysmal atrial fibrillation, bradycardia, Hx of STEMI, Hx of CVA, HX of uterine cancer,
Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids
Diagnostic Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative
CDC Split Type:

Write-up: No adverse effects noted after vaccination. Patient with cardiac history was found unresponsive at 16:45 on 1/6/21. Abnormal breathing patterns, eyes partially closed SPO2 was 41%, pulseless with no cardiac sounds upon auscultation. CPR and pulse was regained and patient was breathing. Patient sent to Hospital ER were she remained in an unstable condition had multiple cardiac arrest and severe bradycardia and in the end the hospital was unable to bring her back.
VAERS ID: 928062 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Massachusetts  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood lactic acid increased, Cardiac arrest, Death, Endotracheal intubation, Hypotension, Hypoxia, Laboratory test, Lethargy, Liver function test, Lung infiltration, Pancytopenia, Pulmonary congestion, Pulmonary imaging procedure abnormal, Troponin, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Agranulocytosis (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), 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), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   Days after onset: 2
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: ACETAMINOPHEN CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA ER CITALOPRAM HBR DONEPEZIL HCL EUCERIN FINASTERIDE FLOMAX LATANOPROST OMEPRAZOLE QUETIAPINE FUMARATE QUETIAPINE FUMARATE SENNA LAX
Current Illness: Parkinson''s Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD
Preexisting Conditions: Parkinson''s Disease with advanced dementia, dysphagia. Alcoholism in remission. HTN. BPH. GERD
Allergies: angioedema due to ACE and ARB meds
Diagnostic Lab Data: Pancytopenia, elevated lactate, troponin, LFTs. Left mid lung infiltrate and pulmonary vascular congestion.
CDC Split Type:

Write-up: vomiting later on 01/05/21. Lethargy and hypoxia in pm of 01/06/21. Hypotension am of 01/07/21. Hospitalized, intubated, cardiac arrest, died 01/07/21.
VAERS ID: 928513 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-05
Onset: 2021-01-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Amiodarone Hcl, Carvedilol, Ferrous sulfate, Eliquis (cont)
Current Illness: Atrial fibrillation, Anemia, 1st degree AV block, CDK stage 4,
Preexisting Conditions: CDK stage 4, Atrial fibrillation, 1st degree AV block, Patient was under hospice care
Allergies: Aldactone, contrast dye
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident passed away in her sleep
VAERS ID: 928933 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2020-12-23
Onset: 2021-01-08
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Resuscitation
SMQs:

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had been diagnosed with COVID-19 on Dec. 11th, 2020. Symptoms were thought to have started on 12/5/2020. Received Moderna vaccine on 12/23. Unexpected death on 1/8/2021. Resuscitation attempts unsuccessful
VAERS ID: 929359 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-06
Onset: 2021-01-06
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Breath sounds abnormal, Death, Oxygen saturation decreased
SMQs:, Acute central respiratory depression (narrow), Respiratory failure (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   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: none
Current Illness: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism
Preexisting Conditions: Cerebral Atherosclerosis, malnutrition, thrombocytopenia, cva, hypothyroidism
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: 3:07 pm lung sounds diminished oxygen sats 68%, oxygen applied Oxygen sats remained low for next 36 hours ( patient on Hospice care ) expired 6:22 am 1-8-21
VAERS ID: 929764 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Washington  
Vaccinated: 2020-12-28
Onset: 2020-12-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: Hydrochlorthiazide (by record, not confirmed)
Current Illness:
Preexisting Conditions: Hypertension, sleep apnea, obesity. based on medical record
Allergies: no known allergies recorded in medical record
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient was found deceased at home about 24 hours after immunization. Date of Death:: 12/29/2020; estimated time of death 6:00pm
VAERS ID: 929997 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-04
Onset: 2021-01-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysphagia, Feeding disorder, Lethargy, Mobility decreased, Speech disorder
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-07
   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: Amlodipine 5 mg daily, Dexamethasone 4 mg daily (for itching related to renal failure), Isosorbide dinitrate 30 mg daily, Levothyroxine 0.075 mg daily, Bisoprolol 5 mg BID, Furosemide 80 mg BID, saline nasal spray, Tylenol 1000 mg PO TID
Current Illness: none acute
Preexisting Conditions: He was on hospice for about the last 1 month for CHF (EF 20-25%) and renal failure (creat 3-4). He was on hospice but was up and around and able to eat and take pills. The day after he had his injection, he was very lethargic and only mumbled. Was not able to take meds or eat. He was on hospice, so did not want work-up or treatment. He passed away on 1/7 am. We don''t know if it was a coincidence that he died or if the vaccine caused him to deteriorate more quickly.
Allergies: Losartan, lisinopril, metoprolol
Diagnostic Lab Data: He did not have testing at that point because he was on Hospice.
CDC Split Type:

Write-up: Patient received vaccine on 1/4/2021. He was in Hospice for CHF and renal failure, but was able to get up in his wheelchair and eat and take medications and talk. On 1/5/2021 am, he was noted to be very lethargic an could only mumble, could not swallow. No localizing neurologic findings. He was too lethargic to get up in chair.
VAERS ID: 930154 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-05
Onset: 2021-01-08
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K2020A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

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: unknown
Current Illness: unkown
Preexisting Conditions: unknown
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type: VFC # 21109

Write-up: Notified today that he passed away. No other details known at this time.
VAERS ID: 930431 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Connecticut  
Vaccinated: 2021-01-06
Onset: 2021-01-08
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac disorder, Death
SMQs:

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: Enteric Coded Aspirin, Atenolol, Centrum Silver, Citrical, Levothyroxin, Lisinipril, Phillips Colon Health Caps, Vitamin D
Current Illness: none
Preexisting Conditions: Aortic Stenosis, Status post Tavr procedure, Hypothyroidism, Hypertension, Thoracogenic Scoliosis, Polymyalgia Rheumatica, Heart Valve Replacement, Hyperparathyroidism
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Cardiac event, 2 days after vaccination, patient expired.
VAERS ID: 930466 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Dyspnoea, Myocardial infarction, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (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: 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
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever, shortness of breath and chest pain that resulted in a heart attack a few hours after vaccination
VAERS ID: 930487 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-08
Onset: 2021-01-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

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: calcium-D tablet, cholecalciferol, fish oil, melatonin, tylenol,
Current Illness: na
Preexisting Conditions: bph, apraxia, , dysphagia, muscle weakness, alzheimers disease
Allergies: cephalexin
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Medical docter state patient has a acute cardiac attack
VAERS ID: 930876 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-07
Onset: 2021-01-08
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, X-ray with contrast
SMQs:

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:
Current Illness:
Preexisting Conditions: Prostate Cancer
Allergies:
Diagnostic Lab Data: Had IV dye imaging procedure after he received the COVID-19 vaccine (the same day in the afternoon) and passed away overnight.
CDC Split Type:

Write-up: Death
VAERS ID: 958443 (history)  
Form: Version 2.0  
Age: 1.08  
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-24
Onset: 2020-12-26
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Completed suicide, Death, Gun shot wound
SMQs:, Suicide/self-injury (narrow), Accidents and injuries (narrow), Hostility/aggression (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-26
   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 by suicide Narrative: death by suicide; 12/26/20, self inflicted gun shot wound; found deceased by family member
VAERS ID: 930910 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Hawaii  
Vaccinated: 2021-01-08
Onset: 2021-01-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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: Patient was refusing to take all medications for over a year
Current Illness: None
Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation
Allergies: Metformin, morphine, statins, latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm.
VAERS ID: 930912 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-07
Onset: 2021-01-08
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Diarrhoea
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2001-01-08
   Days after onset: 7305
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: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diarrhea followed by death 24 hrs after vaccination
VAERS ID: 951518 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Wyoming  
Vaccinated: 2020-12-28
Onset: 2021-01-04
   Days after vaccination: 7
Submitted: 2021-01-05
   Days after onset: 1
Entered: 2021-01-09
   Days after submission: 4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death, SARS-CoV-2 test negative, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (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: Specimen: NASOPHARYNX. Specimen Collection Date: Dec 29, 2020@09:45 Test name Result units Ref. range Site Code COVID-19 (M2000) Not Detected
CDC Split Type:

Write-up: Narrative: Patient with severe aphasia and only able to say "hey, hey, hey" or "uh huh" or shake his head no as a way to communicate. Patient previously able to ambulate with significant limp and hyperextension of right knee, but mostly wheelchair bound over last several years as he had had a slow and steady decline in overall health and mobility. Patient developed aggressive behavior of shouting "hey" and grabbing of groin in 2016. This was worked up with CT scans, labs, referral to urology, neurology, and referrals to psychiatry. The exact etiology of this action was never able to be affirmed, but thought to be more psychiatrically related. It improved significantly with addition of antipsychotics, worsened when antipsychotics were reduced, and improved again with addition of injectable antipsychotic on 12-10-2020.Patient suffered from falls on occasion given his significantly impaired physical mobility. His last documented fall was 8-31-2019. Patient began utilizing wheelchair most of time following that fall. No significant injuries noted in documentation of the falls. In the last 3 months, patient would often refuse medications. He would sometimes indicate that they would cause dizziness, and other times he would simply refuse. We attempted to hide medications in his food/fluid (with wife''s blessing) and when he detected this he would occasionally refuse to eat. Patient previously on DOAC. After pharmacy review in 12/2020 it was recommended to discontinue this as no clear indication to continue use. He was high fall risk and would often refuse this medication as well since 10/2020. Noted to be in NSR on EKGs and decision made to discontinue the DOAC. Patient had no evidence of adverse effects noted after vaccination on December 28th. Patient seen by provider on the morning of his death (1/4/2021) with no noticeable significant change in health condition. Temperature 36.8Con January 4th at 19:45. During routine bedtime cares, patient suddenly collapsed and death was pronounced January 4, 2021 at 20:05. Autopsy was requested from next of kin and no autopsy was granted. Symptoms: & DEATH Treatment:
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)

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.
VAERS ID: 933578 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-08
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       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: metform, atorvastin
Current Illness: Diabetes, Hypertension, Sleep Apnea, Obese
Preexisting Conditions: Hx smoking
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pronounced dead 1/9/2021 at 12:42. Received first dose of vaccine 1/8/2021
VAERS ID: 933739 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-08
Onset: 2021-01-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Brain death, Bronchial secretion retention, Cardio-respiratory arrest, Death, Dyspnoea, Electroencephalogram abnormal, Intensive care, Mechanical ventilation, Resuscitation, SARS-CoV-2 test negative, Withdrawal of life support
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: Aspirin, Diazepam, Doxepin HCL, Duloxetine, Juven POW, Lamotri Levothyroxin, Loratadine, Melatonin, Mucus Relief, Olanzapine, Prazosin HCL, Pregabalin,
Current Illness: Recent g-tube placement, Several hospitalizations over the pas few months due to low Oxygen Levels.
Preexisting Conditions: Major depression, borderline personality disorder, Cerebral Palsy, History of dissected left carotid artery
Allergies: Penicillin
Diagnostic Lab Data: COVID-19 test administered - 1/9/2021 - Negative 2 EEGs were performed on 1/9/2021 and both indicated she had not brain activity
CDC Split Type:

Write-up: Staff member checked on her at 3am and patient stated that she felt like she couldn''t breathe. 911 was called and taken to the hospital. While in the ambulance, patient coded. Patient was given CPR and "brought back". Once at the hospital, patient was placed on a ventilator and efforts were made to contact the guardian for end of life decisions. Two EEGs were given to determine that patient had no brain activity. Guardian, made the decision to end all life saving measures. Patient was taken off the ventilator on 1/9/2021 and passed away at 1:30am on 1/10/2021. The initial indication from the ICU doctor was the patient had a mucus plug that she couldn''t clear.
VAERS ID: 933846 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: West Virginia  
Vaccinated: 2021-01-02
Onset: 2021-01-02
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 077L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Back pain, Cardiac disorder, Death, Dizziness, Pain in extremity
SMQs:, Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   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: NONE
Current Illness: MACULAR DEGENERATION 10 YEARS OR MORE
Preexisting Conditions: NONE
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1-2-2021 10:30 PM Complained Right arm/back hurt - took Tylenol 1-3-2021 Complained Right arm hurt, dizzy 1-4-2021 Felt better - did laundry, daughter found her deceased at 3:30 pm. Dr. at hospital said it was "cardiac event" according to death certificate.
VAERS ID: 934050 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2021-01-07
Onset: 2021-01-08
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Fall, Posture abnormal, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), 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: Patient was a resident in Group Home Current Medications Treatments/PRN Medications: Start Date: 04/02/14: Benztropine 2mg tab BID (8-8) 02/27/15: Midodrine (Proamatine) 5mg tab TID (8-12-8) 12/30/15: Cetirizine 10mg tab daily @8am 1
Current Illness: No Acute Illnesses
Preexisting Conditions: Diagnosis: - Impulse Control Disorder - Epilepsy - Tardive Dyskinesia - Ulcerative Proctitis and Colitis - Mental Retardation (mod) - Hammer toes (bilat.) - Dermatitis (scalp/torso) - Seborrheic keratosis of left armpit - Major Depression - Infantile Meningitis - History of Squamous Cell Carcinoma (L arm)
Allergies: Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Staff reported that patient was found Friday morning (Jan 8) sitting at a table with his head tilted forward and unresponsive to verbal or physical stimuli. Staff lowered patient to floor and started CPR. EMS was called and continued CPR at scene, however they were not able to revive patient. Patient was pronounced dead at the scene. Staff written statements following the death of patient show that he had a fall about 1 hr. prior. It is unknown if this fall contributed to patient''s death. An autopsy has been requested.
VAERS ID: 934059 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-01-08
Onset: 2021-01-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute myocardial infarction, Death
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: tramadol, calcium, Tylenol, lisinopril, Mucinex, MVI, namenda
Current Illness: Had Covid 19 infection in November recovered, had spinal stenosis with leg weakness chronic
Preexisting Conditions:
Allergies: anastrozole
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute anterior MI with death
VAERS ID: 934263 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: New Mexico  
Vaccinated: 2020-12-30
Onset: 2021-01-01
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Malaise, 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: 2021-01-02
   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: Again, I cannot confirm the results of any test, i.e., COVID or other, because the patient is independent and sought care independent of the center.
CDC Split Type:

Write-up: The resident resides in an independent living facility/apartment. The reporter at the center was informed by his daughter he was not feeling well on 1/1/2021 (specific symptoms could not be ascertained). He reportedly went to be COVID tested on 1/1/2020 and observed to be deceased in his apartment on 1/2/2020. I do not have confirmation of his COVID results, although the reporter indicates his daughter reports his test was positive.
VAERS ID: 934373 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: West Virginia  
Vaccinated: 2021-01-09
Onset: 2021-01-10
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Pulse absent, Resuscitation
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
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: Husband only knew that she took several medications.
Current Illness: Newly diagnosed heart murmur the week prior by PCP. Was referred to her cardiologist.
Preexisting Conditions: She did have open heart surgery in 2013. She last saw her cardiologist 4 months ago, and she did a phone consult with him a week or so ago.
Allergies: PCN & Sulfa drugs
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient went to bed around 11pm on Saturday PM and sometime between then and 1:30am on Sunday morning got up and went into the living room without waking up her husband (which is normal). At 1:30am, the husband got up to use the restroom and she was out of bed then, but the husband did not know if she was having any problems at this time. When he got up at 7:45am, she was in the recliner and did not move or anything, which is normal for her. At 8:45am, the husband went back into the living room and tried to wake his wife and that is when he noticed there was no pulse and he called 9-1-1 at this time. EMS got on scene and did CPR for 30 mins and she was pronounced dead at 9:21am.
VAERS ID: 934507 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-03
Onset: 2021-01-05
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (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: Coumadin 2mg po Sat-Mon-Tues-Thurs Coumadin 1mg po Fri Sun APAP 650 mg po PRN pain or temp above 101 Amiodarone 200mg po daily Ativan 0.5mg po PRN anxiety Claritin 10mg po daily Gabapentin 100mg po BID PRN phantom pain Miralax 17Gm po with
Current Illness: No other illness prior to vaccination or within the month prior
Preexisting Conditions: Covid 19 Recovered spring 2020 Chronic stage 5 kidney disease with dialysis 3 times weekly Chronic diastolic congestive heart failure Chronic A-fib Diabetes Mellitus with other circulatory complications Hypertension Right and Left Below the knee amputations
Allergies: KNDA KNFA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident died suddenly and expectantly on 01/05/2021
VAERS ID: 934539 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-08
Onset: 2021-01-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA D12L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Blood test, Culture tissue specimen, Death, Toxicologic test, 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: 2021-01-09
   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: Singulair, Oxybutynin, Fosamax, Prednisone, Meloxicam, Eliquis, Bumetanide, Triamcinolone cream, Klor-Con, Lisinopril, Promethazine,
Current Illness: Cellulitis of left lower limb (12/2020)
Preexisting Conditions: Hypertension
Allergies: No known allergies
Diagnostic Lab Data: Postmortem examination was performed at the State Medical Examiner Office on January 10, 2021 (MEC21-0019). Tissue samples were obtained for histology and red top/tiger top/purple top tubes of blood were obtained for potential further studies. Samples of blood and vitreous humor were also obtained and submitted to AXIS Laboratories for toxicologic analysis.
CDC Split Type:

Write-up: Patient received COVID-19 (Moderna) vaccine from the Health Department on afternoon of January 8, 2021 and went to sleep approximately 2300 that night. Was found unresponsive in bed the following morning and pronounced dead at 1336 on January 9, 2021
VAERS ID: 934745 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-01-09
Onset: 2021-01-10
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Heart rate increased, Musculoskeletal stiffness, Oxygen saturation decreased, Peripheral coldness, Presyncope, Pulse absent, Respiratory rate increased, Seizure like phenomena, Skin discolouration, Skin warm, Thrombosis, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Dystonia (broad), Parkinson-like events (broad), Thrombophlebitis (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: Exelon 13.3 mg daily, APAP 500 mg three times a day, Namenda 10 mg two times a day, Senna 8.6 mg two tablets daily, Mirilax 27 grams two times a day, 2 cal 4oz three times a day, Amlodipine 5 mg daily
Current Illness: NA
Preexisting Conditions: Alzheimers, dementia, hypertension,
Allergies: NKA
Diagnostic Lab Data: Family requested comfort cares. No tests provided.
CDC Split Type:

Write-up: Resident had seizure like activity followed by a vagel response with large bowel movement. Resident then began to show signs of blood clot to left lower extremity. No pedal pulse, area on leg warm to touch. Left lower leg now cold to touch, stiff, purple and white in color. No other signs of modeling, body warm to touch, no fever noted. Respirations and pulse increased with low oxygen levels. Resident not responding to stimuli.
VAERS ID: 934966 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated: 2021-01-02
Onset: 2021-01-04
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia, Pyrexia, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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: Medical History/Concurrent Conditions: Alzheimer''s disease
Allergies:
Diagnostic Lab Data: Test Date: 20201225; Test Name: COVID-19; Test Result: Negative ; Test Date: 20210104; Test Name: COVID-19; Test Result: Positive
CDC Split Type: USPFIZER INC2021011125

Write-up: COVID-19; COVID-19; Pneumonia; respiratory failure; This is a spontaneous report from a contactable consumer. An 80-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 02Jan2021 for COVID-19 immunization. Medical history included Alzheimer''s and others. No known allergies. Concomitant medications included unspecified medications. The reporter''s mother in law was tested for COVID-19 at a nursing facility on 25Dec2020 and she was negative. On 02Jan2021, she received the first dose of Pfizer vaccine. On 04Jan2020, she developed a high fever, needed oxygen and was positive for COVID-19. Date of death was 04Jan2021. The cause of her death was listed as pneumonia, respiratory failure and COVID-19. No autopsy performed. No treatment received. No one knew if the vaccination contributed to her death. It was hard to know if her death was due to the administration of the vaccine or it exacerbated the COVID19 symptoms which led to her death. Since this was unknown, it could have been a possibility. The reporter wanted to give us this information because we might want to consider having high risk population, patients with underlying conditions, older population tested for COVID-19 prior to the vaccination, as this is not currently a recommendation or a requirement. All is very new and they are all learning so the reporter wanted to share this information with us. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. There are medications the patient received within 2 weeks of vaccination. Prior to vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient has been tested for COVID-19. The outcome of the events was fatal. Information about Lot/Batch has been requested.; Sender''s Comments: The association between the fatal event lack of effect (pneumonia, respiratory failure and COVID-19) with BNT162b2 can not be fully excluded. 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: Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19; Pneumonia, respiratory failure and COVID-19
VAERS ID: 934968 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-04
Onset: 2021-01-04
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Agitation, Death, Decreased appetite, Dehydration, Dyspnoea, Malaise, Pallor, Restlessness, Tachyphrenia, Unresponsive to stimuli, Vaccination complication, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: ; ; ;
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure high; Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021011383

Write-up: he passed away; not responsive; mind just seemed like it was racing; body was hyper dried; Restless; not feeling well; ate a bit but not much; kind of pale; Agitated; Vomiting; trouble in breathing; This is a spontaneous report from a contactable consumer (brother of the patient). A 54-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration, on 04Jan2021 (at the age of 54-years-old) as a single dose for COVID-19 immunization. Medical history included diabetes and high blood pressure. Concomitant medications included metformin (MANUFACTURER UNKNOWN) taken for diabetes, glimepiride (MANUFACTURER UNKNOWN) taken for diabetes, lisinopril (MANUFACTURER UNKNOWN), and amlodipine (MANUFACTURER UNKNOWN). The patient experienced not feeling well, ate a bit but not much, kind of pale, vomiting, trouble in breathing, and agitated on 04Jan2021; body was hyper dried and restless on 05Jan2021; mind just seemed like it was racing on 06Jan2021; and not responsive and he passed away on 06Jan2021 at 10:15 (reported as: around 10:15 AM). The clinical course was reported as follows: The patient received the vaccine on 04Jan2021, after which he started not feeling well. He went right home and went to bed. He woke up and ate a bit but not much and then was kind of pale. The patient then started to vomit, which continued throughout the night. He was having trouble in breathing. Emergency services were called, and they took his vitals and said that everything was okay, but he was very agitated; reported as not like this prior to the vaccine. The patient was taken to urgent care where they gave him an unspecified steroid shot and unspecified medication for vomiting. The patient was told he was probably having a reaction to the vaccine, but he was just dried up. The patient continued to vomit throughout the day and then he was very agitated again and would fall asleep for may be 15-20 minutes. When the patient woke up, he was very restless (reported as: his body was just amped up and could not calm down). The patient calmed down just a little bit in the evening. When the patient was awoken at 6:00 AM in the morning, he was still agitated. The patient stated that he couldn''t breathe, and his mind was racing. The patient''s other brother went to him and he was not responsive, and he passed away on 06Jan2021 around 10:15 AM. It was reported that none of the symptoms occurred until the patient received the vaccine. Therapeutic measures were taken as a result of vomiting as aforementioned. The clinical outcome of all of the events was unknown; not responsive was not recovered, the patient died on 06Jan2021. The cause of death was unknown (reported as: not known by reporter). An autopsy was not performed. The batch/lot number for the vaccine, BNT162B2, was not provided and has been requested during follow up.; Reported Cause(s) of Death: not responsive and he passed away
VAERS ID: 935222 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-30
Onset: 2021-01-07
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Private       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: Oxybutynin Chloride, Lasix 80mg, hydyralazine 50mg, amlodipine 10mg, amitriptyline 10mg, ASA, Klor-Con 20meq, Tylenol, allopurinol 100mg, Vit D3, turmeric 400mg, Lipitor 80mg, gabapentin 100mg, baclofen 5mg, candesartan 32mg, insulin lispro
Current Illness: No acute illnesses
Preexisting Conditions: Diabetes, CKD, CHF, HTN
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was reported to be deceased at home by law enforcement on 1/7/21
VAERS ID: 935343 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kansas  
Vaccinated: 2021-01-08
Onset: 2021-01-11
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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:
Preexisting Conditions: This resident had covid a couple months ago. she had a bad heart and also dementia. I do not believe it was the vaccine that killed her. I was instructed by EMS to report because the date of vaccination was three days ago.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: There were no adverse reactions. Resident Died, she had a history of issues with her health prior to the vaccine.
VAERS ID: 935350 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Texas  
Vaccinated: 2020-12-31
Onset: 2021-01-02
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: 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: 2021-01-06
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021
VAERS ID: 935511 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: South Dakota  
Vaccinated: 2021-01-08
Onset: 2021-01-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MODERNA / 1 LA / IM

Administered by: Private       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: unknown
Current Illness: none known of
Preexisting Conditions: history of vaginal adenocarcinoma- removed with surgery in 2019
Allergies: latex (skin reaction)
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received the 1st dose of Moderna and was found deceased in her home the next day.
VAERS ID: 935767 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-10
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
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: IDK
Current Illness: Pneumomia
Preexisting Conditions: Dementia
Allergies: IDK
Diagnostic Lab Data: She had tested NEGATIVE for Covid per Doc Win he told us on Sunday.
CDC Split Type:

Write-up: My mother was given Pfizer vaccine on Thursday and she died 3 days later yesterday on Sunday!!!
VAERS ID: 935815 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK - / -

Administered by: Senior Living       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: 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: Difficulty breathing, death.
VAERS ID: 936043 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-04
Onset: 2021-01-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: 2021-01-05
   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: atorvastatin,senna,MultiVitamin,Metamucil,metformin,Levothyroxine
Current Illness: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Preexisting Conditions: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Allergies: PENICILLINS
Diagnostic Lab Data:
CDC Split Type:

Write-up: RESIDENT 1ST DOSE OF MODERNA VACCINE ADMINISTERED ON 01/04/2021 AT 8:30PM, RESIDENT FOUND UNRESPONSIVE ON 01/05/2021.
VAERS ID: 936738 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-06
Onset: 2021-01-09
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Adenovirus test, Blood pressure immeasurable, Bordetella test negative, Chlamydia test negative, Death, Enterovirus test negative, Human metapneumovirus test, Human rhinovirus test, Hypopnoea, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Intensive care, Loss of consciousness, Mycoplasma test negative, Polymerase chain reaction, Radial pulse abnormal, Respiratory syncytial virus test negative, SARS-CoV-2 test negative, Staphylococcus test negative, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad), COVID-19 (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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: RSV, Bordetella Parapertussis, Bordetella Pertussis, Chlamydia pneumoniae, mycoplasma pneumoniae, Coronavirus, Adenovirus, Human metapneumovirus, human rhino/entero virus, influenza A/B, parainfluenza PCRs negative (NOT DETECTED) per 12/27/20 results COVID-19 PCR, Influenza A/B, and RSV PCRs negative (NOT DETECTED) per 1/4/21 results MRSA SURVL NARES DNA negative (NOT DETECTED) per 12/27/20, 12/28/20, & 1/5/21 results
CDC Split Type:

Write-up: loss of consciousness Narrative: Patient received COVID-19 vaccine dose #1 on 1/6/21 w/o complications. Per 1/6/21- 1/9/21 nursing notes, patient did not experience any injection site reactions, denied pain or tenderness at injection site, no dizziness, no n/v, remained afebrile. Around 1/9/21 @1810, patient became acutely nonresponsive after being helped to the edge of bed. Per nurses, he was previously awake/alert, talking and asymptomatic. Patient is DNR/DNI but facility rapid response emergency team called d/t patient''s sudden change of condition. Emergency team helped patient into lying position. Per 1/9/21 ICU emergency team note, patient appeared comfortable w/ no palpable radial pulse and had minimal shallow agonal breathing. Pulse ox 94%, HR in 60s per machine. BP unmeasurably low by BP cuffx3. Resident passed at 18:20 pm.
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: 938097 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021017780

Write-up: died; This is a spontaneous report from a non-contactable consumer via a Pfizer-sponsored program. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, via an unspecified route of administration on an unspecified date at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. It was reported the patient was a doctor, died after the vaccine with no apparent disease. It was not reported if an autopsy was performed. No follow-up attempts are possible. Information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 938118 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-05
Onset: 2021-01-08
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Abdominal X-ray, Aneurysm, Angiogram cerebral, Arteriogram carotid, Cerebellar haemorrhage, Cerebrovascular accident, Chest X-ray, Computerised tomogram abdomen, Computerised tomogram head, Computerised tomogram pelvis, Computerised tomogram spine, Computerised tomogram thorax
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), 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? Yes
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? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: multivitamin; vitamin D
Current Illness: none mentioned
Preexisting Conditions: no significant past medical history
Allergies: latex
Diagnostic Lab Data: CT brain head; CT cervical spine; chest xray; CT chest, abdomen, pelvis; abdominal xray; CT angiogram neck & brain
CDC Split Type:

Write-up: on 1/8/2021 17:30 patient taken to ER, cerebellar hemorrhage, stroke, aneurysm
VAERS ID: 938974 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-06
Onset: 2021-01-11
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Diarrhoea, Haematemesis, Haematochezia, Haemoglobin decreased, Vomiting
SMQs:, Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Noninfectious diarrhoea (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: Hospice
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data: Labs contacted facility with critical lab, Hemoglobin 4.8, at 9:45am after resident passed
CDC Split Type:

Write-up: Hospice Resident received first Covid 19 vaccine dose on 1/6/21. 1/7/21 resident had decreased appetite noted in am but ate 100% of meal at dinner. 1/9/21 resident had decreased appetite with emesis x 2, loose BM x 2. Call placed to hospice. 1/10/21 5:44 am resident able to take HS meds, ingest 2 cups of shake. No emesis or loose stool noted. 12PM nurse noted resident not eating meals but ingesting milkshake and medications without any problems. Hospice contacted for change in condition. 1:00 pm hospice ordered Phenergan 12.5 mg Q 6 hrs PRN. Labs to be drawn 1/11/21. Hospice notified POA. 1/11/21 12:24am Resident had blood in stool. Resident denies any pain, on 2L of O2 for comfort.
VAERS ID: 939050 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: New York  
Vaccinated: 2020-12-28
Onset: 2020-12-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aphasia, Cough, Death, Endotracheal intubation, Hemiparesis, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (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), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-04
   Days after onset: 6
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: Morbid obesity and hypothyroidism
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient vaccinated on 12/28. Approximately one day later, develops cough and on azithromycin x 1 week. On 1/3, patient develops left-sided weakness and aphasia. Taken to the hospital, tested COVID+, required intubation -- acute hypoxic respiratory failure secondary to COVID - on H&P. Patient died on 1/4/21 at 7:20am.
VAERS ID: 939270 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Hawaii  
Vaccinated: 2020-12-22
Onset: 2020-12-31
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 - / IM

Administered by: Work       Purchased by: ?
Symptoms: Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   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: Sudden cardiac death
VAERS ID: 963163 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-06
Onset: 2021-01-08
   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: 2021-01-08
   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: Narrative:
VAERS ID: 939845 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-11
Onset: 2021-01-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Oxygen saturation decreased
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), Infective pneumonia (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:
Current Illness:
Preexisting Conditions: CHF
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Three hours after receiving COVID 19 vaccination, Patient oxygen level decreased to a critical level and went into cardiac arrest. Staff performed full code but was unable to bring back patient from cardiac arrest.
VAERS ID: 940602 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-08
Onset: 2021-01-10
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K209 / 5 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Injection site pain, Myocardial infarction, Pain, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (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: see attached
Current Illness: None reported
Preexisting Conditions: HTN, Type II DM, High cholesterol
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 1/8/2021. On 1/9/2021 I checked on patient via phone for symptoms or problems and he reported none but mild soreness at injection site. On 1/10/2021 family friend called me to tell me that patient had expired at about 8:00 pm. Patient reportedly complained of "pain" unspecific and collapsed at home. Hospital reportedly told family that it appeared to be a "heart attack".
VAERS ID: 940822 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-07
Onset: 2021-01-08
   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 EK9231 / UNK RA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: None
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021015752

Write-up: patient passed away after receiving the Covid vaccine; This is a spontaneous report from a contactable nurse. An 81-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE), intramuscular into the right arm on 07Jan2021 at 0.3 mL, single for covid-19 immunization. There was no medical history and no concomitant medications. On 08Jan2021, the patient passed away after receiving the COVID vaccine. The patient died on 08Jan2021. An autopsy was not performed. Investigations indicate that unspecified labs were done, but nothing two weeks prior; no further details were provided. The patient received the first dose the day prior. The reporting nurse discussed it with the medical director, and he thought that he potentially passed away from the COVID vaccine. The relatedness of the event to the suspect vaccine was reported as related by the reporting nurse per The Agency. The batch/lot number for the vaccine, BNT162B2, was not provided and will be requested during follow-up .; Sender''s Comments: Based on the limited information available, it is medically not possible to make meaningful causality assessment, it is unlikely the vaccine could have contributed to the death of the patient based on the known safety profile. However case will be reevaluated when additional information is received during the follow-up 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: Stated that the patient passed away after receiving the Covid vaccine
VAERS ID: 940855 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-12
Onset: 2021-01-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LORazepam Solution 2 MG/ML
Current Illness: Resident was a hospice patient but POA requested that she get the vaccination. Resident was already near end of life and the vaccine may not have had anything to do with her death.
Preexisting Conditions: Resident on hospice care due to end of life.
Allergies: None
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her vaccination on 1/12/21 administered by pharmacy*+. She expired on 1/12/21 an approximately 7:30pm. Resident did not have any adverse reactions and was a hospice patient.
VAERS ID: 940866 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: South Carolina  
Vaccinated: 2021-01-07
Onset: 2021-01-09
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Cardiac arrest, Cardio-respiratory arrest, Death, Pulse absent, Resuscitation
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), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Respiratory failure (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr
Current Illness: None
Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia
Allergies: Loxapine, Thioridazine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest.
VAERS ID: 940955 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-11
Onset: 2021-01-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Death, Pulse absent, Respiratory arrest, SARS-CoV-2 test negative
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), COVID-19 (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: ; ; EFFEXOR; ; ABILIFY; ; CRANBERRY; ; TYLENOL; ; LASIX [FUROSEMIDE]; IPRATROPIUM/ALBUTEROL; ; SENNA [SENNA ALEXANDRINA LEAF]; POLYETHYLENE GLYCOL 3350;
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (Prior to vaccination, the patient was diagnosed with COVID-19); Diastolic heart failure; Epilepsy; Morbid obesity; Pulmonary hypertension; Spinal stenosis
Allergies:
Diagnostic Lab Data: Test Date: 20210111; Test Name: pulseless; Result Unstructured Data: Test Result:pulseless; Test Date: 20210111; Test Name: breathless; Result Unstructured Data: Test Result:breathless; Test Date: 20210106; Test Name: Covid-19 PCR; Result Unstructured Data: Test Result:Negative (Nasal Swab)
CDC Split Type: USPFIZER INC2021018488

Write-up: Cardiac Arrest; Patient was found pulseless and breathless 20 minutes following the vaccine administration.; Patient was found pulseless and breathless 20 minutes following the vaccine administration.; This is a spontaneous report from a contactable other healthcare professional (HCP). A 66-year-old female patient (pregnant at the time of vaccination: no) received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL1284) via intramuscular at left arm on 11Jan2021 12:15 PM at single dose for COVID-19 immunization. Medical history included diastolic CHF, spinal stenosis, morbid obesity, epilepsy, pulmonary hypertension and COVID-19 (Prior to vaccination, the patient was diagnosed with COVID-19). The patient received medication within 2 weeks of vaccination included amiodarone, melatonin, venlafaxine hydrochloride (EFFEXOR), ibuprofen, aripiprazole (ABILIFY), lisinopril, cranberry capsules, diltiazem, paracetamol (TYLENOL), famotidine, furosemide (LASIX [FUROSEMIDE]), ipratropium bromide, salbutamol sulfate (IPRATROPIUM/ALBUTEROL), buspirone, senna alexandrina leaf (SENNA [SENNA ALEXANDRINA LEAF]), polyethylene glycol 3350 and morphine. The patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine. Patient used took Penicillin, propranolol, quetiapine, topiramate, Lamictal and had allergy to them. Patient used took the first dose of BNT162B2 (lot number: EJ1685) via intramuscular at right arm on 21Dec2020 12:00 PM at single dose for COVID-19 immunization. Since the vaccination, the patient been tested for COVID-19 (Sars-cov-2 PCR) via nasal swab on 06Jan2021, covid test result was negative. Patient was found pulseless and breathless 20 minutes following the vaccine administration (11Jan2021 12:30 AM). MD found no signs of anaphylaxis. Patient died on 11Jan2021 12:30 AM because of cardiac arrest. No treatment received for the events. Outcome of pulseless and breathless was unknown. the autopsy was performed, and autopsy remarks was unknown. Autopsy-determined cause of death was unknown. It was reported as non-serious, not results in death, Life threatening, caused/prolonged hospitalization, disabling/Incapacitating nor congenital anomaly/birth defect.; Sender''s Comments: Based on the available information this patient had multiple underlying medical conditions including morbid obesity, diastolic CHF, epilepsy, pulmonary hypertension and COVID-19 diagnosed prior to vaccination. All these conditions more likely contributed to patients cardiac arrest resulting in death. However, based on a close temporal association ("Patient was found pulseless and breathless 20 minutes following the second dose of BNT162B2 vaccine administration, contributory role of BNT162B2 vaccine to the onset of reported events cannot be completely excluded. 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: Cardiac arrest; Autopsy-determined Cause(s) of Death: autopsy remarks was unknown. Autopsy-determined cause of death was unknown
VAERS ID: 941215 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-06
Onset: 2021-01-08
   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 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: 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: 2021-01-08
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Aortic valve replacement (Verbatim: Aortic valve replacement)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021018269

Write-up: Actual event and cause of death were unknown; This is a spontaneous report from a non-contactable consumer. A 90-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 06Jan2021 at single dose for COVID Prevention. The relevant medical history included aortic valve replacement from Nov2019. Concomitant medications were not reported. The consumer stated that she was taking the reporting responsibilities to report that a friend of hers, informed that the patient passed away on Friday, and had received the COVID vaccine on Wednesday. The consumer stated that it was unknown to her at this time, if the friend had called to complete a report herself, regarding the incident. Their conversation was very brief. The patient was 90 years old, and it was her friend''s mother that was the patient. Actual event and cause of death were unknown. The patient had her vaccine on Wednesday 06Jan2021, and then the patient collapsed in front of the reporter at Friday night on 08Jan2021 and passed away that same day. The autopsy was unknown. The outcome of the event was fatal. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Actual event and cause of death were unknown
VAERS ID: 941561 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-07
Onset: 2021-01-08
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Decreased appetite, Grip strength decreased, Hemiplegia, Hypotonia, Speech disorder, Weight decreased
SMQs:, Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   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: Escitalopram Oxalate, Metformin ER, Systane balance, Colace, Refresh tears, Milk of Magnesia, Diltiazem
Current Illness: Resident was on hospice for Alzheimer''s disease.
Preexisting Conditions: Alzheimer''s Disease, Type II diabetes, Major depression disorder, Elevated B/P readings with Hypertension, history of stroke (7/22/2019 - Acute Lacunar Stroke)
Allergies: No known Allergies
Diagnostic Lab Data: Resident was declining for some time. He normally had a high heart rate. Appetite was poor with a significant weight loss noted.
CDC Split Type:

Write-up: Staff walked into resident''s room around 10:00am and noted resident''s left side of his face was flaccid. Nurse was called and upon assessment resident noted to have an unequal hand grasp with left worse. He was able to talk but was mumbled and hard to understand. Physician, hospice, and family were notified. Resident had a stroke at 10:06 am on 1/8/2020. He lost all ability to use his left side. Resident passed away on 1/11/2020.
VAERS ID: 941607 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Indiana  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anal incontinence, Death, Hypotonia, Unresponsive to stimuli
SMQs:, Peripheral neuropathy (broad), 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), Generalised convulsive seizures following immunisation (broad), Noninfectious diarrhoea (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: Tylenol 325mg, Lasix 20mg, Senna 8.6mg, Aspirin 81mg, Levothyroxine 75mcg
Current Illness: N/A
Preexisting Conditions: End stage dementia, cerebro vascular disease, Hx left vertebral artery aneurysm
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: The patient passed away today, 1/13/2021. She was a hospice patient. She showed no adverse effects after receiving the vaccine on 1/12/2021. This morning she woke up as normal and during her morning shower she had a bowel movement, went limp and was non-responsive. The patient passed away at 7:45 am.
VAERS ID: 941743 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

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: Amitiza, Anastrozole, Calcium Carbonate, Levemir, Novolog, Docusate, Fiber Lax, Fluvoxamine Maleate, Gavilax, Glucerna, Ketoconazole, levetiracetam, loratadine, Selenium sulfide lotion, vimpat, vitamin D3, Prolia AS needed medications: fle
Current Illness: None
Preexisting Conditions: Benign polycythemia, Type II DM, Anxiety, Epilepsy, Blepharitis (bilateral), cataract (not specified), Allergic rhinitis, constipation, scoliosis, osteoporosis, dyspahgia, urinary incontinence, Dermatitis, breast cancer (right breast lumpectomy), history of respiratory infection, DNR AND MOLST were in place at time of death
Allergies: No known drug or food allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This person was found to be deceased on routine rounds during the night, 3am. No symptoms of reaction noted post vaccine. No injection site reaction. No reports of any allergic reaction.
VAERS ID: 941811 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-01-04
Onset: 2021-01-11
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Albumin urine present, Bacterial test positive, Chest X-ray abnormal, Death, Hypoxia, Lung infiltration, Pyrexia, Respiratory distress, Respiratory failure, SARS-CoV-2 test negative, Sepsis, Urine leukocyte esterase positive, White blood cell count normal, White blood cells urine positive
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad), COVID-19 (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: Haldol 2mg TWICE DAILY, DEPAKENE 750MG THREE TIMES
Current Illness: NONE
Preexisting Conditions: HUNTINGTON''S CHOREA, HTN, HLP, HYPOTHYROID, DEPRESSION, CONSTIPATION, AND DYSPHAGIA
Allergies: NKDA & NO FOOD ALLERGIES
Diagnostic Lab Data: CXR on 1/11/21: Suspicion of minimal infrahilar infiltrates bilaterally. U/A on 1/11/21: Leuk Esterase 3+, Albumin 2+, Few Bacteria, White cells 10 CBC on 1/11/21: WBC 8.9
CDC Split Type:

Write-up: Resident began having fever on 1/11/21 @0600. VS= T-102 B/P- 100/57 P- 112 RR- 24 O2 Sat 92% on RA. MD called. Rapid COVID Test was negative. CBC,CMP, U/A were ordered as well as CXR. Resident''s condition declined. At 3:00pm resident started having respiratory distress and hypoxia O2 Sat 89%. Supplemental O2/mask @ 5LPM. Neb TX, EKG, and Rocephin 1 GM ordered. Condition worsened. Resident sent to nearest ER for evaluation. Later in the evening the staff AT Medical Center called to inform staff that resident had expired @ 2230 as a result of Respiratory Failure and Sepsis.
VAERS ID: 942040 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Iowa  
Vaccinated: 2021-01-13
Onset: 2021-01-13
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dizziness, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (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
Current Illness: none
Preexisting Conditions: yes
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: little bit of a reaction light headed after 5 minutes. vitals were low, so observed for 30 minutes after being light headed. Patient was found unresponsive and pronounced dead later that day.
VAERS ID: 942072 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Vermont  
Vaccinated: 2021-01-02
Onset: 2021-01-05
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Death, Dementia, SARS-CoV-2 test negative
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad), COVID-19 (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: Tramadol, risperidone, fluoxetine, cyanocobalamin, colchicine, torsemide, levothyroxine
Current Illness: aspiration pneumonia- completed treatment prior to vaccination.
Preexisting Conditions: Advanced dementia with severe violent behavioral symptoms. Progressive decline and frailty due to late stage dementia with likely terminal aspiration after completion of treatment for previous aspiration pneumonia. Death attributed to complications of her advanced dementia. No evidence of acute reaction to vaccine (rash, dyspnea, swelling, redness). Chronic kidney disease, hypothyroidism, type 2 diabetes, gout, B12 deficiency
Allergies: No known allergies
Diagnostic Lab Data: COVID-19 PCR neg on 12/31/20 and 1/3/21
CDC Split Type:

Write-up: Death occurred 3 days after vaccine receipt; attributed to complications of her chronic advanced dementia with aspiration at age 87. No evidence of acute vaccine reaction.
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)

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)

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)

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)

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.
VAERS ID: 944439 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-26
Onset: 2021-01-03
   Days after vaccination: 8
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: 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: Keppra, Levothyroxine, Miralax, Olanzapine, Trazadone, Risperidone, and Lorazepam
Current Illness: Receiving hospice services
Preexisting Conditions: Stage 4 kidney function
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident expired on 1/2/21.
VAERS ID: 944595 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Florida  
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 EL3302 / 2 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Brain death, Cardiac arrest, Death, Intensive care, Life support, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: losartan, spironolactone, carvedilol
Current Illness: No known new illnesses,
Preexisting Conditions: Cardiomyopathy
Allergies: nkda
Diagnostic Lab Data: mulitple Full ER code and then ICU support for 2 days
CDC Split Type:

Write-up: Cardiac arrest within 1 hour Patient had the second vaccine approximately 2 pm on Tuesday Jan 12th He works at the extended care community and was in good health that morning with no complaints. He waited 10-15 minutes at the vaccine admin site and then told them he felt fine and was ready to get back to work. He then was found unresponsive at 3 pm within an hour of the 2nd vaccine. EMS called immediately worked on him 30 minutes in field then 30 minutes at ER was able to put him on life support yet deemed Brain dead 1-14-21 and pronounced dead an hour or so later
VAERS ID: 944641 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

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: Atorvastatin 80mg daily, biotin 2500mg daily, Calcium-Mag-Zinc tab daily, Restasis eye drop q12hr, ezetimibe 10mg qhs, gabapentin 100mg bid, lysine 1000mg daily, metoprolol tart 50mg bid, fish oil 1000mg daily, prilosec 20mg daily, ranola
Current Illness: CAD, angina, coronary bypass in 1990''s, Cardiac Cath on 12/28/2020
Preexisting Conditions: CAD
Allergies: Sulfa
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient died on 1/21-2021
VAERS ID: 944732 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K2OA / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Pulse absent, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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: 2021-01-14
   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: Cholecalciferol, furosemide, metoprolol tartrate, tamsulosin, amlodipine, finasteride
Current Illness: Covid-19 infection from 12/31-01/10/2021
Preexisting Conditions: CHF, atrial fibrilation, Dysphagia, macular degeneration, Vitamin D deficiency, impaired fasting glucose, benign prostatic hyperplasia, osteoporosis, retention of urine, anemia
Allergies: hydrocodone
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Resident found unresponsive and without pulse at 05:45am.
VAERS ID: 944998 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-04
Onset: 2021-01-12
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Headache, Malaise, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: Resident in skilled nursing facility. Please contact facility if needing all medications.
Current Illness:
Preexisting Conditions: Asthma, hypothyroidism, essential hypertension, atherosclerotic heart disease of native coronary artery, spinal stenosis, fibromyalgia, dementia. Please contact nursing facility for further needed information.
Allergies: Phenazopyridine, Demerol, Pyridium, Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/11/21 noted with headache, nausea/vomiting, severe melaise. On 1/12/21 resident expired.
VAERS ID: 945241 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   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 EL1284 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Exposure to SARS-CoV-2, Resuscitation, 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), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: UNK
Current Illness: UNK
Preexisting Conditions: UNK
Allergies: UNK
Diagnostic Lab Data:
CDC Split Type:

Write-up: 71yo female resident who died after receiving Pfizer BioNTech vaccine. On 1/14/2021, VS taken at 10am, B/P 99/60, O2 sats, 95% (trach w/O2). At 11:30am, Patient showed no s/sx of distress, A&Ox3. At 11:50am, a nurse went to perform a COVID test and assessment (the facility is experiencing an outbreak), and found the patient unresponsive on the bathroom floor. CPR was immediately started; no shock advised per AED; 12:15pm EMS arrived and took over. At 12:38pm, EMT called time of death.
VAERS ID: 945247 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2020-12-29
Onset: 2021-01-05
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebrovascular accident, Chest X-ray normal, Death, Dysphagia, Hemiparesis, Urinary tract infection, Urine analysis abnormal
SMQs:, Anticholinergic syndrome (broad), 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), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: depakote, lexapro, lisinopril, multiple vitamin, senna, seroquel, tylenol
Current Illness: Nothing acute prior
Preexisting Conditions: dementia, hypertension, depression, delusions, anxiety
Allergies: aricept, namenda, penicillin, actonel, erythromycin, niacin
Diagnostic Lab Data: Urinalysis did show a UTI and CXR was negative for aspiration pneumonia. Family did not want her sent to the hospital. She died on 1/13/21
CDC Split Type:

Write-up: Has underlying dementia and often with difficulty eating. 1 week after immunization she developed a stroke with left sided weakness and difficulty swallowing. Comfort measures instituted. Not sure if this is related to the vaccine, but thought I should report
VAERS ID: 945253 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   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 EL1284 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Feeling abnormal, Nausea, Pulse absent, Respiratory arrest, Restlessness, Resuscitation, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Akathisia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: UNK
Current Illness: UNK
Preexisting Conditions: UNK
Allergies: UNK
Diagnostic Lab Data: UNK
CDC Split Type:

Write-up: 83yo female resident who died after receiving Pfizer BioNTech vaccine. On 1/14/2021, the patient reportedly got up in the middle of the night with c/o feeling "blah", restlessness, and nausea. VS normal, no other s/sx. At 4:15am, the patient was asked to go back to bed, assisted by a nurse and GNA. At 6am, GNA was going to do morning VS and found the patient unresponsive, no pulse, no respirations. GNA notified the nurse. At 6:03am, CPR started and EMS called. At 6:15am, EMS arrived and took over. At or around 6:30am, EMT called time of death
VAERS ID: 945578 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Kansas  
Vaccinated: 2021-01-02
Onset: 2021-01-10
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Hyporesponsive to stimuli, Livedo reticularis, Skin discolouration
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic 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: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg, metformin, namenda, effexor XR, donepezil, potassium chloride, Vitamin B12, Brillinta, clonzepam, flomax, ultram, oxybutynin chloride, sucralfate, ferrous sulfate, protonix, percocent, metoprolol succinate ER, senna Colace, n
Current Illness: Had a tooth extraction done on 1/6/21. Was on amoxicillin for 7 days and it caused diarrhea. Changed to Keflex.
Preexisting Conditions: Dementia, COPD, Type 2 DM, Atherosclerotic Heart Disease, Depression, Hypertensive Heart disease without heart failure GI hemorrhage, calculus of ureter, systolic CHF, Peripheral vascular disease, GERD, anxiety.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reactions immediately after vaccine was given. Resident has dementia, has had multiple hospitalizations related to a renal stone recently. Had a tooth that was bothering her, went to see her dentist and it was extracted on 1/6/21. On 1/10 they noted feet and ankles are dark purple with white splotches appears to be mottling. Minimally responsive to voice and touch. Not eating. Compassionate visit with family. Family did not want hospice, did not feel it was needed, said, what more could they do for her than you''re already doing? On 1/11 at 1950 was determined to be deceased.
VAERS ID: 945603 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2021-01-02
Onset: 2021-01-08
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0412 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac pacemaker evaluation, Cyanosis, Metabolic function test, Pulse absent
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Hypotonic-hyporesponsive episode (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: Verapamil ER, Pepcid, Norco, Vit D3, synthroid, flecainide Ace acetate, mucinex, lisinpril, amitriptyline, eliquis, atorvastatin, furosemide, acetaminophen, Coenzyme Q-10, metoprolol succinate ER
Current Illness: Hospitalized for abnormal heart rhythm 12/18/20.
Preexisting Conditions: anemia, hypothyroidism, BPH, paroxysmal atrial fib, HTN, atherosclerotic heart disease, Chronic Kidney dz stage 3, CHF
Allergies: NKA
Diagnostic Lab Data: 1/5/21 BMP drawn
CDC Split Type:

Write-up: Had no immediate issues with the vaccine. He had returned from the hospital on 12/21 and had some concerns about his weight which were shared with his physician on 1/4/21. On 1/5/21 had a visit with his cardiologist for a pacemaker check. On 1/8/21 staff were called to his room, he was on the floor, bluish skin color. No vital signs found, no heart rhythm heard at 2200.
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)

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)

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)

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
VAERS ID: 947841 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Michigan  
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 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: unknown.
CDC Split Type:

Write-up: Patient had no immediate effects from the vaccine, but died approximately 8 hours after receiving first dose of vaccine.
VAERS ID: 948150 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-08
Onset: 2021-01-09
   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 EJ1685 / 1 LL / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Blood pressure decreased, Breath sounds abnormal, Death, Dyskinesia, Fatigue, Hyperhidrosis, Incontinence, Loss of consciousness, Muscular weakness, Oxygen saturation decreased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dyskinesia (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: MANTOUX; ACIDOPHILUS; ALPHA LIPOIC ACID; ASPIRIN EC; BUMETANIDE; C-GEL; ESCITALOPRAM; PROSCAR; KRILL OIL; LEVOTHYROXINE; MAGOX; K-DUR; FLOMAX; VITAMIN B-12; VITAMIN D3; LIORESAL; CALCIUM CITRATE; COCONUT OIL; CURCUMIN; PROAMATINE; PRESERVIS
Current Illness: pneumonia,
Preexisting Conditions: A-FIB; HYPERCHOLESTEROLEMIA; CKD 3; BPH; DEPRESSION; CERVICAL DISC DISORDER; SPINAL STENOSIS; BLADDER; COPD
Allergies: ibuprofen,sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: increase weakness and fatigue, weakness in extremities, incontinent, jerky arm movements, within first 24 hours, continue to decline sent to hospital returned weaker, within 24 hrs hours BP dropped, low pulse oximeter reading, diaphoretic, lung sounds diminished, loss consciousness and passed away. 01-12-2021
VAERS ID: 948164 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-06
Onset: 2021-01-08
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 02SL20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Chest X-ray, Chest pain, Computerised tomogram, Computerised tomogram abdomen, Confusional state, Decreased appetite, Full blood count, Headache, Hepatic enzyme increased, Metabolic function test
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Multivitamin, Zinc, Doxycycline, Ultram, Xanax, Pepcid, Nitroglycerin, Tylenol, Simethicone, Metoprolol Succinate ER, Loperamide, Levothyroxine,
Current Illness: UTI and Sinus infection
Preexisting Conditions: Encephalopathy, Type 2 diabetes, Morbid obesity, hypothyroidism, CKD, HTN, iron deficiency anemia, Atrial fibrillation, IBS,
Allergies:
Diagnostic Lab Data: CT- 1/14/21, chest x-ray 1/14/21 & 1/15/21, abdomen CT 1/14/21; CBC, CMP, Liver panel 1/14/21
CDC Split Type:

Write-up: Abdominal pain, Headaches, chest pain, loss of appetite, confusion, elevated liver enzymes 1/8-1/15/21
VAERS ID: 948181 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Michigan  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Heart rate irregular
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

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: ANORA, Albuterol, Flovent, Bumex, Carvediol; omeprazole
Current Illness:
Preexisting Conditions: COPD, CHF, renal; ASCVD; MI hx
Allergies: 0
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death Chest pain; irreg heart rhythm; evening of vaccine; death on toilet on 1/13/21
VAERS ID: 948228 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   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 EL 1284 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reportedly expired the day following receipt of the vaccine.
VAERS ID: 948418 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Colorado  
Vaccinated: 2021-01-07
Onset: 2021-01-12
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / UNK LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: Received 1st Covid vaccine 12/18/2020; 2nd 1/7/2021. This patient is now deceased 1/12/2021.
Preexisting Conditions: Per patient health history: hearing loss, asthma, bronchiolitis, chronic cough, anemia, depression
Allergies: No known
Diagnostic Lab Data: Autopsy pending;
CDC Split Type:

Write-up: Expired on 1/12/2021; unknown cause of death
VAERS ID: 948428 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / SYR

Administered by: Pharmacy       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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: We got a call from a home health nurse Brandu Talamo, stating that the patient passed away.
VAERS ID: 949474 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Respiratory arrest, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: Melatonin 3mg PO QHS Amlopidine Besylate 5mg PO QD Atorvastin Calcium 20mg PO QHS Carbidopa-Levodopa 25-100mg PO TID Multiple Vitamin 1 PO QD Senna 8.6mg PO BID Calcium-Vitamin D 600mg PO BID Metformin HCl 500mg PO BID Rivastigmine patch 9
Current Illness: None but he has History of COVID-19 previously when initially admitted to the facility.
Preexisting Conditions: Parkinson''s Disease, Diabetes Mellitus Type 2, Hyperlipidemia, Dementia, ASHD, Psychosis, Hypertension, Dysphagia, Acute Sinusitis
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident had lunch on 01/14/21 and after lunch around 2:00pm, he vomited and stopped breathing. We coded the resident and 911 paramedics came. They pronounced him dead at 2:18pm.
VAERS ID: 949523 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-13
Onset: 2021-01-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical condition abnormal, Resuscitation, 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: 2021-01-15
   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: Ascorbic Acid Tablet 500 MG GT QD Multi-Vite Liquid (Multiple Vitamins-Minerals) 15 ml GT QD Famotidine Tablet 20 MG GT BID Memantine HCl Tablet 10 MG GT BID Polyethylene Glycol 3350 Kit 7gm GT QD Senna Tablet 8.6 MG (Sennosides) 2 tablets
Current Illness: None
Preexisting Conditions: History of Stroke, Diabetes Mellitus Type 2, Dementia, Dysphagia, Depression, Pressure Injuries Sacral and Left Heel
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Around 00:50am on 01/15/21, C.N.A. reported that the resident looked different and not responding. Initiated Code Blue and started CPR. 911 arrived and pronounced resident dead at 1:01 am.
VAERS ID: 949630 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Hawaii  
Vaccinated: 2021-01-02
Onset: 2021-01-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure decreased, Death, Hypophagia, Hypotension, Hypoxia, Oxygen therapy, Tachypnoea
SMQs:, Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-08
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Senna-S, cranberry pills
Current Illness: Redness to left foot about 1 week prior to vaccination that resolved a few days prior
Preexisting Conditions: Advanced Dementia, Seizure disorder, CAD, prior stroke, HTN
Allergies: Simvastatin
Diagnostic Lab Data: None as she was under hospice care
CDC Split Type:

Write-up: This patient has been under hospice care for over 2 years at the nursing home. She has had a steady decline with gradual weight loss. She was totally dependent in her care needs. She received the vaccine on 1/2/2021 as part of the facility vaccination campaign. No adverse events noted initially. On 1/3/2021 at 6:06 pm, she was noted on vital sign checks (done every 4 hours for first 72 hours after vaccination) with BP 64/52 but otherwise asymptomatic. Subsequent BP improved. On 1/4/2021 at 4:45 am, pt found with respiratory rate of 30 with otherwise normal vital signs. Tachypnea persisted, so she received liquid morphine 2.5 mg without improvement. Supplemental oxygen was applied. Tachypnea persisted. She had poor oral intake after that point had persistent tachypnea and worsening hypoxemia despite clear lungs on exam. She remained under hospice care and comfort measures were continued. No blood testing or imaging tests were done. She required increasing amounts of oxygen, became hypotensive, and died peacefully on 1/8/2021 at 7:45 pm.
VAERS ID: 949657 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: D.C.  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   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 EK9231 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Posture abnormal, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dystonia (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: 2021-01-13
   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: Xarelto ,topical lidocaine patch
Current Illness:
Preexisting Conditions: Atrial fibrillation, Congestive heart failure, Anterior ischemic optic neuropathy of right eye
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Veteran was found by family slumped over and unresponsive at the breakfast table on 1/13/21, had expired
VAERS ID: 949965 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-11
Onset: 2021-01-13
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood culture negative, Bradycardia, Chest X-ray normal, Culture urine negative, Death, Hypotension, Hypothermia, Laboratory test normal, Respiratory viral panel, Unresponsive to stimuli, Viral test, Viral test negative
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: No cause of death found on labs/cxr including cultures (blood and urine) that are now growth to date and viral respiratory pcr that was negative.
CDC Split Type:

Write-up: Patient 101 years old, nursing home resident, received vaccine 1/11, on 1/13 found on floor without obvious trauma, unresponsive. Brought to ED and was bradycardic, hypotensive, hypothermic and refractory to aggressive medical management. No obvious cause of death found on exam or labs, cxr. Unknown if event could be related to vaccine or not. Medical Examiner accepted case although initially unknown that patient had recently received vaccine. ME updated with that information today as soon as discovered.
VAERS ID: 950057 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: Alabama  
Vaccinated: 2021-01-15
Onset: 2021-01-15
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (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:
Preexisting Conditions: Hydrocephalus with ventricular shunting Prior history of leukemia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient suffered a cardiac arrest and was unable to give details about her symptoms. Per husband, patient did not complain of any symptoms after vaccine administration. She began seizing without warning which was complicated by cardiac arrest of uncertain etiology
VAERS ID: 950073 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-15
Onset: 2021-01-15
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Death, Headache, Lethargy, Mycobacterium tuberculosis complex test negative, Neck pain, Respiration abnormal, Tremor, Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Arthritis (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Amlodipine, Aspirin, Atenolol, Chlorthalidone, Dexamethasone, Fluconazole, Multivitamin with Minerals, Probiotic, Acyclovir, Topiramate, Cefpodoxime, levetiracetam, Potassium, Acetaminophen, Aleve, Lisinopril
Current Illness: Non-Hodgkin Lymphoma, Rhabdomyolysis, Anemia, Acute Kidney Failure, Chronic Embolism and Thrombosis of Lower Extremity
Preexisting Conditions: Epilepsy, Hypertension, Atrial Fibrillation, Anxiety
Allergies: Lisinopril, Losartan
Diagnostic Lab Data: Mantoux given 1/12/21 with negative results on 1/14/21
CDC Split Type:

Write-up: On 1/15/2021 at 1800, resident noted to be lethargic and shaking, stating "I don''t care." repeatedly. C/O head and neck pain. T100.6. Given Tylenol with no relief of pain. Order received for Aleve and administered.. Assisted to bed as usual in evening. Monitored during night shift and noted to be resting comfortably/sleeping.. Noted agonal breathing at 4:10 AM 1/16/2021 , T 99.4, Absence of vital signs at 4:15AM 1/16/21 and death pronounced at 4:40AM 1/16/21.
VAERS ID: 950108 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-12
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Catheterisation cardiac abnormal, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 3
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: Unknown
Current Illness: Pt. stated she was not ill at the time of vaccination.
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: "Moderna COVID-19 Vaccine EUA" It has been reported to me that pt. had gone into hospital for a heart catheterization on 1/12/2021. It was found during this procedure that pt. had suffered a MI. She was release to home the following day and passed away at her residence on 1/15/2021.
VAERS ID: 950441 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-15
Onset: 2021-01-15
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Adjusted calcium, Alanine aminotransferase increased, Albumin globulin ratio, Anion gap, Aspartate aminotransferase increased, Band neutrophil percentage decreased, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride decreased, Blood creatinine normal, Blood glucose normal, Blood magnesium increased, Blood potassium decreased, Blood sodium decreased, Blood urea nitrogen/creatinine ratio, Blood urea normal, Carbon dioxide normal, Cardiac arrest, Death, Differential white blood cell count abnormal, Echocardiogram abnormal, Eosinophil count normal, Eosinophil percentage, Full blood count abnormal, Globulin, Glomerular filtration rate, Haematocrit normal, Haemoglobin normal, Immature granulocyte percentage increased, Lymphocyte count normal, Lymphocyte percentage increased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume increased, Mean platelet volume increased, Mechanical ventilation, Metabolic function test abnormal, Monocyte count normal, Monocyte percentage, Neutrophil count normal, Neutrophil percentage decreased, Neutrophil toxic granulation present, Platelet count normal, Protein total normal, Pupil fixed, Red blood cell count normal, Red blood cell nucleated morphology present, Red cell distribution width normal, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Myelodysplastic syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Hypokalaemia (narrow)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Hydrochlorothiazide Toprol XL spironolactone prasugrel furosemide Vit D3 albuterol inhaler sildenafil aspirin 81mg Crestor nitroglycerin SL singulair testosterone gel levothyroxine
Current Illness: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris
Preexisting Conditions: Chronic systolic heart failure Coronary artery disease involving native coronary artery of native heart without angina pectoris lower extremity edema
Allergies: Walnuts
Diagnostic Lab Data: 1/15/2021 CBC WITH AUTO DIFF - Abnormal Result Value ? WBC 8.8 ? ? RBC 5.1 ? ? Hgb 15.7 ? ? Hematocrit 49.5 ? ? MCV 97.1 (*) ? ? MCH 30.8 ? ? MCHC 31.7 (*) ? ? Red Cell Distribution Width 14.3 ? ? Platelets 173 ? ? Mean Platelet Volume 11.4 ? COMPREHENSIVE METABOLIC PANEL - Abnormal ? Glucose 167 (*) ? ? Blood Urea Nitrogen 14 ? ? Creat, Serum 1.2 ? ? Sodium 134 (*) ? ? Potassium 3.1 (*) ? ? Chloride 93 (*) ? ? CO2 25 ? ? Anion Gap 16 (*) ? ? Calcium 9.9 ? ? Total Bilirubin 1.0 ? ? Alkaline Phosphatase 126 ? ? AST 62 ? ? ALT (SGPT) 41 ? ? Total Protein 6.7 ? ? Albumin 3.6 ? ? Globulin, Total 3.1 ? ? A/G Ratio 1.16 ? ? BUN/Creatinine Ratio 11.67 ? ? Corrected Calcium 10.2 ? ? eGFR $g60.00 ? ? Narrative: ? Specimen slightly hemolyzed, K, AST & ALK may be affected. ? MAGNESIUM - Abnormal ? Magnesium 2.4 (*) ? ? Narrative: ? Specimen slightly hemolyzed, Mg may be affected. ? DIFFERENTIAL, MANUAL - Abnormal ? Total Counted 100 ? ? Nucleated Red Blood Cell 1.0 ? ? Neutrophils Relative 45 ? ? Band Neutrophils Relative 0 ? ? Lymphocytes Relative 46 ? ? Monocytes Relative 5 ? ? Eosinophils Relative 1 ? ? Basophils Relative 1 ? ? Immature Granulocytes Relative 2 ? ? Neutrophils Absolute 4.0 ? ? Lymphocytes Absolute 4.0 (*) ? ? Monocytes Absolute 0.4 ? ? Eosinophils Absolute 0.1 ? ? Basophils Absolute 0.1 ? ? Toxic Granulation Present ? ? Platelet Estimate Normal ? ? ?
CDC Split Type:

Write-up: Pt had witnessed arrest by wife. Pt wife started CPR and called EMS. CPR started at 15:12. Continued by EMS. Pt arrived to medical center asystole with CRP in progress and ventilated via igel device. He was in refractory ventricular fibrillation and continued CPR for a total of 1 hour. At that point, we checked a bedside ultrasound which showed his heart at a standstill. He was unresponsive to verbal and tactile stimulus and had fixed unreactive pupils. He was pronounced at 16:13.
VAERS ID: 950893 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-03
Onset: 2021-01-07
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       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: Ask the nursing home,
Current Illness: Diabetes dementia, cll, trigeminal neuralgia
Preexisting Conditions: Diabetes dementia cll trigeminal neuralgia
Allergies: Shellfish, other
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death
VAERS ID: 967747 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-13
Onset: 2021-01-13
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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 passed away evening of 1/13 - unknown reason currently Narrative:
VAERS ID: 967749 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Brain natriuretic peptide increased, Cardiac arrest, SARS-CoV-2 test positive
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (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), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Jan 11, 2021@15:111 NASOPHARYNX COVID-19 MONT (VELA): DETECTED Jan 11, 2021@10:51 PLASMA BNP: 403 H pg/mL 0 - 100
CDC Split Type:

Write-up: Cardiac Arrest Narrative:
VAERS ID: 950935 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: California  
Vaccinated: 2021-01-12
Onset: 2021-01-15
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired
VAERS ID: 950979 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-14
Onset: 2021-01-14
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death, Headache
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: allopurinol -Zyoprim 3000 mg amlodipine Norvasc 5 mg Lispro 100/unit /ml ups us to 150 unit daily per insulin scale Levemir U-100 - 100/unit/ml - (3ML) 55 units nightly Levothryoxine -Synthroid - 137 mcg - daily Simvastatin 25 mg - d
Current Illness:
Preexisting Conditions: IPF - Idoipathic Pulmonary Fibrosis Diabetic
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache after dose was given at 10:00 a.m Died at after 7:30 pm the same night the dose was given.
VAERS ID: 951101 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2020-12-31
Onset: 2021-01-03
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abnormal behaviour, Acute kidney injury, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Cerebral infarction, Cerebrovascular accident, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Influenza like illness, Liver function test abnormal, Malaise, Movement disorder, Nausea, Speech disorder, Troponin increased, Vomiting, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (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), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (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, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: metoprolol tartrate, furosemide
Current Illness:
Preexisting Conditions: hypertension, dementia, osteoarthritis, diverticulosis
Allergies: tramadol
Diagnostic Lab Data: CREATININE = 4.73 AST= 410 ALT= 579 WBC= 25.95 TROPONIN = 0.174 CT SCAN OF HEAD PER THE RADIOLOGIST = ACUTE LEFT PCA DISTRIBUTION INFARCT. NO HEMORRHAGICE CONVERSION. NO MIDLINE SHIFT. BASILAR CISTERNS ARE PATENT. CT OF CHEST= NEGATIVE
CDC Split Type:

Write-up: PATIENT GOT HER FIRST COVID PFIZER VACCINE AT 12/31 IN THE AM. HAD GOTTEN FLU LIKE SYMPTOMS AND HAD BEEN SICK FOR A COUPLE OF DAYS. HAD NAUSEA AND VOMITTING DURING THIS TIME AS WELL. ON 1/3 THE CARE GIVER WENT TO CHECK ON HER PT AT HER LTC FACILITY WHERE SHE LIVES AND SHE WASN''T ACTING RIGHT. SHE WAS UNABLE TO DO A STROKE EXAM. PT HAD NO MOVEMNET IN ARMS OR LEGS AND WAS UNABLE TO SPEAK. PT WAS VITALLY STABLE AT THE TIME. EMS RECORDED THAT THEY THOUGHT DIAGNOSIS WOULD BE STROKE, PNEUMONIA OR SEPSIS. AFTER ARRIVAL AT THE HOSPITIAL DETERMED THAT SHE HAD A STORKE, ACUTE KIDNEY INJURY, ABNORMAL LFTS.
VAERS ID: 951678 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-13
Onset: 1921-01-17
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / -

Administered by: Private       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: 2021-01-17
   Days after onset: 36525
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Crestor 20 mg, Claritin-D 24 hour, Zaria 10 mg, baby aspirin, replatha,valsart hits 160-12.5mg Fish oil, wheat germ oil, D3 1000 mg, testosterone 8% gel, CO Q 10, weirder prime , eye drops
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Heart attack death medical test
CDC Split Type:

Write-up: Heart attack death medical test
VAERS ID: 951688 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Arkansas  
Vaccinated: 2021-01-02
Onset: 2021-01-17
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: Diclofenac Sodium Gel 1 %, Atorvastatin Calcium Tablet 40 MG, Acetaminophen Tablet 325 MG, Melatonin Tablet 3 MG, Vitamin D3 Tablet 25 MCG, Iron Tablet 325, Multivital-M Tablet, Eliquis Tablet 5 MG, metFORMIN HCl Tablet 500 MG, NIFEdipine
Current Illness: 11/25/20 Lower mid back abscess 11/4/20 toenail removal
Preexisting Conditions: CEREBRAL INFARCTION DUE TO UNSPECIFIED OCCLUSION OR STENOSIS OF LEFT MIDDLE CEREBRAL ARTERY, PRESENCE OF AUTOMATIC (IMPLANTABLE) CARDIAC DEFIBRILLATOR, UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE, APHASIA, DYSPHAGIA, UNSPECIFIED, WEAKNESS, COVID-19, OTHER REDUCED MOBILITY, URINARY TRACT INFECTION, SITE NOT SPECIFIED, ABNORMAL WEIGHT LOSS, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, VITAMIN DEFICIENCY, UNSPECIFIED, VITAMIN D DEFICIENCY, UNSPECIFIED, ANEMIA, UNSPECIFIED, CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE, CHRONIC KIDNEY DISEASE, STAGE 2 (MILD), ESSENTIAL (PRIMARY) HYPERTENSION, GOUT, UNSPECIFIED, INSOMNIA, UNSPECIFIED
Allergies: No Known Allergies
Diagnostic Lab Data: na
CDC Split Type:

Write-up: Resident expired 1/17/21
VAERS ID: 955256 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-16
Onset: 2021-01-16
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Immediate post-injection reaction, Muscle contractions involuntary, Pulse absent, Resuscitation, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Hypoglycaemia (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: None listed
Current Illness: None Listed
Preexisting Conditions: None Listed
Allergies: None Listed
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was vaccinated in right arm. Within 5 to 10 seconds after vaccination, patient started clinching his hands tightly and became unresponsive. Patient was lowered to the floor and did not exhibit a pulse. CPR was initiated and 911 was called. An AED was used and healthcare professionals onsite continued compressions until the paramedics arrived.
VAERS ID: 952204 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH PFIZERER9201 / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Autopsy, Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-01
   Days after onset: 29
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amoxicillin 500mg
Current Illness: None: Clean bill of health and a full cardiac exam was performed 2 months prior.
Preexisting Conditions: None.
Allergies: None
Diagnostic Lab Data: A full autopsy was done but results are pending.
CDC Split Type:

Write-up: Patient became sick 3 hours after the vaccine and was found deceased 1 day after his vaccination. He passed away in his sleep.
VAERS ID: 952704 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Oklahoma  
Vaccinated: 2021-01-14
Onset: 2021-01-14
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Abdominal pain upper, Abnormal behaviour, Agitation, Anxiety, Completed suicide, Confusional state, Dementia, Dyspnoea, Panic disorder, Pyrexia, SARS-CoV-2 test negative, Tremor, Vaccination complication
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Suicide/self-injury (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Daughter does not know all medications to list at time of reporting
Current Illness: Pneumonia 12/20 not Covid19 related
Preexisting Conditions: COPD, Curvature of Spine pressed against lung, High blood pressure, Diabetes
Allergies: N/A
Diagnostic Lab Data: Covid 19 : negative and pt lungs clear, all else unknown to reporter -- Daughter
CDC Split Type:

Write-up: Daughter call in for VAERS report to file for father whom committed suicide 1/16/2021 in the AM after reportable ae of COVID 19 vaccine administered 1/14/2021. Patient sought care twice at ER; first visit by ambulance around 5PM and Friday 1/15/2021 Medical Center: Emergency Room. 1st Discharge summary diagnosis: adverse reaction to COVID shot; 2nd Discharge summary diagnosis: adverse reaction to COVID shot, fever, Panic Disorder-- ER. Medical Center Discharge summary diagnosis: Adverse reaction to the vaccine, acute anxiety. Reportable patient symptoms at, 1st visit : fever, shaking stomach cramps, breathing issues. Medical Center -- No fever, confusion and dementia type, patient would not stay in patient bed; patient would get up and sit down again repeatedly, agitated and anxious. Attempted to urinated hospital bed. Patient committed suicide in home.
VAERS ID: 952713 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2020-12-30
Onset: 2021-01-12
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Diabetes, Parkinson Disease
Allergies: PCN, Zithromax, Flomax
Diagnostic Lab Data: PCR and antigen test
CDC Split Type:

Write-up: Weakness, Low O2, death. Positive for COVID on 1/12/21, dies on 1/16/21
VAERS ID: 952799 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-05
Onset: 2021-01-17
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Apnoeic attack, Death, Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: On 1/17/2021 at 4:35 am resident found apneic and pulseless, at 4:40am death confirmed
VAERS ID: 952881 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-10
Onset: 2021-01-11
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Blood albumin decreased, Blood chloride decreased, Blood potassium normal, Blood sodium decreased, Blood urea normal, Brain natriuretic peptide increased, Carbon dioxide increased, Death, Dyspnoea, Glomerular filtration rate, Haematocrit decreased, Haemoglobin decreased, Lymphocyte count decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Neutrophil count normal, Oedema, Red blood cell count decreased, Red cell distribution width increased
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (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: 2021-01-15
   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: Lasix, Timolol Maleate, Benefiber, Pravastatin, Multivitamin, Carbidopa ER 50-Levodopa 200 daily; Carbidopa ER 50-Levodopa 200 2 tabs daily, I-vite, Lactobacillus; Metoprolol Succinate; Tamsulosin, Finasteride, Oxubytynin
Current Illness: Edema, Hypokalemia, Hypertensive heart with heart failure
Preexisting Conditions: Parkinson''s Disease; COPD; Heart failure unspecified; Old myocardial infarction, Overactive bladder, Hyperlipidemia, Adult Failure to thrive, Urinary retention, Constipation unspecified, Unspecified urinary incontinence, Benign prostatic hyperplasia, other seasonal allergies rhinitis, unspecified glaucoma, mild cognitive impairment, Pressure ulcer of right heel, history of falling, dependence in wheelchair, COVID-19 on 11/23/2020
Allergies: No known allergies
Diagnostic Lab Data: RBC 3.72; HGB 9.8; HCT 32.7; MCH 26.3; MCHC 30; RDW 15.2; Neut # 7.18; Lymph # 0.97; NA 135; K 5.0; CL 97; CO2 34; BUN 11; CRT 0.76; ALB 1.9; ALT/SGPT 6; GFR $g60; BNP 415
CDC Split Type:

Write-up: Resident was seen by MD on 1/11/2021 due to increasing in edema and shortness of breath. Lasix 40 mg STAT given. New orders to get a STAT CBC, CMP, and BNP. Resident has been dependent on Oxygen since his diagnosis of COVID-19 on 11/23/2020. Labs were abnormal. Continued on the lasix 40 mgs. Resident remained short of breath with exertion and on oxygen. He was assisted to the toilet on 1/15/2021 in the morning where he subsequently passed away.
VAERS ID: 953129 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-09
Onset: 2021-01-18
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K208 / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Arthralgia, Back pain, Cardiac arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: none known
Preexisting Conditions: hypertension; colon cancer (recovered); smoker
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient presented to our Emergency Department via EMS in full code status; asystole. Patient expired. Per nursing, husband stated patient awoke this AM and reported pain in back between shoulders and in bilateral shoulders. Patient then went unresponsive and husband called EMS.
VAERS ID: 953183 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-05
Onset: 2021-01-11
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Oxygen saturation decreased, Pyrexia, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: 1/11/21 at 8:57 Resident with fever and at 11 am saturation down to 83 O2 to 10 liters. Resident continued to decline until CTB on 1/14/2021 at 1325
VAERS ID: 953348 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Arkansas  
Vaccinated: 2020-12-22
Onset: 2020-12-24
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Ibuprofen, Oxybutinin, Morphine Sulfate
Current Illness:
Preexisting Conditions: Chronic pain, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was living in a nursing home with positive cases when administered. His age and chronic condition was such that he did not have time after the vaccination to avoid exposure or develop immunity.
VAERS ID: 953590 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-05
Onset: 2021-01-11
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Culture negative, Death
SMQs:

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:
Preexisting Conditions: Medical History/Concurrent Conditions: Arthritis; Chronic kidney disease; COPD; Dementia; Diabetes mellitus; Failure to thrive; Hyperlipidemia; Metabolic encephalopathy; Weakness
Allergies:
Diagnostic Lab Data: Test Date: 20210109; Test Name: Nasal Swab; Test Result: Negative
CDC Split Type: USPFIZER INC2021025371

Write-up: resident expired; This is a spontaneous report from a contactable healthcare professional. An 82-year-old male patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot number: EL0140), intramuscular in the left arm on 05Jan2021 15:00 at a single dose for COVID-19 immunization. Medical history included metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia. Known allergies was none. The patient took unspecified concomitant medication. On 11Jan2021, the resident expired. The patient underwent lab tests and procedures which included nasal swab: negative on 09Jan2021. There was no treatment given for the event. The patient died on 11Jan2021. An autopsy was not performed.; Sender''s Comments: Lacking information on the cause of patient''s demise, the Company cannot completely exclude a causal relationship between COVID 19 vaccine, BNT162B2, and patient''s death of unknown cause, as a cautionary measure and for reporting purposes. The patient''s pre-existing medical condition of metabolic encephalopathy from, failure to thrive (FTT), diabetes mellitus (DM) 2 , chronic obstructive pulmonary disease (COPD), arthritis, weakness, hyperlipidemia, chronic kidney disease (CKD), dementia may have provided the contribution to the event in this 82-year-old male patient. The impacts of this report on the benefit/risk profile of the 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 expired
VAERS ID: 953754 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: New Jersey  
Vaccinated: 2021-01-06
Onset: 2021-01-13
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

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: not provided by facility
Current Illness:
Preexisting Conditions: COVID-19 4/24/2020, hyperlipidemia, type 2 diabetes, generalized idiopathic epilepsy, chronic gingivitis, paranoid schizophrenia, extrapyramidal movements (G25.9), BMI 29, major depressive disorder, hypertensive heart disease, GERD
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient suddenly developed pneumonia 7 days after vaccination and died the evening of developing pneumonia
VAERS ID: 953785 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-07
Onset: 2021-01-16
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Hypersensitivity/ anaphylaxis to standard flu vaccine (egg containing) ~ 20 years ago. Of note, did tolerate FluBlok this past
Other Medications: No scheduled medications Tylenol and Zyrtec as needed
Current Illness: None
Preexisting Conditions: None Known
Allergies: Egg (anaphylaxis) Chicken
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Death
VAERS ID: 953858 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-08
Onset: 2021-01-13
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

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: Seroquel, ibandronate, atenolol, Lexapro, simvastatin, acetaminophen, estradiol, famotidine, calcium citrate, antacid, donepezil, ferrous sulfate, Probiotic Pearls Complete, memantine, Antifungal cream, potassium chloride, Creon, bisacodyl
Current Illness: COVID-19, ARDS, enterocolitis, Sepsis, UTI, Acute renal failure
Preexisting Conditions: Chronic kidney disease, dementia with lewy bodies, COPD, GERD, anxiety, anemia, osteoarthritis, unspecified heart failure, paroxysmal atrial fibrillation
Allergies: nka
Diagnostic Lab Data: general decline starting 1/10/2021 - patient deceased 1/13/2021
CDC Split Type:

Write-up: patient started to decline 1/10/2021, patient seen at facility by medical professional - patient deceased 1/13/2021
VAERS ID: 953865 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Rhode Island  
Vaccinated: 2021-01-14
Onset: 2021-01-17
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Breath sounds abnormal, Death, Hypoxia, Pulmonary congestion, SARS-CoV-2 test negative
SMQs:, Cardiac failure (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Respiratory failure (narrow), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: FINASTERIDE 5MG QD, FAMOTIDINE 20 MG DAILY, FOLIC ACID 400 MCG QD, SENNA 8.6 DAILY
Current Illness: NONE
Preexisting Conditions: HYPOTHYROIDISM, DEMENTIA, SCHIZOPHRENIA, HTN, DYSPAGIA, INTELLECTUAL DISABILITIES, CKD MACULAR DEGENERATION
Allergies: NKA
Diagnostic Lab Data: RAPID COVID-19 TEST ON 1/17 NEGATIVE NO OTHER TESTS
CDC Split Type:

Write-up: REPORTING ONLY AS RESIDENT EXPIRED ON 1/17/2021 3 DAYS AFTER. S/S HYPOXIA/CONGESTED LUNG SOUNDS
VAERS ID: 953922 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Massachusetts  
Vaccinated: 2020-12-26
Onset: 2020-12-27
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Anxiety, Chest discomfort, Death, Dyspnoea, Myocardial infarction, Oropharyngeal discomfort, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes, COPD, Chrone''s Disease, DJD, OSA, PTSD, GERD, HLD, Depression, HTN, lobectomy 3/4/2019, cancer
Preexisting Conditions: See above
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: The day following the vaccine, the patient complained of throat issues and anxiety. This was not new... however . That evening he reported difficulty breathing and was placed on oxygen; a COVID test was performed and was negative. On 12/30/2020, patient complained of sternal pressure and was transferred to the hospital. The patient died 12/31/2020 and records obtained from the hospital indicated the patient died from a massive myocardial infarction.
VAERS ID: 954251 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-08
Onset: 2021-01-12
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Confusional state, Death
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 5
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: Cirrhosis of the liver, asthma, heart condition
Preexisting Conditions: Cirrhosis of the liver, asthma, heart condition
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 71 year old woman at rehabilitation center for physical therapy with history of cirrhosis of the liver, asthma, and heart condition was tested for COVID-19 on 01/07/21, received 1st dose of Pfizer COVID-19 vaccine on 01/08/21, positive test result for COVID-19 received on 01/09/21. She was sent to the hospital and admitted on 01/12/21 after O2 was 70% and was in a confused state. Patient passed away on 01/17/21.
VAERS ID: 954780 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-05
Onset: 2021-01-13
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Vomiting
SMQs:, Acute pancreatitis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

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: Norvasc 10mg daily Multivitamin daily Vitamin C 500mg twice daily Folic Acid 1mg daily Aspirin 81mg daily Thiamine 100mg daily Coreg 6.25mg twice daily Ativan 0.5mg three time daily Cymbalta 30mg daily ProStat 30ml three time daily D
Current Illness: None
Preexisting Conditions: Essential Hypertension Anxiety Disorder Unspecified Convulsions Pulmonary Candidiasis Paroxysmal atrial fibrillation Occlusion and stenosis of carotid arteries Congestive Heart Failure Left below the knee amputation Peripheral Vascular Disease Hypokalemia Urinary Retention
Allergies: Shellfish/Seafood
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: On 1/13/2021, resident had sudden emesis. Immediately following emesis he was noted without a pulse and pronounced deceased. No acute symptoms noted prior to this episode. Resident does have a significant cardiac history.
VAERS ID: 954812 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-15
Onset: 2021-01-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Cardiac arrest, Chest discomfort, Headache, Heart rate irregular, Nausea, Pulseless electrical activity, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (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), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: apixaban, levothyroxine, prednisone, diltiazem, (cont page 2)
Current Illness: Unknown
Preexisting Conditions: non stentable distal occlusive disease, coronary heart disease, stroke, heart failure, diabetes mellitus, (cont. p 2)
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: She had the first dose of Pfizer vaccine at the Campus on Friday 1/15 at 4:30 pm. After the vaccine, she had no new symptoms or signs of vaccine reaction and MD friend reports that he checked her pulse which was not elevated from baseline. On 1/16, she awakened and continued to feel at her recent baseline. However, in the early afternoon, she complained of headache, nausea/epigastric pain, and chest heaviness. These apparently were not unusual symptoms for her to feel intermittently. Per her niece, who has a home O2 sat device, her 02 sat that morning was 97 with a HR of 87 irregularly irregular. She was afebrile. (continue on page 2)
VAERS ID: 955261 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-18
Onset: 2021-01-19
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Nystatin, vitamin C, Klor Con, Vit B12, Coreg, Lactulose, simethicone, colace, trazodone, multi vitamin, torsemide, miralax, calcium, pantoprazole, breo ellipta,
Current Illness: Hip fracture,
Preexisting Conditions: afib, hyperlipidemia
Allergies: darvocet, toradol
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death
VAERS ID: 955390 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Alabama  
Vaccinated: 2021-01-15
Onset: 2021-01-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypopnoea, Intensive care, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Resident received vaccination on January 15, 2021. She was found unresponsive with shallow respirations on the morning of January 16, 2021 and was sent to ER via ambulance. The resident was admitted to medical center ICU where she passed away later that day.
VAERS ID: 955425 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-05
Onset: 2021-01-15
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031C20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Depressed level of consciousness
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: amlodipine, aricept, bactrim, namenda, remeron
Current Illness: pressure ulcer
Preexisting Conditions: alxheimer''s, depression, vitamin D deficience, BPH
Allergies: PCN
Diagnostic Lab Data: none
CDC Split Type:

Write-up: resident had a pressure ulcer to RT hip, was getting treatment on. Was scheduled to have wound debrided and wound vac applied on 1-19-2021. Appetite was poor, not wanting to get out of bed, and decline in alertness. Passed away on 1-16-2021
VAERS ID: 955436 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-29
Onset: 2021-01-05
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 LA / IM

Administered by: Unknown       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: aspirin atorvastatin bumetanide carvedilol vit d 3 miralax tamsulosin tylenol keppra lisinopril mirtazapine pantoprazole senna
Current Illness: CAD s/p CABG, prior ischemic HFpEF (EF 45% $g 50%), mild-mod Mitral Stenosis, bradycardia s/p PPM, HTN, HLD, DMII (A1C 6.5), CKD (baseline Cr 2-2.5), GERD, BPH, seizure disorder (on keppra)
Preexisting Conditions: as above
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient received vaccine 12/29. Unexpected death 1/5.
VAERS ID: 955532 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: New Jersey  
Vaccinated: 2021-01-12
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Death, Posture abnormal, Pulse absent, Respiratory arrest, Resuscitation, 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), Dystonia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus SoloStar; Atorvastatin Calcium; Gabapentin; Potassium Chloride ER; Levothyroxine Sodium; Alogliptin Benzoate; Acetaminophen; Milk of Magnesia; Enema Rectal; Bisacodyl Rectal Suppository; Tramadol HCl; Ceftriaxone Sodium; Santyl Exter
Current Illness: Cellulitis of RLE, S/P wound debridement
Preexisting Conditions: HTN, Morbid obese, Diabetes, Hypothyroidism, HTN
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: COVID 19 Vaccination administered by pharmacy staff. No adverse effect at the present time. Staff will continue to observe adverse reaction. Will continue to monitor. Patient at start of shift awake in the bed. Pt at 3am was on the commode leaned to the side. Patient body still warm to touch no pulse. Called for assistance Asap. Cpr started promptly. Cpr given patient on floor 911 arrived at the scene at 3:10am Cpr rotated Between Nursing and EMT on Scene. Cpr was given to patient for over 45 minutes. Patient was pronounced at the scene at 3:50am. Call placed to Pt family by supervisor on shift. MD to be notified. AT 3:00am, I was notified by the nurse that resident is unresponsive. Upon entering room, resident was sitting on the commode unresponsive with absent respiration and pulse. Resident lowered down on the floor with 4 person assist. CPR initiated, AED pads placed on chest with no shock indicated. 911 called and EMT and paramedics arrived around 3:10am. ACLS performed until code stopped and pronounced death at 3:48am. I called and notified family member of his demise and awaiting for family to call us back for funeral arrangements.
VAERS ID: 955597 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2021-01-13
Onset: 2021-01-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

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: Levothyroxine Calcium Acetate Albuterol Clonidine Hydralazine Ropinirole Aspirin Ergocalciferol Metoprolol Ondansetron Rifaximin Hydroxyzine Mutlivitamins Buspirone Pantoprazole Oxycodone Atorvastatin
Current Illness:
Preexisting Conditions: Major Depressive Disorder Hepatitis C Essential Hypertension Diabetes Type 2 Alcoholic Cirrhosis Hypothyroidism Chronic Kidney Disease Stage 5 Asthma
Allergies: Contrast media
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death
VAERS ID: 955879 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034599

Write-up: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar death events for 8 patients. This report is for 5th of 8 patients. A patient of unspecified age and gender received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 22Dec2020 at single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. The patient died on an unspecified date. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: The limited information provided in this report does not allow a full assessment of the case. The event death with unknown cause is assessed as related to the suspect drug per company guidance. This case will be reassessed when additional information, particularly the clinical course before death, complete medical history and concomitant medication and autopsy report, becomes available.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: expired before receiving the second dose
VAERS ID: 955880 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034603

Write-up: passed unexpectedly; This is a spontaneous report from a contactable nurse communicated to a Pfizer colleague. This nurse reported similar death events for 8 patients. This report is for 8th of 8 patients. A patient of unspecified age and gender received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on 22Dec2020 at single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. The patient passed unexpectedly on an unspecified date. The patient died on an unspecified date. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: The limited information provided in this report does not allow a full assessment of the case. The event death with unknown cause is assessed as related to the suspect drug per company guidance. This case will be reassessed when additional information, particularly the clinical course before death, complete medical history and concomitant medication and autopsy report, becomes available. The case will be reassessed if additional information becomes available. 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.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: passed unexpectedly
VAERS ID: 955959 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: New Mexico  
Vaccinated: 2021-01-11
Onset: 2021-01-18
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0399K20-2A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: alfuzosin, allopurinol. amlodipine, aspirin, Sinemet, vitamin D, multivitamin, Lexapro, finasteride, mirtazipine, ropinirole, trospium
Current Illness: recently diagnosed with progressive supranuclear palsy
Preexisting Conditions: BPH, HTN, gout, GERD, hyperlipidemia
Allergies: none
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died 1 week after vaccination. According to family was having very rapid decline in status in recent weeks and they did not think related to vaccination.
VAERS ID: 956225 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-16
Onset: 2021-01-16
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: 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: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Pt monitored by nursing for 30min after inj,pt was stable/no reaction.At ~1hr post inj pt was unresponsive.Pt was a hospice/dnr per director
VAERS ID: 956365 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: California  
Vaccinated: 2020-12-21
Onset: 2021-01-04
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Bilevel positive airway pressure, COVID-19 pneumonia, Cough, Death, Dyspnoea, Endotracheal intubation, Fall, Nausea, Pain, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 14
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: 12/28/2020: generalized weakness and fell twice at home, cough, nausea,1/04/2021: cough, nausea, fever and chronic pain when she fell from being weak. admitted to hospital with Covid pneumonia, shortness of breath, covid postive, 1/09/2021: pt on bipap, 1/15/2021: pt was intubated, on TPN, pt DNR, 1/18/2021: was extubated and put on comfort measures and passed away
VAERS ID: 956458 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Massachusetts  
Vaccinated: 2021-01-06
Onset: 2021-01-14
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Work       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase increased, Autopsy, Bilirubin conjugated increased, Blood alkaline phosphatase increased, Blood bilirubin increased, Blood creatinine increased, COVID-19 pneumonia, Chest pain, Cough, Death, Electrocardiogram QT prolonged, Electrocardiogram abnormal, Full blood count, Liver function test, Lung infiltration, Metabolic function test, Metamyelocyte percentage, Myelocyte percentage, Nausea, Neutrophil count decreased, Platelet count decreased, Rales, SARS-CoV-2 test negative, Sinus tachycardia, Unresponsive to stimuli, White blood cell count decreased
SMQs:, Torsade de pointes/QT prolongation (narrow), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (narrow), Agranulocytosis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Torsade de pointes, shock-associated conditions (narrow), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Amlodipine, Lipitor, Lisinopril
Current Illness: None
Preexisting Conditions: Hypertension, hyperlidemia, gout, pre-diabetes
Allergies: Nnone
Diagnostic Lab Data: Tests of 1/15/2021 included CBC, BMP and LFTs - abnormal results noted in narrative of question 18.
CDC Split Type:

Write-up: Patient was vaccinated for SARS-CoV-2 on 6-Jan-21 at his site of employment, a Nursing Home. Patient presented to Urgent Care on 15-Jan-21 complaining of left sided chest pain that started the evening before with an associated slight cough. Pt was afebrile with a heart rate of 88 and an O2 sat on room air of 98% in triage. His EKG showed a sinus tachycardia of 114 with a slightly prolonged QTc of 463 ms. Physical exam was significant for bibasilar crackles and X-ray showed bibasilar infiltrates consistent with COVID pneumonia but bacterial pneumonia could not be excluded. The patients BP was documented as 97/64. He was treated with Zofran for nausea and tylenol. He was prescribed a five day course of Azithromycin, an Albuterol inhaler, guaifenessin with codeine cough syrup, and Zofran. Labs were drawn and he was discharged. His lab results were reported after his departure and were significant for a white blood cell count of 1.33, platelet count of 73, 2% myelocytes, 1% metamyelocytes, an absolute neutrophil count of 0.75 K/ul, a creatinine of 1.83, total bilirubin of 1.3, with direct bilirubin of 0.8, alkaline phosphatase of 294 and AST of 112 with ALT noted to be within normal limit. His COVID nasopharyngeal swab from the visit was reported as negative and a swab performed at his employment on 13-Jan-21 was also reported to be negative. Patient could not be reached by phone after discharge from Urgent Care about these labs. On the evening of 16-Jan-21, Police Department received a 911 call about an adult at the patient''s address who was found unresponsive. Upon arrival on scene, the patient was found to be deceased and a decision was made not to attempt to resuscitate. The death was deemed to be non-suspicious and the patient''s body was transported to a funeral home. On 19-Jan-21, I contacted the State Medical Examiner''s Office. They have decided to perform an autopsy and have recovered the CBC and chemistry specimens obtained for further testing.
VAERS ID: 956761 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New Jersey  
Vaccinated: 2021-01-13
Onset: 2021-01-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Fatigue
SMQs:

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: Eliquis, losartan, torsemide, metolazone, carvedilol, docusate
Current Illness: episode of congestive heart failure two months ago requiring hospitalization
Preexisting Conditions: hypertension, atrial fibrillation, congestive heart failure, prior aortic valve replacement, permanent pacemaker, venous insufficiency
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Family was told that Patient expired in his sleep during the early morning hours of 1/15. I spoke with him the evening before (on 1/14), which was a day after he had received the Covid vaccine. He was not having any symptoms of allergy or reaction then. He did say that he felt tired, but he often complained of feeling tired over time.
VAERS ID: 956811 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: New Jersey  
Vaccinated: 2021-01-18
Onset: 2021-01-18
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Resident was noted unresponsive, no respiration, no blood pressure, no pulse, code blue called according to facility protocol, resident is full code, CPR started, 911 called, arrived and took over from staff. Resident was pronounced dead at 1:16pm 1/18/21
VAERS ID: 956843 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Iowa  
Vaccinated: 2021-01-17
Onset: 2021-01-19
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Tylenol 500 Mg 2 tabs Bid; Allopurinol 100 Mg Daily; Atorvastatin 40 Mg Hs; Bumetanide 4 Mg Bid; Bupropn 150 Mg Daily; Carvedilol 3.125 Mg Bid; Cinacalcet 30 Mg Daily; Eplerenone 25 Mg Bid; Fluoxetine 40 Mg Daily; Mirtazapine 7.5 Mg Hs; Pan
Current Illness: No illnesses at time of vaccination or up to one month prior
Preexisting Conditions: Stage V Chronic Kidney Disease; Depression; Hypertension; Hyperthyroidism; Anemia; A Fib; Hyperlipidemia; Aortic Aneurysm; Neuropathy; History of Alcohol Abuse; CAD;
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident was found deceased in his bed at 7:15 am.
VAERS ID: 956962 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-06
Onset: 2021-01-19
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER COVID 19 KNOWN< / 1 UN / UN

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Hyperhidrosis, Hypotension, Hypoxia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (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), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Unavail
Current Illness: CVA seizure disorder all chronic HTN CAD had COVID 19 in April 2020
Preexisting Conditions: as above PAtient had accute respiratory distress followed prolptly by cardiac arrest
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: COVID 19 vaccine, unknown which company Chronically ill in a skilled nursing facility found diaphoretic, hypotensive, hypoxia to 85% arrived to Emergency dept in cardiac arrest Died within 65 minutes of nursing finding patient in distress Wife felt it may have been related to vaccine date of vaccination 1/6/20 hx covid 19 PNA in April 2020
VAERS ID: 956994 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-15
Onset: 2021-01-15
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Dyspnoea, Rash
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Cholecalciferol, duloxetine, fenofibrate, gabapentin, hydrocortisone suppository, melatonin, metformin, metoprolol succinate, mineral oil, nitroglycerin, omeprazole, pravastatin, quetiapine, selenium sulfide shampoo, quetiapine, sumatriptan
Current Illness:
Preexisting Conditions: Hypertension, Type II diabetes, hyperlipidemia, GERD
Allergies: Aspirin, penicillin, vicodin, acetaminophen, niacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient had severe shortness of breath resulting in cardiac arrest on the 5th day after the vaccine. Shortness of breath started 12 hours after injection. On the 5th day, the patient was discovered to also have a rash throughout his body, but it is unknown when this rash started.
VAERS ID: 957116 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Hawaii  
Vaccinated: 2021-01-14
Onset: 2021-01-18
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Military       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Atovastatin, Ferrous sulfate, Finasteride, Flomax, Humulin N, Pantoprazole, ProAir, Reglan, Spiriva, Turmeric
Current Illness: Diabetes, Chronic renal failure on hemodialysis, Atrial fibrillation, Quadriplegia, Thrombocytopenia, Gastroparesis, Vitamin D deficiency, BPH, Neurogenic bladder, distant history of small intestine carcinoid tumor, right cerebral artery aneurysm, Barrett''s esophagus, MGUS, Hypertension, obstructive sleep apnea, Pulmonary hypertension, Junctional tachycardia.
Preexisting Conditions: see above. Sudden death without warning likely due to medical problems above but spouse feels it was somehow related to the vaccine 4 days before and it is a new vaccine.
Allergies: Cipro caused nausea, Coreg caused bradycardia, Hydrocodone, calcium acetate
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Sudden death without warning symptoms 4 days after vaccine. Many medical problems which most likely explain the outcome but spouse feels it is related and it is a new vaccine. Monitor for pattern?
VAERS ID: 957163 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: New Jersey  
Vaccinated: 2021-01-11
Onset: 2021-01-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received 1st on 1/11/21 at 12:10am (1/12/21) resident was found unresponsive. Code Blue, 911 called at 12:11am. FD and EMS arrived, resident pronounced at 12:51am.
VAERS ID: 957799 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-14
Onset: 2021-01-15
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Cardiac arrest, Confusional state, Death, Electrocardiogram, Full blood count normal, Metabolic function test, Troponin normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Respiratory failure (broad), Hypoglycaemia (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F
Current Illness:
Preexisting Conditions: HTN AAA with endovascular stent ESRD COPD
Allergies: Lipitor
Diagnostic Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute
CDC Split Type:

Write-up: Presented to Urgent Care for weakness and confusion, transferred to ED, patient had a cardiac arrest and was unable to be resuscitated
VAERS ID: 958069 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-14
Onset: 2021-01-19
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cough, Dyspnoea, Feeling abnormal
SMQs:, Anaphylactic reaction (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Cartia XT 120mg daily, Zaditor 0.025% 1 drop into eye twice a day, Folic Acid 1mg daily, Metoprolol Succinate ER 100mg twice a day, Lasix 40mg daily, Erythromycin 2% to area twice a day, Hydroxychloroquine Sulfate 200mg 2 tabs daily, Ferrou
Current Illness: None
Preexisting Conditions: Rheumatoid arthritis, osteoarthritis, lumbar spinal stenosis, diabetes, bradycardia with pacemaker
Allergies: Codeine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Started with cough, mild shortness of breath and feeling terrible in evening of 1/19.
VAERS ID: 958072 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-16
Onset: 2021-01-18
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 2 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 3 days after receiving 2nd dose of COVID vaccine, unknown if related to vaccine administration.
VAERS ID: 958228 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-12
Onset: 2021-01-18
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0329K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Carbon dioxide decreased, Death, Diet refusal, Hypernatraemia, Metabolic function test, Protein total normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100
Current Illness: none other than chronic conditions as listed under item 12.
Preexisting Conditions: acute on chronic kidney failure, Alzheimer''s dementia, diabetes mellitus type II, hypothyroidism, bipolar disorder, hypertension, hyperlipidemia
Allergies: Niacin - rash
Diagnostic Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20
CDC Split Type:

Write-up: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm.
VAERS ID: 958322 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Tremor, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (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: 2021-01-19
   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: ASPIRIN ASPIRIN EC 325 MG TABLET TAKE 1 TABLET BY MOUTH DAILY ATORVASTATIN 40 MG TABLET LIPITOR 40 MG TABLET TAKE 1 TABLET BY MOUTH IN THE EVENING AT 5PM OLANZAPINE 10 MG TABLET ZYPREXA 10 MG TABLET TAKE ONE-HALF (1/2) TABLET BY MOUTH TWICE
Current Illness: Hyperlipidemia, Head Trauma, Hx of Seizures, Unspecified Psychosis, Depression, Mood Disorder, Substance Abuse
Preexisting Conditions: Hyperlipidemia, Psychosis, Depression
Allergies: None
Diagnostic Lab Data: Was sent to ER
CDC Split Type:

Write-up: Shaking and then became unresponsive
VAERS ID: 958565 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-11
Onset: 2021-01-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Arrhythmia, Chest discomfort, Death
SMQs:, Anaphylactic reaction (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol nebulizer, Saline nebulizer, Metoprolol, Vespi, Albuterol Inhaler, antibiotic 2-3 times per week
Current Illness: lung infection treated with antibiotics a couple of weeks ago
Preexisting Conditions: Hypertension, COPD
Allergies: None Known
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Clients wife reported on 1/18/2021, that her husband died unexpectedly the day after receiving the COVID 19 vaccine. I called and spoke with her. She stated that the client had started experienced some tightness in his chest the evening of 1/11/2021. She stated that it was normal for him to have the tightness in his chest if he got stressed. She stated that she found him on the garage floor on 1/12/2021 at 2120. He was taken by ambulance to the hospital. She stated that the hospital told her that his COPD had caused him to go into arrythmia.
VAERS ID: 958745 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-01-12
Onset: 2021-01-14
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Fall, Pulse absent, Pyrexia, Skin warm, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Divalproex Sodium Tab DR 250mg and 500mg, Lexapro 20mg, Quetiapine Fumarate 200mg tab, Senna 8.6 mg, Latanoprost drops,
Current Illness: Hx of TBI and schizophrenia with worsening behaviors over the past few months including refusing care including meals and medications and striking out with care. Resident had a fall on 1/14/2021. Resident received treatment for a UTI with Keflex for 7 days starting 12/6/2020.
Preexisting Conditions: Traumatic Brain Injury, Shizophrenia, hydrocephalus, hemiplegia following cerebrovascular disease affecting right side, aphasia, reduced mobility with use of w/c, repeated falls, dysphagia, major depression, thrombocytopenia, gluacoma, epilepsy.
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident was noted to have increase weakness on 1/15/2021. Resident was warm to touch with low grade fever of 99.3 F. Resident was up propelling self in w/c on 1/16/2021 he was pleasant, accepted medications and ate lunch. He was found slumped over in his w/c not responding and vital signs absent.
VAERS ID: 958914 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2020-12-30
Onset: 2020-01-15
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 366
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Melatonin, Sertraline, Omeprazole, Resperidone, Depakote ER, vitamin E, multi vit, ASA, Lasix, gabapentin, potassium, Imodium, Zofran, Buspar, benztropine.
Current Illness:
Preexisting Conditions: Alzheimer''s, disorganized schizophrenia, HTN, CKD stage 3, Athritis, legal blindness, Dementia, Major Depression Disorder, Parkinson''s, GERD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 1/15/2020
VAERS ID: 958935 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-19
Onset: 2021-01-20
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Aspirin, Biotin, Levothyroxine, melatonin, Namenda, Zyprexa, Trazodone, B12, B6, Vit D, Xanax
Current Illness:
Preexisting Conditions: Dementia, HTN, Hypothyroidism
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden Death within 24 hours of vaccine
VAERS ID: 958971 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Basal ganglia stroke, Computerised tomogram, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), 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: 2021-01-14
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Simvastatin
Current Illness:
Preexisting Conditions: Aortic Insuf Dyslipidemia h/o prostate CA
Allergies: NKDA
Diagnostic Lab Data: CT scan
CDC Split Type:

Write-up: Hemorrhagic Stroke, Right Basal Ganglion
VAERS ID: 959001 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-15
Onset: 2021-01-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Nausea, Pulse absent, Resuscitation, Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: triamcinolone (KENALOG) 0.1 % Ointment amLODIPine (NORVASC) 5 MG Tablet Take 5 mg by mouth. ondansetron (ZOFRAN-ODT) 4 MG TABLET DISPERSIBLE Take 1 Tab by mouth every 8 hours as needed for Nausea - 1st line. acetaminophe
Current Illness: Unknown
Preexisting Conditions: Asthma Developmental delay (Pediatric) Eczema HLD (hyperlipidemia) HTN (hypertension)
Allergies: Penicillin''s, Chocolate, Lactase, Fish, Nuts, Strawberry
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient woke apx 0200 complaining of nausea to group home staff. Vitals were checked at that time and WNL. Patient went back to bed. When staff went to wake patient apx 0530, he was unresponsive and had no pulse. Chest compressions were started and EMS called.
VAERS ID: 959079 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-01-06
Onset: 2021-01-09
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Bundle branch block right, Electrocardiogram QRS complex abnormal, Heart rate increased, Pain, Respiratory rate increased, Sinus tachycardia, Supraventricular tachycardia, Vital functions abnormal
SMQs:, Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Supraventricular tachyarrhythmias (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   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: Ascorbic Acid 500mg, Cetirizine HCL 5mg, Escitalopram Oxalate 10mg, Finasteride 5mg, Metoprolol succinate ER 25mg, Tamsulosin 0.4mg, Teriparatide 20mcg injection, Vitamin D3 Tablet, voltaren Gel 1%, Eliquis 5mg, Pantoprazole Sodium 40mg, Ac
Current Illness: Residents condition was declining over the past several months and has been treated for depression and dementia. Resident refusing care including meals, medication and ADL care.
Preexisting Conditions: Atrial Fibrillation, obstructive uropathy, chronic kidney disease, asthma, bradycardia, major depression, dysphagia, Parkinson''s disease, dependence on supplemental oxygen, osteoporosis, hyperlipidemia,
Allergies: No Known Allergies
Diagnostic Lab Data: 1/9/2021- 12 lead EKG performed which states sinus tachycardia with supraventricular complexes and low voltage QRS as well as right bundle 1/9/2021- CXR ordered but discontinued at request of POA
CDC Split Type:

Write-up: On 1/9/2021 observed with elevated respirations of 38-42 per minute, BP manually 72/50. pulse is jumping rapidly between 110-16 bpm. oxygen sat 76% RA, resident refusing oxygen at first attempt, allowed oxygen to be placed, is now 84% on 4L. resident shaking head yes that he is hurting, and yes that he would take medication for pain. Dr. notified, branch block. Received order for morphine 2mg per hr as needed for elevated respirations and pain. Dr. also gave orders to D/C Tamsulosin and finasteride. Resident continue with decreased O2 sats and elevated respirations. Absence of vital signs on 1/10/21 at 826PM.
VAERS ID: 959147 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2020-12-28
Onset: 2021-01-02
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E10140 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Jaundice
SMQs:, Cholestasis and jaundice of hepatic origin (narrow), Acute pancreatitis (broad), Biliary system related investigations, signs and symptoms (narrow), Biliary tract disorders (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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:
Current Illness: Alzheimer''s disease, Type 2 with chronic kidney disease,
Preexisting Conditions: copd, Depression,psychosis,atherosclerotic heart disease
Allergies: penicillin
Diagnostic Lab Data: none as resident was comfort care only
CDC Split Type:

Write-up: Unknown as to any correlation with vaccine as this was a hospice patient that was already experiencing decline. Patient became Jaundice for approximately one week prior to expiring.
VAERS ID: 959167 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Alabama  
Vaccinated: 2021-01-14
Onset: 2021-01-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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:
Preexisting Conditions: Seizures were reported on vaccine form
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID 19 vaccine 01/14/2021. Patient died in his sleep 01/16/2021.
VAERS ID: 959179 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-01-14
Onset: 2021-01-17
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood albumin decreased, Blood bilirubin normal, Blood calcium decreased, Blood chloride decreased, Blood creatinine increased, Blood culture negative, Blood glucose increased, Blood lactic acid, Blood magnesium normal, Blood phosphorus increased, Blood potassium normal, Blood sodium normal, Blood urea increased, Cardiac arrest, Culture urine negative, Death, Diastolic dysfunction, Echocardiogram abnormal, Ejection fraction decreased, Haematocrit decreased, Haemoglobin decreased, Hyperkalaemia, Left ventricular dysfunction, Left ventricular hypertrophy, Platelet count normal, Pulseless electrical activity, SARS-CoV-2 test negative, Troponin increased, Ventricular fibrillation, Ventricular hypokinesia, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: losartan 100 mg QD, metformin 1000 mg BID, simvastatin 40 mg QD, tamsulosin 0.4 mg QD
Current Illness:
Preexisting Conditions: Type 2 DM, Diabetic neuropathy/nephropathy, CKD Stage 3, Hyperlipidemia, Hypertension
Allergies: None
Diagnostic Lab Data: COVID-19 negative (1/18/2021); Blood X 2 ngtd (1/17/2021); urine ngtd (1/17/2021); ECHO (1/18/2021) - Left Ventricle: The left ventricle is normal in size. There is mild asymmetric left ventricular hypertrophy. Left ventricular function is mildly reduced. Considering 2D visualization and technical calculations the left ventricular ejection fraction estimate is 40-45%. The inferolateral wall is hypokinetic. There is no evidence of a thrombus in the left ventricle. There is echocardiographic evidence of diastolic dysfunction; CMP (1/18/2021) Na 144, K 4.6, Cl 96, gluc 290, BUN 73, Scr 7.68, Ca 7.2, Mg 1.8, Phos 7.3, AST 436, ALT 271, Alb 2.7, T bili 0.4, lactate $g 12.0; CBC (1/18/2021) WBC 24.6, Hgb 12.4, Hct 38.4, Plt 383
CDC Split Type:

Write-up: Patient received COVID-19 vaccination on 1/14/2021. On 1/17/2021, patient was transferred to Hospital s/p multiple cardiac arrests. Patient was hyperkalemic and in acute renal failure at time of transfer. Hyperkalemia was treated, but the patient suffered PEA vs VFib. At the time of transfer, patient was on vasopressin, norepinephrine, and epinephrine. The patient had an EF of 40-45% and elevated troponins. Patient was made DNR and placed on comfort care. Patient passed away on 1/18/2021. Ultimately we suspect that the patients condition was a direct result of his underlying disease states, but wanted to make sure reporting was made available.
VAERS ID: 959272 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2021-01-12
Onset: 2021-01-15
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

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: unknown
Current Illness: uncertain illness, however, patient was on Hospice.
Preexisting Conditions: uncertain illness, however, patient was on Hospice. We are not his primary care providers, just provided the vaccine.
Allergies: none
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient died 4 days after immunization. Probably unrelated to immunization, as patient has been in poor health and was receiving hospice services. I have no details related to his illness or symptoms. Daughter is the HIPAA/emergency contact and will have all the information needed.
VAERS ID: 959356 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: N/A not a resident at the living center.
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Pt passed away the day after the vaccine was given.
VAERS ID: 959568 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Colorado  
Vaccinated: 2021-01-16
Onset: 2021-01-19
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aneurysm ruptured, Cerebral haemorrhage, Death, Intensive care, Loss of consciousness, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None disclosed
Current Illness: None disclosed
Preexisting Conditions: None disclosed
Allergies: None disclosed
Diagnostic Lab Data: ROI not signed and we do not have access to these records as Clinic is not patient''s PCP
CDC Split Type:

Write-up: Patient received her first dose of the Moderna COVID-19 Vaccination on Saturday January 16th 2021 at approximately 12pm. She completed all necessary screening forms and was deemed to be at low risk for serious allergic reactions. She tolerated the vaccination well, and no complications or immediate adverse events occurred. She was observed for a full 15 mins per CDPHE/CDC guidelines and left the Clinic in stable condition after her observation period was complete. On the morning of Tuesday, January 19th, 2021, the patient was found unconscious and unresponsive by her husband. She was transferred by Ambulance to Hospital shortly thereafter. She was diagnosed with a brain bleed that was determined to be inoperable. She was transferred to other Hospital for higher level care. She was seen by neurosurgery and diagnosed with a ruptured aneurysm. She was treated in the ICU for 24 hours, at which point her team determined that the severity of her brain bleed would not respond to treatment. Supportive cares were withdrawn on Wednesday Jan 20th, and she passed away shortly thereafter.
VAERS ID: 959591 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2020-12-22
Onset: 2020-12-31
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Blood chloride decreased, Blood glucose normal, Blood sodium decreased, Blood urea increased, Full blood count, Hyporesponsive to stimuli, Hypotension, Lethargy, Metabolic function test, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 17
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 14 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg, Atrovastatin 80mg, CaroSpir Suspension 25mg/5mL, Clopidogrel Bisulfate 75mg, Duloxetine HCL 30mg, Insulin- Lantus 14 units, Levothyroxine 137mcg, Lidocaine patch 5%, Potassium Chloride ER 20MEQ, Prilosec DR 40mg, Psylliu
Current Illness: He was treated for pneumonia and C-Diff at the beginning of December. He had abnormal blood work with elevated BUN and WBC on 12/31 and 1/3/21. Appetite was fluctuating and recently began increase medication for depression. Decrease responsiveness sent to ER on 1/4/2021.
Preexisting Conditions: oxygen dependent, metabolic encephalopathy, atrial fibrillation, hypertension, diabetes, cardiac pacemaker, depression, congestive heart failure, obesity, hypothyroidism, sleep apnea, hyperlipidemia, cushing''s disease.
Allergies: Amoxicillin, Ceftriaxone, Lisinopril, Niacin, Pilglitazone, Rosiglitazone, Penicillins
Diagnostic Lab Data: BMP and CBC done 1/3/2021 - low sodium 131, chloride 94, Glucose 131, BUN 80, WBC 18.9
CDC Split Type:

Write-up: Resident has increase weakness and lethargy with abnormal labs. He was transferred to the ER. He was admitted to the hospital and treated for worsening AKI and hypotension.
VAERS ID: 959729 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Maryland  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / 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: unknown
Current Illness: Tachycardia, Hypertension
Preexisting Conditions: Hytertension
Allergies: NKDA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Per Nursing Staff- patient died within 24 hours of receiving the vaccine. patient has hospice. Please contact director of nursing for more details.
VAERS ID: 959747 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Maryland  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / 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: Unknown
Current Illness: Unknown
Preexisting Conditions: Ischemic Cardiomyopathy
Allergies: unknown - no
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: per staff at facility patient died 24 hours post vaccination. Please contact Director of Nursing for further details.
VAERS ID: 959929 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-17
Onset: 2021-01-18
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Abdominal pain upper, Bacterial test negative, Blood culture negative, Cardio-respiratory arrest, Chest X-ray normal, Confusional state, Death, Electrocardiogram change, Feeling abnormal, Gait inability, General physical health deterioration, Liver function test normal, Myalgia, Procalcitonin increased, Pyrexia, Resuscitation, Supraventricular tachycardia, Systemic inflammatory response syndrome, Tachycardia, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Dystonia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Patient seen in ED 1-17-21 with c/c of "bloated with epigastric pain". Patient with complicated medical history including stage 1B pancreatic cancer (was currently on chemotherapy mFOLFIRINOX), and a leadless permanent pacemaker implantation on 1-11-21 for long episodes of SR with complete heart block following symptoms of syncope (other cardiac history: CAD s/p CABG 2009, PAF, and HTN). Regarding ER visit for epigastric pain, nothing notable was found on workup and patient was to discharge home to rest. There were available doses of COVID-19 Vaccine following a vaccine clinic that same day, and patient was offered and agreed to a dose of vaccine. Patient was monitored for 15 minutes post vaccine with no notable issues. The following day, Monday 1-18-21, patient''s caregiver called facility at 22:30 to report he had a fever of 102.8 degrees and that he had been "feeling kind of bad all day". Patient was advise to seek urgent medical care and reported back to ED on 1-19-21 at 00:55. Patient wasd admitted for SIRS (tachycardia and febrile) -- patient also reported diffuse myalgia. WBC WNL, CXR unremarkable for infection, UA neg for bacteria, LFTs WNL, blood cultures negative. Procalcitonin elevated at 17.8 -- suggesting inflammatory response. Patient initially reported feeling better on the morning of 1-19-21, but around 13:00 began rapidly declining (confusion, unable to walk) and started experiencing EKG changes (9 beats of SVT). Patient then coded and resuscitation was attempted for approximately 30 minutes. Patient did not survive the code. Coroner has been notified and family is considering autopsy at time of this report.
VAERS ID: 960426 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034595

Write-up: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar death events for 8 patients. This report is for 1st of 8 patient. A patient of unspecified age and gender received first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history was and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender''s Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. 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.,Linked Report(s) : US-PFIZER INC-2021034597 same drug, reporter and event but different patient;US-PFIZER INC-2021034598 same drug, reporter and event but different patient;US-PFIZER INC-2021034599 same drug, reporter and event but different patient;US-PFIZER INC-2021034600 same drug, reporter and event but different patient;US-PFIZER INC-2021034601 same drug, reporter and event but different patient;US-PFIZER INC-2021034603 same drug, reporter and event but different patient;US-PFIZER INC-2021034596 same drug, reporter and event but different patient.; Reported Cause(s) of Death: expired before receiving the second dose
VAERS ID: 960427 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034596

Write-up: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 2nd of 8 patients. A patient of unspecified age and gender received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender''s Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. 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: expired before receiving the second dose
VAERS ID: 960428 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034597

Write-up: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 3rd of 8 patients. A patient of unspecified age and gender received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender''s Comments: Based on the reasonable temporal association, the Company cannot completely exclude the possible causality between the reported death and the administration of COVID 19 vaccine, bnt162b2. However, more information on the patient''s underlying medical condition, concomitant medications, patient''s age group, clinical course and relevant lab tests would be helpful for the Company to make a more meaningful causality assessment. 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 RA, IEC, as appropriate.; Reported Cause(s) of Death: expired before receiving the second dose
VAERS ID: 960429 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034598

Write-up: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 4th of 8 patient. A patient of unspecified age and gender received the first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number has been requested.; Sender''s Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. 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.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: expired before receiving the second dose
VAERS ID: 960430 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034600

Write-up: 7 residents expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar events for 8 patients. This report is for 6th of 8 patients. A patient of unspecified age and gender received first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at SINGLE DOSE for covid-19 immunisation. The patient''s medical history and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: The event death is assessed as related to BNT162b2 vaccine and documented as such in the global safety database until sufficient information is available to allow an unrelated causality assessment. 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.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: 7 residents expired before receiving the second dose
VAERS ID: 960431 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021034601

Write-up: expired before receiving the second dose; This is a spontaneous report from a contactable nurse. This nurse reported similar death events for 8 patients. This report is for 7th of 8 patient. A patient of unspecified age and gender received first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 22Dec2020 at single dose for covid-19 immunisation. The patient medical history was and concomitant medications were not reported. The patient expired before receiving the second dose on an unspecified date. It was not reported if an autopsy was performed. Information about Lot/Batch number is requested.; Sender''s Comments: Current information is very limited for full assessment. The patient died following the vaccine use; further information such as patient demographics, complete medical history, concomitant medications, concurrent illness and event term details especially death cause and autopsy results are needed for meaningful evaluation. 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.,Linked Report(s) : US-PFIZER INC-2021034595 same drug, reporter and event but different patient; Reported Cause(s) of Death: expired before receiving the second dose
VAERS ID: 960460 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2020-12-30
Onset: 2021-01-07
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       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: 2021-01-17
   Days after onset: 10
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: Glaucoma
Allergies:
Diagnostic Lab Data: Test Date: 20210107; Test Name: COVID-19 virus test; Test Result: Positive
CDC Split Type: USPFIZER INC2021042488

Write-up: died; tested positive for COVID; tested positive for COVID; This is a spontaneous report from a contactable consumer from a Pfizer-sponsored program, Pfizer First Connect. A 97-year-old male patient received the first dose of the bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on 30Dec2020 at 97-years-old at a single dose for COVID-19 immunization; administered by the nursing home. Medical history included glaucoma from an unknown date and unknown if ongoing. Concomitant medications included: "used a sav for skin tears", and "eye drops for glaucoma" from an unknown date to an unknown date. On 07Jan2021, the patient experienced: tested positive for COVID (medically significant). The patient died (death, medically significant) on 17Jan2021. The clinical course was reported as follows: The reporter stated that in regard to the patient''s height and weight: "was probably getting down to about five foot eight. Shrinking." The reporter stated that If she remembered correctly, they were trying to maintain the patient''s weight 135 to 136 pounds. The reporter stated that her father was in a nursing home. The patient received his first dose of the COVID vaccine on 30Dec2020. The patient died on 17Jan2021. The reporter stated that she "wanted Pfizer to know that the little old people in the nursing might not be strong enough for the vaccine." The reporter stated that she was "not calling to complaining." The reporter stated that there was nothing wrong with her dad. He was elderly with no health issues. "He was literally on no medications. The only reason he was in the nursing home was because he was afraid to walk." The reporter stated that she received a call about giving the patient the vaccine and she said yes because she wanted him to have the vaccine. One week after the vaccine, the patient tested positive for COVID "like all the other people" (no further details provided). The reporter stated that her dad had no symptoms of COVID. The director of nursing said the patient was doing so well. The patient ate his lunch, he laid down for nap, and at 14:30 he was gone. The patient "went peacefully in his sleep." The reporter then again stated that the patient literally had nothing wrong with him. "They were shocked. They fed him and he took a nap. He was sleeping, but it was eternally." The reporter stated that, "it might not have been the Pfizer vaccine, maybe his heart wore out." In regard to an autopsy: the reporter stated that they would get it done if needed. The patient underwent lab tests and procedures which included COVID-19 virus test: positive on 07Jan2021. History of all previous immunization with the Pfizer vaccine considered as suspect: none. It was unknown if there were additional vaccines administered on the same date of the Pfizer suspect, but the reporter doubted it. There were no prior vaccinations within 4 weeks. There were no adverse events following the prior vaccinations. The clinical outcome of the event, died, was fatal. The clinical outcome of the event, tested positive for COVID, was unknown. The patient died on 17Jan2021 due to an unknown cause of death. An autopsy was not performed. The batch/lot numbers for the vaccine, PFIZER-BIONTECH COVID-19 MRNA VACCINE, were not provided and will be requested during follow up.; Reported Cause(s) of Death: died
VAERS ID: 960552 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-18
Onset: 2021-01-18
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       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: 2021-01-18
   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: Patient was a hospice patient who was not doing well for several days per nurse. Patient had not eaten or consumed liquids in a few days.
Preexisting Conditions: Patient was a hospice patient.
Allergies: No known Allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: At approximately 930am I arrived at Memory Care. I met with the director of the facility and she directed me to where my team would be setting up. My team consisted of (technician), (nurse) and I. As we were setting up, the director asked how she can help. I explained to her that we would need a designated area for patients to be monitored after vaccination for 15 minutes and maybe even longer . I also explained that we would need one of her staff monitoring while we vaccinate. She agreed, and proceeded to designate her staff and the cafeteria area, facing the vaccination station,the monitoring station. Throughout the day, nurse and I were both vaccinating,while the staff of the facility would monitor the vaccinated patients. I would also stop occasionally to mix the vaccine and check the temperature of the aero safe. At approximately 12:50pm, the director rushed in and stated that a patient is not responding, and that she had been vaccinated. At that point, I grabbed epipens and a thermometer and I also instructed nurse to grab an Epipen and come with me. We followed the director to pt''s room. Once we got to the room, the patient was in bed and there were 4 staff members standing bedside and one of them turned and stated the patient has passed. At that point I asked the staff how long ago did the patient get the vaccine, they stated about 30 minutes ago. They also stated that the patient was a hospice patient and that the patient had declined, and was rapidly detiorating and had not eaten or drank anything all day . They also stated that the patient had been monitored for 15 minutes post vaccination. I then left the room and grabbed the patients COVID Vaccine intake consent form. I looked at the answered questionaire and all the responses were circled NO. Patient had a temp of 96.5 at the time of vaccination.The vaccine administration information for Immunizer Section was filled out by Nurse. I then proceeded to ask the director once again if there were staff that was monitoring her for 15 minutes, the director stated they had staff monitoring her. She also stated the Hospice nurse has to announce her death, so they waited for the Hospice Nurse to come. I then called Corporate and explained the situation. After speaking to corporate, I also asked nurse, if she remembered the patient. She stated that she did and at the time of the vaccination the patient was not alert, there were two staff members with the patient. She was non oriented and she kept closing her eyes. At that point, Nurse stated that she asked the two staff members with her if this is how she usually is and if its ok to vaccinate her. Both Staff members stated that it its ok,this is how she is. The Nurse then proceeded to vaccinate. At approximately 3:10pm, as I was leaving I spoke to the director, and one of her Staff members. Staff that the patient has actually not eaten/ or drank anything for the past several days, including today(01/18/21). Staff also stated that on Friday, Jan 15th,2021, they had informed the family that the patient was rapidly detiorating. Staff also stated that the family knowingly gave the consent to vaccinate her. She also stated that the hospice Nurse believes that the death was primarily caused by her detiorating state. She also stated that the hospice Nurse informed that the death was not due to the Vaccine. Per Lead Pharmacist at the clinic.
VAERS ID: 960752 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Louisiana  
Vaccinated: 2021-01-14
Onset: 2021-01-14
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Fatigue
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Several .. I have a list
Current Illness: No
Preexisting Conditions: Diabetic , High Blood Pressure
Allergies: No
Diagnostic Lab Data:
CDC Split Type:

Write-up: Extreme Fatigue
VAERS ID: 960841 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-17
Onset: 2021-01-19
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Chest X-ray abnormal, Death, Lung infiltration, Pyrexia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (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 (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: 2021-01-21
   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: Amantadine, clonazepam, clobazam, lovenox, dextroamphetamine-amphetamine , famotidine, gabapentin, keppra, robinul, polyethylene glycol, propanolol, sertaline, senna, valproic acid, vimpat, cefepime
Current Illness: none
Preexisting Conditions: ventilator dependent, anoxic encephalopathy, seizure disorder
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed 104.4 temp approximately 48 hours after being given the vaccine. I treated him with antibiotics, IV fluids, cooling methods. CXR does show a new right perihilar infiltrate. However, his fever came down within the next 24-48 hours. Unfortunately, he suffered a cardiac arrest on 1/21/21 in the early morning and expired.
VAERS ID: 961010 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram head normal, Ecchymosis, Haematoma, Troponin increased
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Myocardial infarction (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: encephalopathy; gastritis unspecified with bleeding; essential primary HTN; benign prostatic hyperplasia without lower urinary tract sx; hypothyroidism; hyperlipidemia; spinal stenosis; sacral and sacro ccygeal region; anxiety; atrial fibrillation; GERD without esophagitis; edema unspecified; weakness; dementia; hammer toe acquired right foot
Allergies: Hydralazine
Diagnostic Lab Data: 1/19/2021 CT of head negative 1/19/2021 Troponin 3,000
CDC Split Type:

Write-up: Resident returned to the memory support unit at 1500. Resident was than toileted and transferred in to bed per his request. At 1515 resident was observed face down beside bed, resident sustained a 1inX1in eccyhmotic/hematoma to the forehead. Neuro Checks with in normal limes Vital signs: 100/52, 100, 97.2, 28. Resident sent to ED for further medical evaluation via EMS.
VAERS ID: 961339 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-18
Onset: 2021-01-19
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK - / SYR

Administered by: Work       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Wellbutrin, Ambien
Current Illness:
Preexisting Conditions: COPD, Sleep apnea
Allergies: contrast die
Diagnostic Lab Data:
CDC Split Type:

Write-up: possibly got it at clinic, possibly who administered shot. Pts. daughter said the pts boyfriend denied any symptoms the whole day but that in the middle of the night the pt passed away.
VAERS ID: 961434 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Echocardiogram abnormal, Musculoskeletal stiffness, Pulseless electrical activity, Pupil fixed, Resuscitation
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), Dystonia (broad), Parkinson-like events (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Arthritis (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Tamsulosin 0.4 mg daily Metoprolol Succinate ER 100 mg daily Rivaroxaban 15 mg daily Levothyroxine 100 mcg daily Furosemide 40 mg daily Atorvastatin 40 mg daily Amiodarone 200 mg daily Nitroglycerin 0.4 mg SL PRN Aspirin 81 mg daily Polyeth
Current Illness: Chronic back pain
Preexisting Conditions: Cardiovascular LBBB (left bundle branch block) HTN (hypertension) Pure hypercholesterolemia CAD (coronary artery disease) Acute systolic heart failure (HCC) Atrial fibrillation (HCC) ? Nephrology Stage 3 chronic kidney disease ? Endocrinology Controlled type 2 diabetes mellitus with microalbuminuria, without long-term current use of insulin (HCC) Amiodarone-induced thyroiditis ? Other BPH (benign prostatic hyperplasia)
Allergies: No know allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is a 94-year-old male who is brought in by ambulance after being found on the floor with unknown downtime. He was in asystole upon EMS arrival. He remains in asystole. No advanced airway is in place. The patient is getting compressions from Lucas device upon arrival. It was reported that he was last talked to by family at 2 PM. The patient got his SARS-CoV-2 vaccination this morning. The patient is evaluated emergently. CPR was ongoing with 3 rounds of epinephrine given. The patient remains in asystole. He has rigor mortis. The patient''s pupils are fixed and dilated. The patient has compressions paused and ultrasound is used to evaluate for cardiac activity. None is detected. The patient has no electrical activity on monitor. The patient''s time of death is 2113.
VAERS ID: 961705 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-18
Onset: 2021-01-20
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E51686 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Vomiting projectile
SMQs:, Acute pancreatitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Phenergan, melatonin, clonazepam, vit d, asorbic acid, zinc, cholecalciferol, lomotrigine, cimetadine, quetiapine,
Current Illness: none
Preexisting Conditions: Frontotemporal dementia, copd, type 2 diabetes with kidney disease, Anxiety, Atherosclerotic heart disease, covid 19 on 10/15/2020
Allergies: no known allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: approximately 3 hours prior to expiring the patient was experiencing forceful emesis. later was found to have expired, patient was comfort care only.
VAERS ID: 961741 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 - / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK UN / -

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

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: copd/chf/sleep apnea/afib/lymphoma
Preexisting Conditions: as above
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient received his vaccine in the. morning of 1/20/2021, while getting into car to go see his pulmonologist, about 2 hours after, collapsed, unresponsive with asystolic cardiac arrest. No symptoms prior other than chronic dyspnea. No allergic type symptoms reported by family. Asystole with EMS, no response to ACLS, presented to ED, DOA.
VAERS ID: 961776 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Resuscitation, 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: 2021-01-14
   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 325mg, Aspirin 81mg, Celecoxib 200mg, Docusate Sodium 100mg, Furosemide 40mg, Glimepiride 2mg, Lantus SoloStar 100unit/ml Pen-Injector, NovoLog FlexPen 100 Unit/ml Injection Pen, Senokot 8.6mg, Nu-Iron 150mg, Lisinopril, 20mg,
Current Illness: None
Preexisting Conditions: Hypertension, Type 2 Diabetes
Allergies: None Known
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1/13/2021 12:00 PM: Patient received COVID-19 Vaccine. 1/14/2021 21:00: Nurse performed routine rounds and the patient appeared okay. 1/14/2021 22:00: CNA discovered patient unresponsive in bed, began CPR, and called 911. 1/14/2021 23:08: Pronounced deceased.
VAERS ID: 961845 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-12
Onset: 2021-01-17
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 1
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: Narrative:
VAERS ID: 961848 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 2021-01-09
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Condition aggravated, Death, Gastrointestinal haemorrhage, Liver function test increased, Upper gastrointestinal haemorrhage
SMQs:, Liver related investigations, signs and symptoms (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (broad), 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: 1
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: AST 1826, ALT 1462 (01/09/2021) up from 01/07/2021 when it was downtrading to AST 52, ALT 193. Initially increased from 12/28/2020 AST 28, ALT 24. 01/01/2021 up to AST 134, ALT 130, increasing and then trending down.
CDC Split Type:

Write-up: Narrative: Was pt previously covid positive?- Yes. Initial- 10/27/2020, 11/29/2020, 12/22/2020 Are there any predisposing factors for patient experiencing adverse drug event?- Yes, patient had multiple co-morbidities including GI bleed, hepatitis congestion due to cardiac issues, treatment for PE, NSTEMI, or antibiotics for PNA, also on concurrent medications APAP, Atorvastatin, Mirtazapine and Duloxetine. Pt with 2 doses of covid-19 vaccine, second one on 01/08/2021, 2 days pre-death Any occurrence of an ADR at time of administration? Did not specify injection site issues, per RN admin note- Vaccine "administered without complications." Did patient recover from event? Not s/p dose on 01/08/2021. First dose given on 12/21/2021, LFTS increased ~01/01/2021, peaked on 01/03/2021 and were decreasing on 01/07/2021 Was there an ADR between observation period and date of death? No Did patient recover from event? No (01/08/2021 event, died 01/10/2021) Was patient hospitalized prior to vaccination? Yes, in between inpatient and nursing home Was patient hospitalized prior to death--was hospitalization attributable to ADE? Yes re-admitted to inpatient on 12/31/2020. GI bleed Is there an alternative cause of death? Yes, as noted above. Quite a complicated case with many comorbidities/concurrent medications as noted above. Primary Diagnosis: Upper GI Bleed in the death note from 01/10/2021
VAERS ID: 962307 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: South Dakota  
Vaccinated: 2021-01-04
Onset: 2021-01-04
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Fatigue, Limb discomfort, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

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: USPFIZER INC2021045398

Write-up: tired; legs felt heavy; stopped breathing; This is a spontaneous report from a Pfizer-sponsored program a non-contactable consumer. A 93-year-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 04Jan2021 11:00 at single dose for covid-19 immunisation. The patient medical history and concomitant medications were not reported. Patient received vaccine around 11:00 a.m. About two hours later, he said he was tired and couldn''t continue with the physical therapy he was doing. He was taken back to his room, where he said his legs felt heavy. Soon after, he stopped breathing. A nurse declared a do-not-resuscitate order. The patient died on 04Jan2021. It was not reported if an autopsy was performed. Outcome of stopped breathing was fatal. Outcome of tired and legs felt heavy was unknown. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: stopped breathing
VAERS ID: 962308 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Utah  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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: Medical History/Concurrent Conditions: Dementia; Hospice care (on hospice, frail, but in good condition)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021045659

Write-up: died; This is a spontaneous report from a Pfizer-sponsored program. A contactable consumer reported that an 83-year-old female patient (reporter mother) received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. Medical history included hospice care and dementia. The patient''s concomitant medications were not reported. The patient died one day after getting vaccine. She was reportedly in good health the day before receiving vaccine. She was on hospice, frail, but in good condition and checked by a hospice nurse the day before which she reported her in good health considering. She was with dementia but stable in her health. The reporter read investigating 23 deaths of people receiving vaccine in similar conditions. The patient died on an unspecified date. It was not reported if an autopsy was performed.; Reported Cause(s) of Death: died
VAERS ID: 962318 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2020-12-29
Onset: 2021-01-19
   Days after vaccination: 21
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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
CDC Split Type:

Write-up: Called to schedule second vaccine and daughter reports that he died on01/19/2021 with "COVID"
VAERS ID: 962325 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Anxiety, Death, Dizziness, Headache, Injection site pain, Nausea, Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Patient''s wife called this morning stating that her husband has passed away last night. After receiving first dose of Pfizer COVID-19 vaccine at around 0830, patient remained in the Immunizations Department for the 15-minute monitoring period. Per wife, patient''s only complaint was pain at the injection site. At 1300, wife states that patient complaint of dizziness which "dissipated after a few minutes" followed by a headache which "dissipated after a few minutes" as well. Then patient complained of nausea, no vomiting and "couldn''t relax." Per wife, from around 1400/1500, patient stayed on his recliner while still having a conversation with her--"he didn''t get up to eat." Last conversation they had was around 2000/2100. Per wife, at around 2100/2200, patient was quiet and when she checked on him, "he wasn''t responding anymore." Wife then called 911, "but they couldn''t revive him."
VAERS ID: 962390 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-10
Onset: 2021-01-10
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Arteriovenous fistula aneurysm, Death, Respiratory failure, Septic shock
SMQs:, Anaphylactic reaction (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 (narrow), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 6
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: intestinal adhesions with obstruction; Intestinal adhesions with partial obstruction; S/P colon resection; SBO (small bowel obstruction)
Preexisting Conditions: chronic renal failure, stage 5; Dilated cardiomyopathy; end stage renal disease on dialysis; End stage heart failure
Allergies: ASPIRIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital after vaccination with Acute hypoxemic respiratory failure, Septic shock; Aneurysm of arteriovenous dialysis fistula; expired 1/16/2021
VAERS ID: 962714 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2020-12-19
Onset: 2021-01-10
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure congestive, Chronic respiratory failure, Death
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
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: Acetaminophen suppository 650mg PRN, atropine 1% opthamlic solution, biotine moisturizing mouth solution, lorazepam concentrate 2mg/ml, milk of magnesia suspension 400mg/5ml, morphine sulfate solution 20mg/ml, zofran ODT tablet 4mg.
Current Illness: Aspiration pneumonia (dx on 12/16/2020)
Preexisting Conditions: Congestive heart failure, chronic respiratory failure, dementia, chronic mylomonocytic leukemia, chronic COPD, coronary artery disease, dysphagia.
Allergies: lisinopril, shellfish
Diagnostic Lab Data: None, no adverse events were observed relating to the COVID vaccine.
CDC Split Type:

Write-up: We do not believe that the patient''s death was an adverse event from the vaccine. Patient received COVID vaccine from Pfizer Dose #1 12/19/2020 (lot # EK5730) and Dose #2 1/7/2021 (lot # EL1284). No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Patient died 1/10/2021 from chronic respiratory failure and congestive heart failure after recent aspiration pneumonia requiring hospitalization. Death was anticipated and not sudden. We were told to report his death to VAERS even though his death was anticipated and not related to his vaccination.
VAERS ID: 962716 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: North Dakota  
Vaccinated: 2020-12-30
Onset: 2021-01-19
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: TRAMADOL, CHOLESTYRAMINE, DICOLFENAC SODIUM TOPICAL GEL, GABAPENTIN, TRAZODONE, LEVETIRACETAM, HYDROXYZINE HCL, FUROSEMIDE, DIVALPROEX SODIUM, ELIQUIS, LEVOTHYROXINE
Current Illness:
Preexisting Conditions:
Allergies: CEPHALEXIN, CODEINE, PENICILLIN, TETRACYCLINE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient deceased
VAERS ID: 962764 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2020-12-17
Onset: 2020-12-21
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure chronic, Condition aggravated, Death, Ischaemic cardiomyopathy, Pneumonia aspiration
SMQs:, Cardiac failure (narrow), Cardiomyopathy (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-23
   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: acetaminophen suppository 650mg, polyvinyl alcohol solution 1.4%, atropine 1% ophthalmic solution, fentanyl patch 72hr 50mcg/hr, lorazepam concentrate 2mg/ml, morphine sulfate solution 20mg/ml.
Current Illness: Scrotal edema, aspiration pneumonia
Preexisting Conditions: Ischemic cardiomyopathy, congestive heart failure, hypertensive heart disease, type 2 diabetes with diabetic neuropathy, spinal stenosis with neurogenic claudication, chronic kidney disease, atrial fibrillation, COPD, venous insufficiency.
Allergies: lisinopril, seroquel, penicillins, beer
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Patient did not have any adverse reaction to the COVID vaccine, but we were asked by our health dept to submit a VAERS report since the patient died between his first and second dose. Received Pfizer Dose #1 12/17/2020. No side effects or adverse events noted; lived in 24/7 care facility and monitored twice daily for reaction. Date of death 12/23/2020 from aspiration pneumonia complicated by end-stage heart failure and ischemic cardiomyopathy. Death was anticipated and not sudden.
VAERS ID: 962784 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-09
Onset: 2021-01-15
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Death, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

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: PNEUMONIA
Preexisting Conditions:
Allergies: LATEX, NATURAL RUBBER
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient expired 1/15/2021; had been treated as outpatient for pneumonia, likely COVID-19 but no positive test result in December 2020. PMH diabetes
VAERS ID: 962827 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-14
Onset: 2021-01-14
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fatigue, General physical health deterioration, Hypoglycaemia, Lactic acidosis
SMQs:, Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Guillain-Barre syndrome (broad), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 0
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:
Preexisting Conditions: chronic combined CHF, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3
Allergies: ATORVASTATIN; CODEINE; DOXY
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted 1/14/21: Patient is an elderly 93-year-old female with multiple medical problems including chronic combined CHF, P 80, diabetes mellitus, HTN, hyperlipidemia, CKD stage 3, has been complaining of generalized weakness, fatigue, decreased appetite for the past few days. She had an outpatient COVID-19 vaccine earlier today. Within 2 hr of admitting the patient to the hospital, condition clinically deteriorated. Patient elected to be DNR/DNI while in the ED. Patient was pronounced dead at 10:30 p.m. earlier today. Preliminary cause of death: Hypoglycemia induced lactic acidosis.
VAERS ID: 962940 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cold sweat, Crepitations, Death, Dyspnoea, Pallor, Productive cough
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Digoxin, Insulin glargine, Loratadine, Simvastatin, Tamsulosin, Warfarin
Current Illness: Unknown
Preexisting Conditions: Dementia, Diabetes, Chronic A Fib, Dyslipidemia, Depression, Osteoarthritis
Allergies: Galantamine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt received second dose of COVID vaccine on 01/20/2021 at 1430. At 1600 Pt developed a wet productive cough with coarse crackles. Pt ate dinner at 5 pm cough persisted. At 18:30 the nurse went to Pt''s room to give him his medications. Pt still had a cough, denied shortness of breath. Pt was in a good mood and joking with staff. Pt asked to be shaved. At 19:45 Pt was sitting in the lounge and a CNA noticed that Pt was pale/white in color and clammy. 02 Sat was 85%. Respirations were labored. Pt was placed on 4 L of 02. Increased to 5 L via face mask and 02 sat was 89-90%. Ambulance was called at unknown time. Pt arrived at Medical Center at 2120 and was pronounced dead at 2127.
VAERS ID: 962966 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-14
Onset: 2021-01-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Laboratory test, Nausea, Pharyngeal swelling, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (narrow), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: atrial fibrillation, hypertension, and hyperlipidemia
Allergies: Codeine
Diagnostic Lab Data:
CDC Split Type:

Write-up: On Saturday, 1/16/2021, Patient went to the grocery store. Upon her return, she indicated she was experiencing N/V and some throat swelling. Patient subsequently collapsed and expired before she could be brought to an emergency room. During investigation by Coroners Office, it has been reported that Patient may have gotten some takeout food while she was out. Labs are pending and the Coroners investigation is ongoing. Spouse believes that her death was caused by the vaccine.
VAERS ID: 962995 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-15
Onset: 2021-01-19
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: No known allergies.
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: No immediate reaction. Patient-reported deceased four days later on Jan. 19, 2021. As of this date cause of death is unknown to our clinic.
VAERS ID: 963016 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-14
Onset: 2021-01-15
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

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: unknown
Current Illness: denied ill symtpoms at time of vaccination
Preexisting Conditions: denied
Allergies: unknown. Denied allergies on vaccine form
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: unknown. Event occurred after leaving vaccination site
VAERS ID: 963057 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-09
Onset: 2021-01-09
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Asthenia, Atrial fibrillation, Azotaemia, Bilevel positive airway pressure, Death, Fatigue, General physical health deterioration, Hypertensive urgency, Hypoxia, Intensive care, Sepsis, Urine output decreased
SMQs:, Acute renal failure (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hypertension, hypothyroidism, emphysema, CKD 3, and history of breast cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: presented to ED 1/9/21 with abdominal pain, progressive worsening weakness and fatigue and new onset A fib with RVR likely due to hypertensive urgency . Patient progressed clinically with severe hypoxia and transferred to ICU and started on BiPAP; progressive decline with decreased urinary output with uremia likely secondary to sepsis. Concern with patient worsening clinical decline, palliative care had been consulted on end of life care. Patient expired 1/17/21
VAERS ID: 963235 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-04
Onset: 2021-01-09
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: COVID-19, Death, Exposure to SARS-CoV-2, SARS-CoV-2 test
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Klonipin, Myrbetriq, Zoloft, Carafate, Isosorbide, Allopurinol, Colace, Calcium Carbonate, Synthroid, Famotidine, Metoprolol, Losartan, Tylenol
Current Illness:
Preexisting Conditions: HTN, Depression, Atherosclerotic heart disease, GERD, Hypothyroidism, Chronic renal failure stage 3, CHF
Allergies: Lisinopril
Diagnostic Lab Data: COVID test
CDC Split Type:

Write-up: Patient diagnosed with COVID on January 9, 2021 after being exposed to family member that was under quarantine in the same household. Admitted to the hospital and was discharged on January 14, 2021 with home hospice. Patient passed away on January 18, 2021
VAERS ID: 963269 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-04
Onset: 2021-01-18
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Work       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Lisinopril, Januvia, Fosamax, Trazodone, Metoprolol, Colace Simvastatin, Levoxyl, Lantus, Zocor
Current Illness:
Preexisting Conditions: Type 2 Diabetes, HTN, DJD, Blindness bilateral, Glaucoma, Dyslipidemia, Diverticulosis, Osteoporosis, Memory loss, Chronic renal failure, CAD
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 01/18/2021
VAERS ID: 963388 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: North Dakota  
Vaccinated: 2021-01-05
Onset: 2021-01-10
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
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: Albuterol, Aspirin, Ativan, Ayr Saline Nasal, Biotene Dry mouth moisturizing spray, docusate sodium, Florajen 3, gabapentin, hydralazine HCL, Hydrocortisone acetate/LI, Isosource VHN 1.5 cal, ketoconazole, Lasix, lopressor, multivitamin, pl
Current Illness: No known illnesses at time of vaccination.
Preexisting Conditions: COPD, Aptyalism, upper respiratory tract infection due to Influenza, acute bronchitis, Pnuemonia, generalized anxiety disorder, impaired intestinal carbohydrate absorption, heart failure, GERD without esophagitis, long term current use of anticoagulant, transplanted skin present, history of UTISs, constipation, Periipheral vascular disease, chronic pain, history of amputation of lower limb above knee, sick sinus syndrome, candidiasis of skin, dysuria, Cerebrovasxular disease, cellulitis of toe of right foot, actinic keratosis, psoriasis, hyperlipidemia, intertrigo, dyspnea, dysphagia, and attention to gastrostomy, history of impacted cerumen in ears.
Allergies: Ceftriaxone sodium, Augmentin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died unexpectedly 5 days after receiving vaccine (1/10/2021).
VAERS ID: 963610 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New Mexico  
Vaccinated: 2021-01-14
Onset: 2021-01-17
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Other       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: 2021-01-17
   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: Asprin 81mg Calcium Acetate 667mg Ensure Plus Eucerin Furosemide 80mg Glipizide 5mg Omeprazole 20mg Renvela 800mg Rifampin 300mg Sensipar Vitamin D3
Current Illness: TB DMII Hyperlipidemia GERD CKD Renal Failure
Preexisting Conditions: MII Hyperlipidemia GERD CKD Renal Failure
Allergies: NKDA
Diagnostic Lab Data: Rapid COVID swab done after death 1/18/21 1:04pm. The result was positive. Previous rapid done on 1/4/21 and was negative.
CDC Split Type: COVID-19 Vaccine

Write-up: Patient deceased on 01/17/2021
VAERS ID: 967743 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 2021-01-21
   Days after onset: 2
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: n/A
Preexisting Conditions: Dementia
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Possible seizer, unknown at this time, aprox 1hr and 20min after vac given. Passed away aprox 2hrs after vac.
VAERS ID: 963902 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-28
Onset: 2020-12-30
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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: ACETAMINOPHEN; ; ; ; HYDROCODONE/ACETAMINOPHEN; ; ; SENNA PLUS [SENNA ALEXANDRINA]; VITAMIN D3
Current Illness: Acute kidney failure; Alzheimer''s disease; Encephalopathy; Hypertension; Urinary retention; UTI
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021019154

Write-up: Death; This is a spontaneous report from four non-contactable consumers via a Pfizer-sponsored program Corporate (Pfizer) Social Media Platforms. A 78-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, on 28Dec2020 at a single dose for COVID-19 immunization. Ongoing medical history included Alzheimer''s Disease, encephalopathy, hypertension, acute kidney failure, urinary retention and recent urinary tract infection (UTI), all from an unspecified date. Concomitant medication included acetaminophen (MANUFACTURER UNKNOWN), bisacodyl (MANUFACTURER UNKNOWN), bupropion (MANUFACTURER UNKNOWN), escitalopram (MANUFACTURER UNKNOWN), hydrocodone bitartrate, paracetamol (HYDROCODONE/ACETAMINOPHEN), loperamide (MANUFACTURER UNKNOWN), ondansetron (MANUFACTURER UNKNOWN), senna alexandrina (SENNA PLUS), vitamin d3 (MANUFACTURER UNKNOWN). The patient had no known drug allergies. The patient experienced death on 30Dec2020. The vaccine was given on 28Dec2020 with no adverse events and no issues on 29Dec2020. The patient died on 30Dec2020, at approximately 2:00 AM. It was unknown if an autopsy was performed. It was unknown if the event was related to the suspect drug, the administrator marked as natural causes. No follow-up attempts are possible; information about batch/lot number cannot be obtained.; Reported Cause(s) of Death: Death
VAERS ID: 964401 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-12
Onset: 2021-01-16
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: none
CDC Split Type:

Write-up: Pt died 4 days after vaccine, no known reaction to the vaccination
VAERS ID: 964617 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Alaska  
Vaccinated: 2021-01-08
Onset: 2021-01-21
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Oxycodone, ventolin, quetiapine, pantoprazole, metoprolol, lorazepam, haloperidol, senna, levetiracetam
Current Illness: Alzheimers, Covid, COPD, Mood disorder, convulsions, HTN, anxiety, DM, parkinson''s,
Preexisting Conditions: Alzheimers, Covid, COPD, Mood disorder, convulsions, HTN, anxiety, DM, parkinson''s,
Allergies: Codeine
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Death, which I believe is unrelated to vaccination
VAERS ID: 964671 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2020-12-18
Onset: 2021-01-02
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-05
   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: Omeprazole, metoprolol, prilosec,, isorbide, senna, nitro, lasix, fluticasone
Current Illness: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Preexisting Conditions: DM, HTN, anemia, gout, BPH, atrial fib, heart failure, CAD, CKD,
Allergies: NKDA, NKFA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death on 1-5-21
VAERS ID: 964724 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2020-12-18
Onset: 2021-01-15
   Days after vaccination: 28
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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: prozac, olanzapine, alendronate, divalproex, mirabegron, metoprolol, proair,
Current Illness: Dementia, Bipolar, COPD, HTN, Schizoaffective
Preexisting Conditions: Dementia, Bipolar, COPD, HTN, Schizoaffective
Allergies: NKDA, NKFA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Death 1-15-21
VAERS ID: 964795 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood culture negative, Computerised tomogram head normal, Diarrhoea, Mental status changes, Pyrexia, White blood cell count normal
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Acetaminophen, Aspirin, Axitinib (Inlyta), Bisacodyl, Duloxetine, Ferrous Sulfate, Glucosamine Chondroitin, Norco, Tresiba, Lovastatin, Magnesium, Senna, Tamsulosin, Warfarin
Current Illness: Metastatic Renal Cell Carcinoma Diagnosed with COVID-19 on 12/7/2020, unknown severity of disease. Received first Pfizer SARS-COV-2 vaccine at the end of December
Preexisting Conditions: Insulin dependent Type 2 Diabetes, CKD3, atrial fibrillation, sick sinus syndrome s/p pacemaker on warfarin, hypertension, diastolic heart failure, gastric ulcers, emphysema
Allergies: Penicillin- Swelling of tongue and neck
Diagnostic Lab Data: 1/14/21 CT head unremarkable, blood culture no growth. Normal WBC 1/18/21 blood cultures no growth
CDC Split Type:

Write-up: Symptoms of fever (Tmax 102.9), diarrhea, and altered mental status started ~ 24 hours after vaccination. No evidence of septicemia with negative blood cultures Minimal improvement over 3 days, transferred to tertiary care center for MRI brain after which LP was recommended. However family declined as intubation would have been required and was not consistent with patient''s goals of care.
VAERS ID: 965256 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2020-12-23
Onset: 2021-01-19
   Days after vaccination: 27
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Atorvastatin calcium 20mg daily
Current Illness:
Preexisting Conditions: Hypertension Hyperlipidemia Obstructive Sleep Apnea Obese Hearing loss Degenerative Disc Lumbar
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found deceased, presumed while exercising
VAERS ID: 965547 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-28
Onset: 2020-12-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / OT

Administered by: Unknown       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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: ASA; ; ; ZYPREXA; FLOMAX [MORNIFLUMATE]; ; VIT C; ; DEPAKOTE; ; ; ALBUTEROL [SALBUTAMOL]; BUSPAR; FIBERCON
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Aspiration; Bipolar disorder; Depressive disorder; Dysphagia; GERD; Hyperlipidemia; Hypertension; Rectal bleeding; Schizophrenia; Violent behavior
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021019107

Write-up: resident coded and expired; This is a spontaneous report from a non-contactable consumer via Pfizer Sponsored Program. A 63-year-old male patient received the 1st dose of bnt162b2 (BNT162B2, Lot # EH9899) intramuscular at single dose at left arm on 28Dec2020 for Covid-19 immunisation. Medical history included no current Illness, no known allergies, but preexisting conditions: dysphagia, violent behaviors, depressive disorder, schizophrenia, aspiration, gastrooesophageal reflux disease (GERD), hyperlipidaemia, bipolar disorder, rectal bleeding, hypertension. The patient had no birth defect. Concomitant medication included asa (ASA) at 81mg, lisinopril (LISINOPRIL) at 10mg daily, ferrous sulfate (FERROUS SULFATE) at 325 (unit unknown), olanzapine (ZYPREXA) at 20mg, morniflumate (FLOMAX [MORNIFLUMATE]) at 0.4 (unit unknown), famotidine (FAMOTIDINE) at 20mg, ascorbic acid (VIT C), carbamazepine (CARBAMAZEPINE) at 250mg bid, valproate semisodium (DEPAKOTE) at 750mg bid, metformin (METFORMIN) at 1000 (unit unknown) bid, sertraline (SERTRALINE) at 100 (unit unknown) bid, albuterol [salbutamol] (ALBUTEROL [SALBUTAMOL]), buspirone hydrochloride (BUSPAR) at 10mg tid, polycarbophil calcium (FIBERCON). The patient died on 29Dec2020. The patient had no ER or Doctor visit and was not hospitalized. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: resident coded and expired
VAERS ID: 965548 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / UNK LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (patient was 14 plus days post COVID); Unresponsive to stimuli
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021019155

Write-up: passed away; This is a spontaneous report from non-contactable consumers received via a Pfizer-sponsored program An 88-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot EL0142) via an unspecified route of administration on 30Dec2020 at a single dose (1 dose) in the left arm (LA) (administered by: senior living) as Covid vaccine. Medical history included patient was 14 plus days post COVID and unresponsive. The patient had no listed allergies. Concomitant medications were not reported. The patient passed away with an hour and half of receiving vaccine on 30Dec2020. Per nursing staff, they did not expect the patient to make it many more days. She was unresponsive in the room when shot was given. It was unknown if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: passed away
VAERS ID: 965561 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-23
Onset: 2020-12-26
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Anxiety, Condition aggravated, Death, Pyrexia, Respiratory distress, SARS-CoV-2 antibody test negative, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-26
   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: LEVOTHYROXINE [LEVOTHYROXINE SODIUM]; ATIVAN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anaphylactic reaction; Anticholinergic syndrome; Central respiratory depression; COPD; COVID-19; Drug reaction with eosinophilia and systemic symptoms; Hypersensitivity; Hypoglycaemia; Neuroleptic malignant syndrome; Respiratory failure
Allergies:
Diagnostic Lab Data: Test Name: covid-19 test; Result Unstructured Data: Test Result:Negative
CDC Split Type: USPFIZER INC2021026454

Write-up: respiratory distress; fever; anxiety developed requiring oxygen; Passed away; This is a spontaneous report via a Pfizer-sponsored program from a non-contactable consumer. A 63-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot and expiry not reported), via an unspecified route of administration on 23Dec2020 at a single dose for COVID-19 immunization. Medical history included anaphylactic reaction (broad), neuroleptic malignant syndrome (broad), anticholinergic syndrome (broad), acute central respiratory depression (broad), hypersensitivity (broad), respiratory failure (narrow), drug reaction with eosinophilia and systemic symptoms (broad), hypoglycaemia (broad), COVID-19 (broad) and chronic obstructive pulmonary disease (COPD); all from an unknown date and unknown if ongoing. Concomitant medications included levothyroxine sodium and lorazepam (ATIVAN). Within 24 hours of receiving the vaccine, the patient experienced fever, respiratory distress, and anxiety developed requiring oxygen, morphine and lorazepam (ATIVAN). The patient passed away on the evening of 26Dec2020. The patient underwent lab tests and procedures which included SARS-COV-2 antibody test: negative on an unspecified date. The outcome of the event death was fatal, while of the other events was unknown. It was not reported if an autopsy was performed. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Passed a
VAERS ID: 965564 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-14
Onset: 2021-01-20
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac 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), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Cardiac arrest Narrative:
VAERS ID: 965565 (history)  
Form: Version 1.0  
Age: 84.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2020-12-26
Onset: 2021-01-05
   Days after vaccination: 10
Submitted: 2021-01-19
   Days after onset: 14
Entered: 2021-01-22
   Days after submission: 3
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 2 - / -

Administered by: Other       Purchased by: Other
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: Narrative: Please note that patient is a hospice patient. Death occurred 10 days post vaccination. Providers do not believe that there was a correlation. Facility requires that we reports all death even if we suspect no correlation between death and vaccine. Symptoms: & death
VAERS ID: 965571 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-13
Onset: 2021-01-20
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Dysarthria, Fatigue, Malaise, Memory impairment
SMQs:, Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: 1/13/21 pt came into clinic for vaccine. Had difficulty remembering age. Called me Mon. 1/18/21 stating she was sick. When asked what her sx were, she stated fatigue. She was well the night of the shot, Thur. and Fri. but became tired on Sat. and Sun. I went through other sx with her such as h/a, fever, n/v, muscle aches, weakness and she said she experienced none of those. I questioned her about eating and drinking and she said she ate and drank water. She seemed fine so I told her to call her doctor if she was worse or the fatigue persisted or call 911. She agreed. Two staff from clinic called her Mon. and Tues, (1/18 and 1/19). On Tues. she may have had sl slurred speech. She was found deceased on
VAERS ID: 965807 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-08
Onset: 2021-01-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Immobile, Pruritus, Respiratory disorder, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), 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), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: metoprolol, methotrexate, calcitrol, digoxin, calcium prednisone, clopidogrel, levothyroxine, folic acid, pantoprazole, eliquis, atorvastatin, latanoprost, melatonin
Current Illness: nose bleeds
Preexisting Conditions: rheumatoid arthritis, atrial fibrillation
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: began itching within 24 hours, within 5 days couldn''t move on her own, by 6th day was having respiratory issues, by day 7 unresponsive, by day 8 dead
VAERS ID: 965831 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-18
Onset: 2021-01-20
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Albuterol Sulfate HFA 108 MCG/ACT AERS Allopurinol 300 MG Oral Tablet Aspirin Low Dose 81 MG TABS Baclofen 10 MG Oral Tablet Bystolic 10 MG Oral Tablet Clobetasol Propionate 0.05 % External Cream Cyanocobalamin 1000 MCG TABS Fish Oil
Current Illness: Emergency Room Visit 1/7/2021 complaining of shortness of breath and swelling. She and elevated D-dimer with no evidence of a Pulmonary Embolus. Persantine Myoview showed small mild area of reversible ischemia to the inferolateral apical wall. Mild symptoms of vague discomfort in her chest, but nothing that has been reproducible with activity. She is chronically short of breath with limited activities because of problems with her hip
Preexisting Conditions: Active Problems Abdominal distention (R14.0) Cellulitis (L03.90) Chronic hip pain (M25.559,G89.29) Chronic UTI (N39.0) Colon polyps (K63.5) Coronary artery disease involving native coronary artery of native heart with angina pectoris (I25.119) Edema, leg (R60.0) GERD (gastroesophageal reflux disease) (K21.9) Gout (M10.9) Left kidney mass (N28.89) Lump of right breast (N63.10) Morbid obesity (E66.01) Neuropathy, diabetic (E11.40) Pain with urination (R30.9) Protein in urine (R80.9) Respiratory crackles at right lung base (R09.89) Type 2 diabetes mellitus (E11.9) Venous (peripheral) insufficiency (I87.2)
Allergies: Allergies: Brilinta, ACE Inhibitors, Bactrim, Cipro, Codeine Derivatives, Penicillins, Statins, sulfa
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her first dose of vaccine on Monday, January 18th. Two days later on Wednesday, January 18th, she retired to bed early. Later that night when her husband went to bed, he found her in the bed deceased. No other details of the event are know.
VAERS ID: 965860 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-21
Onset: 2021-01-21
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Dyspnoea
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Patient had increased SOB while at home. EMS was called. Patient coded in the squad
VAERS ID: 965910 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: D.C.  
Vaccinated: 2021-01-11
Onset: 2021-01-22
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELI284 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: not known
Current Illness: not known
Preexisting Conditions: not known
Allergies: not known
Diagnostic Lab Data: Not known at this time.
CDC Split Type:

Write-up: The employee found dead at her home on 1/21/2021.
VAERS ID: 965922 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Maryland  
Vaccinated: 2021-01-19
Onset: 2021-01-22
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: pt denied
Preexisting Conditions: pt denied
Allergies: pt answered no
Diagnostic Lab Data:
CDC Split Type:

Write-up: We were alerted that the patient died at home.
VAERS ID: 966178 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-19
Onset: 2021-01-22
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: 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: 2021-01-22
   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 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily
Current Illness: skin ulcer of lower right leg due to old gun shot wound
Preexisting Conditions: alcoholism in remission, aortic stenosis-mild, arthritis, blood loss anemia, carpel tunnel syndrome bilateral, cellulitis of right leg, chronic insomnia, COPD, diverticulosis of sigmoid and descending colon, eczema, gun shot wound of leg, heart murmur-right upper external border, hemorrhoids, history of blood transfusion, history of falling, lyme disease, osteoarthritis of left knee, pneumonia, polyp of colon flat, peripyloric ulcer, peptic ulcer disease, sleep apnea, unspecified essential hypertension, viral meningitis
Allergies: aminoglycosides and sulfa meds
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt called son to let him know he couldn''t breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15
VAERS ID: 966359 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Indiana  
Vaccinated: 2021-01-19
Onset: 2021-01-20
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death, Headache, Injection site pain, Vomiting
SMQs:, Acute pancreatitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Levothyroxine, Gabapentina, furosemide, Losartan, pravastatin
Current Illness: Diabetes, hyper tension
Preexisting Conditions: Diabetes
Allergies: Aleve
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache, pain in the injection site, threw up. A few hours later she died.
VAERS ID: 966844 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New Mexico  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Feeling abnormal, Palpitations
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: DM II
Preexisting Conditions: DM II
Allergies: KNA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient is reported to have died at home, the day after his COVID test. Family member states that he did good the afternoon and evening after his COVID-19 injection, but that he started not feeling good the next day. The patient "was having palpitations". The family tried to convince him to go to the Emergency Room, but he refused. Patient died at home.
VAERS ID: 966856 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-31
Onset: 2021-01-04
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E10140 / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bacterial test positive, Blood bilirubin increased, Blood creatinine increased, Blood glucose normal, Blood potassium decreased, Blood sodium increased, Blood urea increased, Chest X-ray normal, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Coronavirus infection, Culture urine negative, Death, Decreased appetite, Fluid intake reduced, General physical health deterioration, Haematoma, Haemoglobin decreased, Hyporesponsive to stimuli, Nitrite urine absent, Platelet count normal, SARS-CoV-2 test positive, White blood cell count increased, White blood cells urine positive
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Covid outbreak in the facility tested two week before negative.
Current Illness: unk
Preexisting Conditions: renal AND Alzheimer''s
Allergies: unk
Diagnostic Lab Data: 1/8: White blood cell count 11.6, hemoglobin 12.2, platelets 369. Sodium is 165, potassium 3.2. BUN/creatinine creatinine are 48 and 1.2. Bilirubin is 1.6. Glucose 127. Urinalysis has 25 leukocytes, negative nitrites, 10-15 white blood cells, 1+ bacteria. Chest x-ray shows no acute cardiopulmonary disease. CT scan of the head shows a tiny left frontal scalp hematoma, with nothing else acute. - 1/9: White blood cell count is 13.5, hemoglobin 12.1. Sodium is 168, potassium 3.4. BUN/creatinine are 47 and 1.3, glucose 145. - 1/10: WBC 15.5, Hgb 10.6. Plt 268. Na 169, K 4.0, Glucose 174. BUN/Cr 38/1.1. Urine culture showed NO GROWTH. - 1/11: WBC: 12.7 HGB: 10.2 PLT: 223 SODIUM: 164 POTASSIUM: 3.9 GLUCOSE: 172 BUN: 32 CREATININE: 1.2 SArs-cor-2 RDRp gen detected 1/4/2021 ( NEDS ID 7797449)
CDC Split Type:

Write-up: Patient is a 90-year-old female. She is a nursing home resident with and ongoing COVID 19 outbreak occurring . She has been diagnosed with corona virus on 1/4/21. She apparently has not eaten or drank anything in about a week. She was being hydrated at the nursing home with normal saline, but has failed to improve. She was sent to the ER and was admitted on 1/8/21 to hospital At no time during the hospital stay has she been more than minimal responsive. She need O2 for Comfort but on CXR and CT cardiopulmonary imagining was clear. Discharge note stated that he was requiring supplemental oxygen, but her chest x-ray on admission actually showed no acute cardiopulmonary disease. She was diagnosed with COVID-19 on 1/4/21. Most likely, this disease set her level of function back to the point that she was no longer eating and drinking, and she just overall rapidly declined after that. There was no evidence of an actual COVID pneumonia or pneumonitis. On 1/12/2021 family made patient a DNR and IVF were stopped and switched to comforted care. Patient expired 1/13/21
VAERS ID: 966888 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Nevada  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: At 04:30 on 1/22/2021, facility was notified of employee death at home.
VAERS ID: 967240 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2020-12-29
Onset: 2021-01-06
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Patient unexpectedly died on o1/6/2020. No known signs or symptoms.
VAERS ID: 967399 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Tennessee  
Vaccinated: 2021-01-12
Onset: 2021-01-21
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: No
Preexisting Conditions: diabetes
Allergies: No
Diagnostic Lab Data: no
CDC Split Type:

Write-up: Sudden death
VAERS ID: 967506 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-16
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 20
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ketoconazole, lisinoprol, atravastatin, xarelto, bupropion, sertraline
Current Illness:
Preexisting Conditions: Congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died within 5 days of receiving vaccine. Exact cause and day unknown.
VAERS ID: 967830 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-21
Onset: 2021-01-21
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / UNK UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Bilevel positive airway pressure, Breath sounds absent, Cardio-respiratory arrest, Death, Endotracheal intubation, Hypoxia, Mechanical ventilation, Pulse absent, Pulseless electrical activity, Pupillary reflex impaired, Respiratory acidosis, Respiratory failure, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (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), 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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: AMLODIPINE BENZOATE , ATORVASTATIN CALCIUM, LOSARTAN POTASSIUM, METOPROLOL SUCCINATE, metFORMIN
Current Illness: HTN, DM2. COVID-19 infection, 12/24/20.
Preexisting Conditions: HTN, DM2.
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was was brought to the ED from facility which he received the vaccine via ambulance with BiPAP, hypoxia, and one dose of Epi of 0.3 mg. He then required intubation, and had struggled with hypoxia, even on increasing PEEP. CODE BLUE called in the ED for PEA. He was medicated for such (please see the code run sheet for details), and he came in and out of the code 5 times. After 95 minutes, with the wife at the bedside, and family conference by phone, the code was called, and he was pronounced at 18:20. He received in total 8 me of Epi, 3 shots of Atropine, 3 amps bicarb. He got lasix 40 mg, lovenox 60 mg subcutaneous once. He had a CVC into the right internal jugular, and levophed was started, then Epinephrine drip was started. Prior to the code he got steroids (solumedrol 125 mg, then later decadron 6 mg iv), benadryl iv, antibiotics (ceftraixone / zithromax), and lasix 40 mg. All this time while in the ED, the Rt was at the bedside, and lots of secretions from the lungs were aspirated, bloody color. Code was the result of PEA secondary to hypoxia (

VAERS ID: 968195 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-12
Onset: 2021-01-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Fatigue, Headache, Hypoaesthesia, Pain in extremity, Pyrexia, Resuscitation, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (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 (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sexual dysfunction (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? No
Previous Vaccinations:
Other Medications: I do not have that information at the time of this filing. I?m his Son making the filing
Current Illness: None known
Preexisting Conditions: Type-2 Diabetes, Hypertension.
Allergies: None known.
Diagnostic Lab Data:
CDC Split Type:

Write-up: My dad got the Moderna Vaccine on Tuesday, January 12, 2021 in his left arm at the Mall injection site for the Health Department. He was told that the side effects could mean his arm hurting, tiredness, headache, and even a low grade fever. Additionally, the site informed us both (as I was with him to get the injection) that this was all normal and not to seek medical attention unless these symptoms last longer than 72 hours. That evening, my dad was experiencing all of those symptoms, and went to bed at 7pm. A little after 10am on Wednesday, January 13, 2021, when he awoke, my dad went to the bathroom vomiting. This was where he collapsed and went into cardiac arrest. Fire/Rescue was dispatched about 10:30am after my mom started CPR. County Fire Rescue EMTs and Paramedics continued CPR and other attempts at reviving him all the way to Hospital Emergency Department. He was pronounced dead at 12:14pm on Wednesday, January 13, 2021. We have no doubt my dad, following the instructions of the injection facility, thought he was just experiencing the side effects of the vaccine. He had no chance. Had this injection been done in the RIGHT arm, perhaps he could have recognized the arm numbness being that of an impending heart attack. We really miss Dad. He served this country with distinction for over 50 years, and we believe his country failed him.
VAERS ID: 968707 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: none
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: My mother died 12 hours after the vaccine was administered
VAERS ID: 968846 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Aphasia, Cerebral haemorrhage, Cerebrovascular accident, Death
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Bisoprolol 10-62, Fluticasone, Montelukast, Oxybutynin 15mg
Current Illness: None
Preexisting Conditions: Hypertension
Allergies: Dust mites and outdoor allergens
Diagnostic Lab Data:
CDC Split Type:

Write-up: Within 15 minutes of the injection, the individual became aphasia and stroke like symptoms. She was taken to the ER where she was later diagnosed with a cerebral hemorrhage and passed away.
VAERS ID: 969219 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: South Carolina  
Vaccinated: 2021-01-23
Onset: 2021-01-24
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 7+ LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: 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: 2021-01-24
   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: furosemide 40 mg indomethacin er 75 mg venlafaxine 75 mg tab hydralazine 50 mg metoprolol tart 100 mg verapamil er 240mg captopril 100 mg tamsulosin 0.4 mg oxybutynin er 15 mg pot cl micro er 20 meg spironolactone 25 mg gabapentin 300 mg
Current Illness: reported on profile were hypertension, pain, gout, bladder and urine flow issues
Preexisting Conditions: hypertensin gout
Allergies: no known allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: patient received the Moderna Covid 19 vaccine on 1/23/2021 around 5:45pm wife called management today and reported that he had collapsed and passed away today around noon
VAERS ID: 969220 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-15
Onset: 2021-01-22
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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:
Preexisting Conditions:
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient expired one week after vaccine. Cause of death unknown to me.
VAERS ID: 969363 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-14
Onset: 2021-01-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0029L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cough, Death, Dyspnoea, Hyperaesthesia, Mental status changes, Oxygen saturation decreased, Pyrexia, Screaming, Speech disorder
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (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: 2021-01-18
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hypothyroidism Hypertension Diabetes Hypercholesterolemia Chronic pain GERD
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient obtained initial dose of Moderna vaccine on Thurday, Jan 14. No adverse effects reported during initial 15 minute post vaccine waiting period. Saturday morning (Jan 16), patient developed severe cough, labored breathing, and fever. Additionally patient mental status changed suddenly, became non-communicative (unable to speak, but would scream if she was touched). O2 status was irregular, dropping to 78. Sunday morning, EMT and then hospice was hospice called. Monday morning, after hospice emergency kit was initiated, patient passed away.
VAERS ID: 969488 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Virginia  
Vaccinated: 2021-01-11
Onset: 2021-01-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram, Fatigue, Full blood count, Haematoma, Metabolic function test, Myalgia, Vomiting
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: losartan, doxazosin, metoprolol, Areds 2 eye vitamins
Current Illness: Covid 19
Preexisting Conditions: hypertension
Allergies: No
Diagnostic Lab Data: CBC, BMP, CT
CDC Split Type:

Write-up: Fatigue, muscle aches, vomiting, hematoma
VAERS ID: 973814 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-12
Onset: 2021-01-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 2
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 Narrative:
VAERS ID: 973820 (history)  
Form: Version 1.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-23
Onset: 2021-01-13
   Days after vaccination: 21
Submitted: 2021-01-22
   Days after onset: 9
Entered: 2021-01-24
   Days after submission: 2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Symptoms: & DEATH DUE TO COVID 01/13/21 Treatment:
VAERS ID: 969636 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-05
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Decreased appetite, Electrocardiogram abnormal, Pain, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (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: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: METFORMIN; GLIMEPIRIDE; LISINOPRIL; ATORVASTATIN; ASPIRIN (E.C.); METHIMAZOLE; PROPRANOLOL; CILOSTAZOL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: AV block; Cataracts; Diabetes; Hashimoto''s disease; Hypertension; Hypertriglyceridemia; Premature ventricular contractions (Occasional); Smoker
Allergies:
Diagnostic Lab Data: Test Name: ecg; Result Unstructured Data: AV Block and occasional PVC''s
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Found dead at home slumped on the floor; Loss of appetite; Body aches; Feverish; A spontaneous report was received from a physician, concerning a 65-years-old male patient, who received Moderna''s COVID-19 Vaccine and experienced feverish, body aches, loss of appetite, and death. The patient''s medical history, as provided by the reporter, included diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia. Concomitant medications reported included metformin, glimepiride, lisinopril, atorvastatin, aspirin, methimazole, propranolol, and cilostazol. On 05 Jan 2021, prior to the onset of events, the patient received the first of two planned doses of mRNA-1273 (lot number 037k20a) for COVID-19 infection prophylaxis. On an unknown date in Jan 2021, some time after receiving the vaccine, the patient was feeling feverish with body aches and loss of appetite. On 09 Jan 2021 at approximately 21:30, the patient was found dead at home slumped on the floor. According to the paramedics, the patient was dead longer than when his wife found him, and no resuscitation was performed. Action taken with mRNA-1273 in response to the events was not applicable. The outcome of the events, feverish, body aches, loss of appetite, was considered resolved. The patient died on 09 Jan 2021. The cause of death was not reported. The reporter assessed the event, death, as not related to Moderna''s COVID-19 Vaccine. The reporter did not provide assessment for the events, feverish and body aches, in relation to Moderna''s COVID-19 Vaccine.; Reporter''s Comments: This case concerns a 65 year old male patient with medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia, who experienced the serious unexpected event of death, non-serious unexpected event of loss of appetite, and non-serious expected events of fever and body pain. The event of death occurred 5 days after the first dose of mRNA-1273. The events of fever, body pain and loss of appetite occurred an unspecified period of time after the first dose of mRNA-1273. Very limited information regarding these events has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Definitive causal association is confounded by age and medical history of diabetes, hypertension, Hashimoto''s, smoker, cataracts, atrioventricular block, occasional premature ventricular contractions, and hypertriglyceridemia.
VAERS ID: 969648 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-29
Onset: 2020-12-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Erythema, Skin warm, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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:
Current Illness: Alzheimer''s disease; COPD
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: death of unknown cause; Swelling on Right side of the neck and under chin; Warmth on right side of neck and under chin; Redness on right side of neck and under chin; A spontaneous report was received from a healthcare professional concerning an 89-year-old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced events of redness, warmth and swelling on right side of neck and under chin, and death of unknown cause. The patient''s medical history included Alzheimer''s and chronic obstructive pulmonary disease (COPD). No concomitant medications were reported. On 29 Dec 2020, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 (Lot number: Unknown) intramuscularly for prophylaxis of COVID-19 infection. On 30 Dec 2020, the patient experienced the events of redness, warmth and swelling on right side of neck and under chin. There was no indication that the patient was transferred out to hospital, which was unlikely because she was under hospice care. On 01 Jan 2021, the patient died due to an unknown cause of death. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 01 Jan 2020. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 89-year-old, female subject with a medical history of Alzheimer''s and chronic obstructive pulmonary disease (COPD) who experienced redness, warmth and swelling on R side of neck and under chin and expired from an unknown cause. The events of redness, warmth and swelling on R side of neck and under chin occurred 2 days after administration of the first and only dose of the mRNA-1273 vaccine and patient expired 4 days after mRNA-1273 vaccine administration. Lot # of the vaccine was not provided. De-challenge and re-challenge are not applicable. The events of redness, warmth and swelling on R side of neck and under chin are temporarily associated with the administration of the mRNA-1273 and thus, a causal relationship cannot be excluded. Due to limited information, the fatal outcome was considered unrelated to mRNA-1273 administration pending additional information. Fatal outcome is confounded by the patient''s underlying condition and advanced age.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 969699 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #027L20A / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Creon 36K -114K Doxycycline Hyciate 100 MG Eliquis 5 mg Furosemide 40 mg Losartan Potassium Pantoprazole Sodium 40 MG Sildenafil Citrate 100 MG Stendra 200 MG Tadalafil 20 MG Tramadol Hcl 50 MG Trazodone Hcl 100 MG Triamcinolone Acetonide
Current Illness: Metastatic duodenal adenocarcinoma , bladder cancer, undergoing chemotherapy with success. Dual chamber pacemaker
Preexisting Conditions: Coronary heart disease
Allergies: None
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient died.
VAERS ID: 970042 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 RA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021019156

Write-up: patient passed away with in 90 minutes of getting vaccine; This is a spontaneous report from three non-contactable consumer reporting on behalf of the patient via a Pfizer sponsored program, Corporate (Pfizer) Social Media Platforms. A 90 (unspecified unit) old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; Solution for injection, lot number: EL0142, unknown expiration), via an unspecified route of administration in right arm (reported as AR) on 30Dec2020 at a single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. It was reported that the patient was a nursing home patient and received the first dose of COVID vaccine on 30Dec2020. The patient was monitored for 15 minutes after getting shot. Staff reported that the patient was 15 days post COVID. The patient passed away with in 90 minutes of getting vaccine on 30Dec2020. The patient did not require office/ ER visit. An autopsy was not performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Patient passed away with in 90 minutes of getting vaccine
VAERS ID: 970043 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 2020-12-10
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Diarrhoea
SMQs:, Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-10
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: Diarrhoea; Gastrointestinal disorder; Pseudomembranous colitis
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021019157

Write-up: Reported causes of death: Diarrhoea; This is a spontaneous report from a contactable healthcare professional via agency and a non-contactable consumer via a Pfizer-sponsored program Corporate (Pfizer) Social Media Platforms. An elderly patient of an unspecified age (also reported as were in their early to mid-60''s) and gender received BNT162B2 (Pfizer-BIONTECH Covid-19 Vaccine), via an unspecified route of administration on 10Dec2020 at a single dose for COVID-19 immunisation. Medical history included pseudomembranous colitis (broad), gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), and noninfectious diarrhoea (narrow) . The patient''s concomitant medications were not reported. The patient experienced diarrhoea on an unspecified date in 2020. It was reported that most of the deaths after the COVID-19 vaccine occurred within 24-48 hours after the shot. The write-ups that accompanied the reports furnished details about these sad fatalities, including the astonishing fact that some of the decreased had actually experienced and recovered from COVID-19 (raising questions about why they were vaccinated). It was also reported that the event was not life-threatening, did not result to a birth defect or permanent disability, did not require any office/ER/doctor visit, and did not require any hospitalization. The patient died on 10Dec2020. It was not reported if an autopsy was performed. The reported cause of death: diarrhoea. No follow up attempts are possible, information about the lot/batch number cannot be obtained.; Sender''s Comments: Based on the available information the event diarrhea resulting in death is attributed to patients preexisting medical conditions including pseudomembranous colitis, gastrointestinal nonspecific symptoms and therapeutic procedures, and noninfectious diarrhea. However, based on a close chronological association (same day) contributory role of BNT162B2 (Pfizer-BIONTECH Covid-19 Vaccine) to event exacerbation cannot be completely excluded. 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: Reported causes of death: Diarrhoea
VAERS ID: 970162 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Maryland  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021046017

Write-up: received the vaccine on Tuesday and was found dead at his kitchen table Wednesday afternoon; This is a spontaneous report from a contactable consumer. An 89 years old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on an unknown date, at single dose, for COVID-19 immunization. Medical history and concomitant medications were not reported. The patient received the vaccine on Tuesday (unspecified date) and was found dead at his kitchen table on Wednesday afternoon (unspecified date). Cause of death was unknown. It was unknown if an autopsy was performed. Information about batch/lot number has been requested.; Reported Cause(s) of Death: received the vaccine on Tuesday and was found dead at his kitchen table Wednesday afternoon
VAERS ID: 970412 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-18
Onset: 2021-01-18
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cardio-respiratory distress, Death, Dyspnoea, Endotracheal intubation, Fatigue, General physical condition abnormal, Pyrexia
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: thiamine 100 MG tablet sevelamer carbonate 800 MG tablet Multiple Vitamins-Minerals (MULTIVITAMIN ADULT) Tab carvedilol 3.125 MG tablet ascorbic acid 500 MG tablet lisinopril 10 MG tablet
Current Illness: High blood pressure. Dialysis
Preexisting Conditions: kidney failure, Dialysis patient
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever Feeling tired short of breath all night and morning after the vaccine My grandma had to be intubated and then passed away to a heart distress we think it was the vaccine because she was fine even with dialysis. When she got the vaccine it took hours and her health conditions changed.
VAERS ID: 970495 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-13
Onset: 2021-01-16
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Hypertension, Diabetes Type 2, cardiac disease.
Allergies:
Diagnostic Lab Data: Unknown.
CDC Split Type:

Write-up: Patient expired three days after receiving first dose of Moderna COVID-19 vaccine. The death certificate states cause of death is sudden cardiac arrest.
VAERS ID: 970618 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-22
Onset: 2021-01-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cerebrovascular accident, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), 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), 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: 2021-01-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: HOSPITAL STATED PATIENT HAD A STROKE
CDC Split Type:

Write-up: SON SAID PATIENT WAS FOUND UNRESPONSIVE AND CALLED 911
VAERS ID: 970930 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-09
Onset: 2021-01-14
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, Fall, Head injury, Respiratory disorder, SARS-CoV-2 antibody test negative, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: I-caps
Current Illness: -
Preexisting Conditions: AAA
Allergies: Penicillins
Diagnostic Lab Data: Patient had positive PCR test on 1/21. IgG to COVID was negative on 1/19.
CDC Split Type:

Write-up: Pt developed COVID-19 infection, symptoms starting 7 days after first dose was given. Patient was admitted to hospital on 1/21 after falling (secondary to weakness) and striking head on toilet. Patient expired due to respiratory complications of COVID on 1/25.
VAERS ID: 970976 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Connecticut  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypotension, Lethargy, Oxygen saturation decreased, Rales, Tachycardia, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), 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), Pulmonary hypertension (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), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: VEntolin inhaler, Ursodial, Protonix, MVI, Mirtazapine, Lasix, Coumadin
Current Illness: Admitted from home to hospital on 1/5 for pancreatitis, Chocystitis, GI bleed. HAd a biliary stent placed. TEsted positive for Covid 19 on 1/7/21. Transferred from hospital to a covid recovery Short term facility and transferred to this facility on 1/18/21 for long term care. She was admitted on comfort measures due to prior decline
Preexisting Conditions: as above.
Allergies: NKA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: At approximately 12:15 pm the resident had a brief unresponsive episode that resolved quickly. Her Vital signs were stable and her mentation was at baseline. Later that evening approximately 10 pm she had labored respirations, shortness of breath, lethargy with bilateral crackles, Oxygen desaturated to 76% on room air, tachycardia and hypotension. She expired at 6:30 a.m. the following day.
VAERS ID: 971176 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-20
Onset: 2021-01-21
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Autopsy, Cardiac arrest, Death, Fatigue, Livedo reticularis, Malaise, Respiratory arrest, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: atorvastatin 10 mg avodart 0.5 mg finasteride 5 mg colace 100 mg fish oil capsule over the counter nabumetone 750 mg omiprazole 20 mg tamsulosin 0.4 mg calcium plus D3 over the counter
Current Illness: last doctor visit on 10/27/2020 and no illness at that time, routine follow up
Preexisting Conditions: BPH reflux (Gerd) Osteoarthritis high cholesterol
Allergies: none
Diagnostic Lab Data: Autopsy being done.
CDC Split Type:

Write-up: Pt. woke up the next morning after vaccination and "didn''t feel well", described by wife as fatigue, no energy. At approximately 2 PM, he vomited. His wife checked on him at 4:20 PM and he wasn''t breathing sitting in his chair. EMS squad was called but when they arrived he was asystole and mottling present. Did not start CPR since he was already gone too long. Pronounced by coroner on scene.
VAERS ID: 971559 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-01
Onset: 2021-01-19
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: USPFIZER INC2021053200

Write-up: her mother passed away 7-8 days after receiving the vaccine; This is a spontaneous report from a contactable consumer, the daughter of the patient. A female patient of an unspecified age received the first dose of COVID-19 mRNA VACCINE (MANUFACTURER UNKNOWN), via an unspecified route of administration in Jan2021 as a single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. On 19Jan2021 about 7-8 days after receiving the vaccine, the patient passed away. The patient was fine before she received the vaccine and then passed away 7-8 days later. The cause of death was not reported. It was not reported if an autopsy was performed. The reporter thought her mother''s death had everything to do with the COVID-19 vaccine. The lot number for the vaccine was not provided and will be requested during follow up.; Reported Cause(s) of Death: Death
VAERS ID: 971562 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: New York  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Immune thrombocytopenia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021058222

Write-up: died; acute immune thrombocytopenia; This is a spontaneous report from two contactable consumers. A patient of unspecified age and gender received BNT162B2(lot number and expiration date not provided) via an unspecified route of administration on unspecified date at single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient died after receiving the covid vaccine on an unknown date. The patient developed acute immune thrombocytopenia on an unknown date. It was unknown if autopsy was performed. The cause of death was unknown. The outcome of the event "died" was fatal and of the event " acute immune thrombocytopenia" was unknown. The reporter wondered if a platelets blood problem may lead to death and if who have a blood platelets condition like essential thrombocytosis should not risk taking the vaccine. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: Died
VAERS ID: 971676 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2020-12-31
Onset: 2021-01-01
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Retroperitoneal fibrosis (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 18
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, aleve, aspirin, bisacodyl, calcium carb-cholecalciferol, diclofenac, fluticasone-Salmeterol inhaler, hydromorphone, hycacyamine sulfate, ketoconazole cream, levemir, lidocaine patch, lisinopril, mematine, methcarbamol, metoprolol,
Current Illness: HYPERLIPIDEMIA, UNSPECIFIED(E78.5), CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED(J44.9), VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE(F01.50), OTHER SPECIFIED ANXIETY DISORDERS(F41.8), VENTRAL HERNIA WITHOUT OBSTRUCTION OR GANGRENE(K43.9), NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED(K52.9), CHRONIC VASCULAR DISORDERS OF INTESTINE (K55.1), SACROCOCCYGEAL DISORDERS, NOT ELSEWHERE CLASSIFIED(M53.3), OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE(M85.80), PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM(Z86.718), PRESENCE OF INTRAOCULAR LENS(Z96.1), ANEMIA, UNSPECIFIED(D64.9), DISORDER OF WHITE BLOOD CELLS, UNSPECIFIED(D72.9), IRRITABLE BOWEL SYNDROME(K58), ABDOMINAL AORTIC ANEURYSM, WITHOUT RUPTURE(I71.4), PAIN IN RIGHT ANKLE AND JOINTS OF RIGHT FOOT(M25.571), TYPE 2 DIABETES MELLITUS WITH DIABETIC PERIPHERAL ANGIOPATHY WITHOUT GANGRENE(E11.51), ACUTE HEMATOGENOUS OSTEOMYELITIS, OTHER SITES(M86.08), ESSENTIAL (PRIMARY) HYPERTENSION(I10), GROSS HEMATURIA(R31.0), MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED(F33.9), CHRONIC KIDNEY DISEASE, STAGE 2 (MILD)(N18.2), WEDGE COMPRESSION FRACTURE OF T11- T12 VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING(S22.080D), PERIPHERAL VASCULAR DISEASE, UNSPECIFIED(I73.9), BODY MASS INDEX [BMI]40.0-44.9, ADULT(Z68.41), HYPERMETROPIA, BILATERAL(H52.03), OTHER MYELODYSPLASTIC SYNDROMES(D46.Z), MUSCLE WEAKNESS (GENERALIZED)(M62.81
Preexisting Conditions: see #11
Allergies: hydrocodone, metformin, niacin, Aricept, lipitor
Diagnostic Lab Data: resident hospitalized on 1/6/21
CDC Split Type:

Write-up: muscle aches-increased pain to lower back
VAERS ID: 971736 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Iowa  
Vaccinated: 2021-01-21
Onset: 2021-01-21
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Neurological symptom, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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, aspirin, atorvastatin, bicalutamide, Plavix, lisinopril, metoprolol, multivitamin, oxycodone, Seroquel, sertraline, vanicream
Current Illness: DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING (S72.142D), MALIGNANT NEOPLASM OF PROSTATE(C61), UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE(F03.90), ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS(I25.10), DISPLACED FRACTURE OF BASE OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING(S72.041D), ESSENTIAL (PRIMARY) HYPERTENSION(I10), ANEMIA, UNSPECIFIED(D64.9), HYPOKALEMIA(E87.6), ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE(I21.3), MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED(F33.9), HYPERLIPIDEMIA, UNSPECIFIED(E78.5), ALZHEIMER''S DISEASE WITH LATE ONSET(G30.1), OTHER ABNORMALITIES OF GAIT AND MOBILITY(R26.89), DISORIENTATION, UNSPECIFIED(R41.0), MUSCLE WEAKNESS (GENERALIZED)(M62.81), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12)
Preexisting Conditions: see #11
Allergies: terbinafine, ACE inhibitors, tetanus toxoids
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vomit 30 minutes after administration. approx. 9 hours later, resident has Stroke-like symptoms. He was previously on Hospice before admitting to our facility and planned to be readmitted to hospice upon discharge.
VAERS ID: 971813 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Alabama  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Posture abnormal
SMQs:, Dystonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: not known
Current Illness: A fib, type 2 diabetes, HTN, seizure disorder, CHF
Preexisting Conditions: A fib, type 2 diabetes, HTN, seizure disorder, CHF, Z alpha hydroxylase deficiency
Allergies: Iodine
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient received vaccine on 1/20/2121, later that night husband found her slumped in chair, called EMS and patient was taken to Hospital where she died on 1/21/2021
VAERS ID: 971969 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-01-15
Onset: 2021-01-21
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: HTN, BCC, HLD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: brought by EMS to ED; seizures at home in bed; 6 Epi and 1 bicarb; no hx of seizure
VAERS ID: 972092 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: Diabetes Prescription
Current Illness: Diabetes Mellitus
Preexisting Conditions: Diabetes Mellitus
Allergies: None reported
Diagnostic Lab Data:
CDC Split Type:

Write-up: Reportedly, this employee''s mother died the night of the vaccine. The details are not known at this time.
VAERS ID: 972113 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Epistaxis, Lethargy, Mouth haemorrhage, Pneumonia
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: Pantoprzole, Miralax, Potassium, buspirone, Aspirin 81mg, Atenolol, Depakote, Glucosamine-chondroitin, mirabegron ER, Zyprexa, Atorvastatin, Ocuviteeye&MVM
Current Illness: Resident was Dx with pneumonia the day after vaccine.
Preexisting Conditions: ENCEPHALOPATHY, UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED,UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE, UNSTEADINESS ON FEET, UNSPECIFIED HEARING LOSS, UNSPECIFIED EAR, DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS, CONSTIPATION, UNSPECIFIED, LONG TERM (CURRENT) USE OF ASPIRIN,MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED , GENERALIZED ANXIETY DISORDER, AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE,HYPERLIPIDEMIA, UNSPECIFIED, LOCALIZED EDEMA, ESSENTIAL (PRIMARY) HYPERTENSIONGASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS, UNSPECIFIED URINARY INCONTINENCE,
Allergies: NKA
Diagnostic Lab Data: No test performed. Resident''s family did not wish for any tx to be provided. Comfort measures only
CDC Split Type:

Write-up: Resident became lethargic and reports of blood coming from resident''s nose and mouth on the morning of 1/13/21. Resident went out to ER for eval, and came back to facility with dx of pneumonia and recommendations for resident to be placed on hospice. Resident deceased on 1/14/21. Unknown if vaccine related, but with timeline of events I was advised to report this per medical director of facility, as well as Pharmacy who administered the vaccine.
VAERS ID: 972148 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Computerised tomogram head, Fall, X-ray of pelvis and hip
SMQs:, Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: ATIVAN 0.5MG EVERY 6 HOURS SYNTHROID 75MCG DAILY METOPROLOL TARTRATE 50MG TWICE DAILY MED PASS 2.0 THREE TIMES DAILY COLACE 200MG DAILY DICYCLOMINE 10MG TWICE DAILY NORCO 5-325MG FOUR TIMES DAILY NEURONTIN 100MG TWICE DAILY NEURONTIN 3
Current Illness: RESIDENT SUSTAINED A FALL ON 1/5/2021.
Preexisting Conditions: HYPOTHYROIDISM HYPERTENSION GERD ANXIETY DEPRESSION OSTEOARTHRITIS TRAUMATIC SUBDURAL HEMORRHAGE DEMENTIA HYPERLIPIDEMIA ALZHEIMERS SPINAL STENOSIS ATHEROSCLEROTIC HEART DISEASE PULMONARY FIBROSIS ABDOMINAL HERNIA BLADDER DISORDER
Allergies: NKDA
Diagnostic Lab Data: X-RAY OF PELVIS/HIP CT SCAN OF BRAIN
CDC Split Type:

Write-up: VACCINATION WAS RECEVIED THE MORNING OF 1/5/2021- IN THE EVENING OF THAT DAY RESIDENT SUSTAINED A FALL AND WAS TRASNPORTED TO FACILITY FOR TREATMENT. IT IS NOT UNUSUAL THAT RESIDENT WAS SELF TRANSFERRING AND HAS A HISTORY OF FALLS.
VAERS ID: 972167 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Alabama  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 0000-00-00
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None listed
Current Illness: none listed
Preexisting Conditions: none listed
Allergies: None listed
Diagnostic Lab Data: None known
CDC Split Type:

Write-up: Wife reported that 3 hours after receiving vaccine, pt had MI.
VAERS ID: 972370 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-20
Onset: 2021-01-21
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       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: 2021-01-21
   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: patient received covid vaccine and had a heart attack the next day and died
VAERS ID: 972392 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2020-12-30
Onset: 2021-01-02
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death, General physical health deterioration, 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: 2021-01-25
   Days after onset: 23
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Left femur fx 12-7-20 UTI 12-7-20
Preexisting Conditions: Diabetes Type 1 Rheumatoid Arthritis GERD HTN
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient sent to hospital 1/2 and 1/5. Returned both times to nursing home covid unit without a hospital admission. Resident had been diagnosed with COVID later in the day on 12/30, when routine testing PCR results returned to facility, after resident had already had her first covid vaccination on 12/30/20 in the morning. Resident continued decline, was again sent to hospital on 1/24/21, and expired in hospital 1/25/21.
VAERS ID: 972394 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-19
Onset: 2021-01-20
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 UN / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Unknown
Preexisting Conditions: No chronic health conditions
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died about 24 hours later
VAERS ID: 972610 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-21
Onset: 2021-01-23
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Death, Dementia, Pulse absent, Resuscitation, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (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), Dementia (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Aspirin EC 81mg, Atorvastatin 10mg, Glipizide 5mg, Lisinopril 40mg, Metoprolol tartrate 25mg, Latanoprost, Sertraline 25mg, Paliperidone 324mg q28 days, Acetaminophen 325mg, Naproxen 500mg, Capsaicin 0.025%, Glucose 40%, Naloxone Nasal Sp
Current Illness: Fall on 1/2/2021
Preexisting Conditions: Allergic Rhinitis, Back Pain, BPH, Cataract, DM2, Essential hypertension, Hyperlipidemia, Morbid Obesity, Schizophrenia
Allergies: No known allergy
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient was tested positive for Covid-19 on 12/9/20. Patient received Covid Vaccine on 1/21/21. Patient was observing for 15 minutes in treatment room by Nursing staff. Patient denied any signs/symptoms adverse effect: headache, dizziness & weakness, difficulty breathing, muscle pain, chills, nausea and vomiting, and fever . Patient seated on treatment table appeared to be relaxed, respiration even and unlabored. Health teaching provided. Patient educated to report any changes in condition to staff immediately. Patient verbalized understanding and able to verbalize signs and symptoms and adverse effects to be aware of related vaccine. On 1/22/21: patient was seen by medical provider for "altered behavior". Per medical provider''s documentation: "Patient was fallen on 1/2/21 and was sent out to outside hospital on 1/4/21. CT head: no intracranial abnormality, age-related changes. Patient had labs (B12, RPR, folate) were within normal limit". We did MMSE today: 22/30 score "mild dementia" On 1/23/20: "Patient was inside his cell. He was walking towards cell door to obtain his breakfast, when custody witnessed him collapse and activated the alarm. Nursing staff arrived at cell front at 06:34 am and found the patient pulseless and unresponsive, and CPR was immediately initiated. AED was attached at 06:35 am and no shock advised. AMR then arrived and patient did not have ROSC, and was pronounced dead at 06:54 am."
VAERS ID: 972782 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-18
Onset: 2021-01-23
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EC3247 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Death
SMQs:, Haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Amlodipine 2.5 mg Eliquis 2.5mg Aspirin 81 mg Cholecalciferol 1.25 mg Ondansetron 4mg , Thiamine HCL 100, Inrebic 100mg Oral Capsule
Current Illness: Acute Myeloid Leukemia
Preexisting Conditions: Myelofibrosis Hypertension Generalized Weakness Ulcerative Colitis Lymphadenopathy Diabetes Mellitus Type 2 Mets to Bone, Lymph node metases, DVT
Allergies: Compazine Trazadone, Augmentin Penicillin
Diagnostic Lab Data: Not Applicable
CDC Split Type:

Write-up: Resident expired on 1/23/21 . Resident receiving care under hospice ,diagnosis Acute Myeloid Leukemia.
VAERS ID: 972836 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-20
Onset: 2021-01-24
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: lorazepam, trazodone, levothyroxine , acetaminophen, multivitamin, senna
Current Illness: no
Preexisting Conditions: Alzheimer''s disease
Allergies: Levofloxacin, ACE inhibitors
Diagnostic Lab Data: no
CDC Split Type:

Write-up: sudden death
VAERS ID: 972890 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: New York  
Vaccinated: 2020-12-29
Onset: 2021-01-10
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Communication disorder, Confusional state, Death, Feeding disorder, Oxygen saturation decreased, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: unknown
Current Illness: COVID-19 positive on November 19, 2020 and didn''t test negative until December 26, 2020
Preexisting Conditions: Macular Degeneration
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: On the evening of 10JAN2021, patient experienced a low grade fever, decreased oxygen saturation of 38%, heart rate of 124, confusion. Patient received oxygen via face mask, morphine and ativan. By 11JAN2021, patient was no longer verbal, able to eat or communicate and was kept on comfort measure only. On the morning of 17JAN2021, the patient passed away.
VAERS ID: 973808 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-17
Onset: 2020-12-31
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anaemia macrocytic, Atrial fibrillation, Bandaemia, Blood beta-D-glucan positive, Blood lactate dehydrogenase increased, Blood lactic acid increased, C-reactive protein increased, Chemotherapy, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Cough, Death, Dyspnoea, Fibrin D dimer increased, Fungal test negative, Haematocrit decreased, Haemoglobin decreased, Hypoxia, Inflammatory marker increased, Intensive care, Lung infiltration, Lung opacity, Packed red blood cell transfusion, Periorbital oedema, Pneumonitis chemical, Procalcitonin increased, Pulmonary oedema, Pulmonary pneumatocele, Radiotherapy, Red blood cell sedimentation rate increased, Respiratory failure, SARS-CoV-2 test negative, Serum ferritin increased, Shift to the left, Tachycardia
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), 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), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Periorbital and eyelid disorders (narrow), Hypersensitivity (narrow), Myelodysplastic syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Sepsis (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 10
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: Covid tests- negative: Jan 10, 2021 10:30 Not Detected Jan 03, 2021 14:13 Not Detected Dec 31, 2020 17:25 Not Detected Dec 31, 2020 08:40 Not Detected Dec 10, 2020 09:45 Not Detected Nov 05, 2020 16:58 Not Detected Nov 01, 2020 18:15 Not Detected Aug 25, 2020 12:20 Not Detected Aug 12, 2020 Not Detected Jan 01, 2021@11:25 SERUM BD GLUCAN: $g500 H Jan 01, 2021@11:25 SERUM BD GLUCAN INTERPRETATION:POSITIVE normalcy status - Abnormal INTERPRETATION REFERENCE RANGE: <60 pg.mL Fungal serology 1/8/21 Crypto: not detected CocLPA: negative CocIDTP: negative 1/15/21: Outside Coccidioidomycosis serology laboratory report received. Complement fixation serum 1/13/21 2:40pm: Negative. Immunodiffusion Serum 1/15/21 11:17am: Negative. Interpretation Serum 1/15/21 11:17am: Any coccidioidal infection is so well focalized that serology is not positive to a diagnostic level. If onset of illness has been within the past four weeks you may wish to follow up with another specimen in 2 to 3 weeks.
CDC Split Type:

Write-up: shortness of breath, chest xray with pulmonary edema, periorbital edema Narrative: 73 yo M w/ PMH HTN, HLD, EVAR (2013) for AAA c/b persistent type II endoleak s/p multilple repairs (2015 & 2017) c/b glue embolization down into the R CIA secured with additional stent placement with the R iliac limb, s/p b/l Iliac artery aneurysm stent 08/31/20, and PTSD. Former smoker, quit 12+ yrs ago. 11/1/20-11/6/20: Hospitalized for acute on chronic back pain, found to multiple hypermetabolic lesions in the axial skeleton. Diagnosed with epithelioid angiosarcoma. Patient discharged to facility. 12/17/20: Patient received his 1st COVID-19 vaccine w/o complications at facility. 12/21/20: Underwent cyberknife treatment. 12/31/20: Transferred from facility to ER for new O2 requirement, SOB, cough, chest X ray / pulm edema, tachycardic and new periorbital edema. 12/31/20: Admitted to ICU before transfer to acute care. 1/1/21: Pulmonary consult, "Labs are notable for progressive left shift with bandemia, markedly elevated inflammatory markers (D-dimer, ESR, CRP, ferritin, LDH), mild elevation in procalcitonin, mild elevation in lactate that has improved, and negative viral panel including COVID-19 x2. CT chest is notable for b/l GGOs along with some interstitial infiltrates with an upper and particularly mid zone and perihilar predominance, septal thickening and crazy paving, and numerous cystic lesions or pneumatoceles. There is a lack of lobar consolidation and pulmonary nodules. Of note, PET/CT about 2 months ago only demonstrated some mild to moderate emphysema mostly in the upper lobes. Therefore, there has been a relatively dramatic change in a few months, suggesting a more subacute process, rather than an acute infectious process such as a viral pneumonia, including COVID-19 infection, in which the GGOs tend to be subpleural and peripheral. Overall, our suspicion for COVID-19 is relatively low, with negative testing x2 yesterday, negative testing a few weeks ago, and lack of sick contacts, but it is possible. Therefore, higher on the differential is a more subacute infection or chemotherapy-induced pneumonitis. Risk factors include malignancy, chemotherapy, and use of steroids (equivalence of about 27 mg of Prednisone in the form of Dexamethasone since 11/6/20 without PJP prophylaxis). These risk factors, along with consistent imaging and elevated LDH, make PJP quite likely. Fungal infection is less likely based on imaging. Chemotherapy-induced pneumonitis is a possibility, especially given the more subacute picture based on imaging. Both Gemcitabine and Docetaxel can cause pneumonitis. However, the patient has been on steroids, which is used to treat drug-induced pneumonitis, although this does not exclude it completely." 1/2/21: Transferred to ICU for worsening hypoxemia as patient reached 40L/100% FIO2 and remained on COVID isolation/COVID patient under investigation per ID recommendation. 1/4/21: Isolation precautions discontinued due to lower suspicion for active COVID infection to explain current presentation 1/6/21: Went into atrial fibrillation w/o RVR overnight 1/6. Tolerating, with MAPs in low 60s and HR in high 90s/low 100s. Suspect due to being-1L yesterday from diuresis, lasix stopped. S/p amiodarone bolus + drip, albumin 5% bolus 1/5/21: Macrocytic anemia NOS w/ slowly worsening H/H s/p PRBC x 1 unit 1/7/21: Per ICU Life-sustaining treatment note, "Following discussion w/ patient that his lung dx has been refractory to txt and hasn''t improved despite maximal therapy, patient agreed to transition to hospice after he settles affairs. " 1/7/21 Infectious Disease note: "This is an immunocompromised host due to cancer on active chemotherapy (albeit ANC$g4000 on admission) and notably had been on daily PO dexamethasone 1 mg TID (total daily dose 3 mg, equivalent to 20 mg PO prednisone) since 11/6/20 without any PJP ppx. There was elevated c/f COVID-19 infection in setting of patient''s presenting symptoms, especially in conjunction with b/l GGOs on imaging. Has undergone multiple COVID test that have all resulted negative. Discussed radiographic findings with radiology colleagues, and overall, it is difficult to definitively narrow the differential with imaging alone, but overall density of GGOs seem to appear less likely PJP and more in line with chemical pneumonitis vs COVID, although less typical for viral pneumonia as well. Given false-negative COVID tests are not unheard of, especially in the immunocompromised population, patient was kept on isolation precautions as a PUI for abundance of caution. He is now off precautions. In setting of patient having been on prednisone for some time without PJP ppx, he was also started on treatment dose TMP/SMX. Beta-d-glucan has returned positive, and although not the ideal test for PJP, this can certainly support a potential dx of PJP. Unfortunately, DFA from sputum was not performed due to insufficient sample and currently the patient is unable to produce an additional sample for testing. He is tolerating the high-dose TMP/SMX; we adjusted the dose to three SS tablets TID based on his somewhat declining UOP. Other fungal etiologies are pending work-up as well. Lastly, patient''s chemotherapy is known to cause pneumonitis, but per pulmonology team, he receives prophylactic dexamethasone with his chemo cycles that should help to prevent drug-induced pneumonitis. Remains on the differential for now and this should also be concurrently treated with the steroids he is receiving." 1/10/21: Comfort care initiated. All non-comfort measures were discontinued. Time of death: Jan 10,2021@14:56; immediate cause of death per death note is "hypoxic respiratory failure"
VAERS ID: 973889 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Connecticut  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 OT / 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: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Other- unknown, depot store received call from facility on 1/22 that patient passed around 7pm
VAERS ID: 973957 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-20
Onset: 2021-01-24
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Activated partial thromboplastin time shortened, Blood pressure increased, Computerised tomogram head abnormal, Death, International normalised ratio increased, Platelet count normal, Prothrombin time prolonged, Subarachnoid haemorrhage, Subdural haemorrhage
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Accidents and injuries (broad), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: pantoprazole 40 mg daily potassium chloride 10 meq daily sotalol 120mg BID warfarin 2.5mg daily warfarin 5mg weekly furosemide 40mg daily allopurinol 200 mg daily donepezil 10mg daily lisinopril 5mg daily
Current Illness: none
Preexisting Conditions: atrial fibrillation, hypertension, GERD, prostate cancer
Allergies: penicillin
Diagnostic Lab Data: PT 36.0 PTT 39.0 INR 3.1 platelets 195 Head CT - Large Geographic left parietal/occipital parenchymal hemorrhage with 12mm rightward shift. Subarachnoid and subdural hemorrhage of the left hemisphere.
CDC Split Type:

Write-up: 5 days after receiving his COVID vaccination the patient had a spontaneous (nontraumatic) subarachnoid hemorrhage which was fatal. The patient had previously been stable on his coumadin dosing with therapeutic INRs for the past several months per his wife. At time of presentation his blood pressure in the ER was elevated to 223/94 and his INR was risen to 3.1
VAERS ID: 974033 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Indiana  
Vaccinated: 2021-01-13
Onset: 2021-01-26
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: coronary artery disease, diabetes mellitus, hypertension, TIA, asthma, CVA stroke, anemia, peripheral neuropathy, heart failure, heart disease with congestion
Allergies: Macrobid, depacote, sulfamethoxazole/trimethorpim, lisinopril, lyrica, sumatriptan succinate
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident deceased on 1/26 at 445am. No signs ahead of time.
VAERS ID: 974138 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Georgia  
Vaccinated: 1920-01-18
Onset: 2021-01-23
   Days after vaccination: 36896
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: DEATH- NO OTHER INFORMATION KNOWN
VAERS ID: 974172 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Washington  
Vaccinated: 2021-01-24
Onset: 2021-01-25
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283-WA / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: guaiFENesin, aspirin, celexa, Buprenorphine, zinc, vitamin D, voltaren gel, miralax, hydralazine, ascorbic acid, coreg, tramadol, metolazone, melatonin, potassium, gabapentin, senna, magnesium, ocuvite, losartan potassium, doss, vitamin B1
Current Illness: COVID-19 diagnosis 12/29/2020, pneumonia, CHF, depression, rheumatoid arthritis and anemia.
Preexisting Conditions: CHF, acute on chronic anemia, pulmonary hypertension, chronic pain, chronic kidney disease stage 3,
Allergies: lisinopril
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident passed away 1/25/2021 at 1048pm after the vaccine was given on 1/24/2021. Resident had been being monitored but death was not expected.
VAERS ID: 974422 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-18
Onset: 2021-01-19
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Decreased appetite, Mental impairment, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: depakote, seroquel, aspirin, loratidine, prilosec, senna plus, vitamin D, gabapentin
Current Illness: none
Preexisting Conditions: dementia with behaviors, GERD. H/o HTN and diabetes in past
Allergies: none
Diagnostic Lab Data: none-family wanted no medical testing
CDC Split Type:

Write-up: Patient developed fever to 102 within 24 hours with decreased mentation. Stopped eating/drinking despite aggressively treating fever. Was DNR B status. Family agreed to a trial of IV fluids on 1/21 but was not successfully started until 1/22 after several attempts. Family wanted only comfort measures with no transfer to hospital. Patient continued to have fevers to 102-103 range. Patient passed on 1/23 . Patient did test positive for COVID in early September without significant illness. She was in usual state of health prior to vaccination.
VAERS ID: 974443 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Tennessee  
Vaccinated: 2020-12-30
Onset: 2021-01-02
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Epistaxis, Eye haemorrhage, Full blood count normal, Metabolic function test normal, Mouth haemorrhage, Pyrexia, SARS-CoV-2 test negative, Staring, Tremor, Unresponsive to stimuli
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Retinal disorders (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unkown
Preexisting Conditions: Unknown
Allergies: N/A
Diagnostic Lab Data: CBC/CMP 1/2/21 - Normal Rapid COVID test 1/2/21 - Negative Unsure of tests performed at hospital
CDC Split Type:

Write-up: Patient received Moderna COVID vaccine on 12/30/2020 at a Pharmacy clinic where he was a resident. Nurses at the facility reported that he was responsive and showed no signs of any adverse effects until 1/2/2021 when he was observed slightly unresponsive and staring at the ceiling and trembling. He had a fever of 101F at this time. The facility ordered labs and a rapid COVID test (all of which came back normal) and started IV antibiotics. A few hours later, patient began bleeding from his eyes, nose, and mouth and was sent to the local ER. The patient refused being admitted to the ICU for possible sepsis/hemorrhage and died the following day on 1/3/2021. All healthcare professionals involved agreed that this was not likely due to the vaccine, but needed to be reported nonetheless.
VAERS ID: 974454 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-28
Onset: 2021-01-20
   Days after vaccination: 23
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Patient passed away 23 days after receiving COVID vaccine
VAERS ID: 974489 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-19
Onset: 2021-01-25
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Ipratropium and prednisone prescribed on 1/6/2021. Other medications include albuterol inhaler & nebulizer solution, calcium carbonate, cetirizine, cyclobenzaprine, fluticasone nasal spray, Advair HFA, home oxygen, guaifenesin, lidocaine 5
Current Illness: Asthma, COPD exacerbation.
Preexisting Conditions: Essential hypertension, dyslipidemia, allergic rhinitis, COPD, brain aneurysm, hiatal hernia, tobacco abuse, hyponatremia, normochromic, normocytic anemia, hx of MI, anxiety, intractable pain.
Allergies: Clarithromycin, cefaclor, ciprofloxacin, codeine, erythromycin, penicillins, tramadol, naproxen. All of these cause shortness of breath. Generic lisinopril-HCTZ caused severe headache and nausea. Statins cause joint pain and stiffness, couldn''t walk.
Diagnostic Lab Data: Medical Examiner does not believe this is related to vaccine.
CDC Split Type:

Write-up: No immediate symptoms. No symptoms ever reported. Patient was found dead in her home on 1/25/2021 and last seen on 1/24/2021. Neighbor called for welfare check because they had not seen her and she had not checked mailbox. No evidence of foul play.
VAERS ID: 974553 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-20
Onset: 2021-01-24
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (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: MOBIC, MVI, OLANZAPINE, REMERON, COLACE, TYLENOL
Current Illness:
Preexisting Conditions: SCIZOPHRENIA, DEPRESSION, ANXIETY, HYPERKALEMIA
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: RESIDENT RECEIVED THE VACCINE ON 1/20/2021, RESIDENT HAD BEEN MONITORED EVERY SHIFT AND HAS NOT EXHIBITED ANY SYMPTOMS. RESIDENT WAS OBSERVED TO BE UNRESPONSIVE WITH NO PRESENCE OF VITAL SIGNS ON 1/24/2021. RESIDENT WAS A FULL CODE, CPR INITIATED UNSUCESSFULLY. BASED ON REVIEW WITH PRIMARY CARE PHYSICIAN AND MEDICAL DIRECTOR, THE RESIDENT HAD NOT HAVE ANY OTHER EVENTS PRIOR TO RECEIVING THE COVID VACCINE 4 DAYS PRIOR TO EVENT.
VAERS ID: 974573 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-05
Onset: 2021-01-21
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bradycardia, Chills, Death, Diarrhoea, Hyperhidrosis, Pallor, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Pseudomembranous colitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: SYNTHROID 25MCG DAILY PRILOSEC 10MG DAILY CASODEX 50MG DAILY TYLENOL 500MG THREE TIMES DAILY MULTIVITAMIN DAILY ZOLOFT 25MG DAILY NAPROXEN 440MG DAILY
Current Illness: URINARY TRACT INFECTION
Preexisting Conditions: HYPERTENSION DEMENTIA INTERSTITAL PULMONARY DISEASE GERD HYPOTHYROIDISM PAIN HYPERLIPIDEMIA MALIGNANT NEOPLASM OF PROSTATE OSTEOARTHRITIS CONSTIPATION WEAKNESS UTI PERIPHERAL VASCULAR DISEASE
Allergies: STATINS
Diagnostic Lab Data: NONE- PALLIATIVE CARE
CDC Split Type:

Write-up: ON 1/21/2020 RESIDENT WAS EXPERINCING CHILLS AND LOOSE STOOLS. FOLLOWING THIS EPISODE BECAME UNRESPONSIVE, PALE, DIAPHORETIC AND BRADYCARDIC. PALLIATIVE CARE WAS PROVIDED. RESIDENT PASSED AWAY APPROX. 10 HOURS LATER.
VAERS ID: 974794 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Nebraska  
Vaccinated: 2021-01-12
Onset: 2021-01-21
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-JA / 1 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Bacterial test positive, Blood albumin decreased, Blood alkaline phosphatase increased, Blood creatinine increased, Blood potassium normal, Blood sodium decreased, C-reactive protein increased, Death, Dyspnoea, Haemoglobin decreased, Platelet count increased, Pneumonia, Procalcitonin increased, Sputum culture, Staphylococcus test negative, Troponin normal, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol, amlopidine, aspirin, atorvastatin, lasix, gabapentin, HCTZ, hydroxyzine, lansoprazole, levalbuterol, losartan, meloxicam, Norco, Nystatin, Preservision, Prolia, Refresh eye drops, Spiriva, Wixela
Current Illness: Pneumonia, pleural effusion, COPD,
Preexisting Conditions: macular degeneration, hyponatremia, osteoporosis, anemia, hx of breast cancer, GERD, hyperlipidemia, OSA, ex-smoker
Allergies: Sulfa, duloxetine
Diagnostic Lab Data: LAB: WBC 37.7, HGB 7.3, CRP, 24.4, platelet 867, negative for MRSA screen, normal flora sputum culture, PCT 5.69, UA 1+bacteria, Na+130, K+ wnl, ALK phos 183, albumin 1.5, Creatinine 1.88, troponin neg. Radiology:
CDC Split Type:

Write-up: Patient presented to Vaccine clinic 1/12/21 to receive COVID vaccination. Patient denied any ill feeling, no fever, cleared for vaccination. Is chronically SOB due to COPD, but patient reported no different than usual. Presented to the ED the next day c/o SOB and weakness for the last week. Patients condition ultimately declined over the next few days and died 01/21/21 from pneumonia (not COVID). Patient did admit she lied about her symptoms on the day of vaccination to get the shot.
VAERS ID: 974833 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: North Dakota  
Vaccinated: 2021-01-19
Onset: 2021-01-24
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Blood culture positive, C-reactive protein increased, Cerebral haemorrhage, Chest X-ray, Chest pain, Coagulation test, Computerised tomogram head abnormal, Computerised tomogram thorax normal, Dyspnoea, Endotracheal intubation, Fibrin D dimer increased, Gram stain positive, Haematology test, Laboratory test, Neck pain, Pyrexia, Seizure like phenomena, Unresponsive to stimuli, Urine analysis, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (broad), Convulsions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: isosorbide mononitrate ER 30mg daily, allopurinol 300mg daily, aspirin 81mg daily, nitroglycerin 0.4mg PRN, rosuvastatin 10mg daily, codine/guaifenesin syrup 5lm PO Q6H PRN, fursemide 40mg BID, levothyroxine 75mg daily, metoprolol succinate
Current Illness: unknown
Preexisting Conditions: CHF, heart murmur, hyperlipidemia, hypertension, aortic valve leak, acute renal failure, history of CABG, AICD and heart stent placement
Allergies: NKA
Diagnostic Lab Data: 1/24/21 0445:hematology, chemistry, coagulation, UA, CXR, Chest CT. 1/24/21 1705: hematology, chemistry, CXR, Head CT.
CDC Split Type:

Write-up: 1/24/21 0445- patient presents to the ED with complaints of neck pain, chest pain, and back pain for about a week. States also feels SOB, intermittent fever with temperature 100.3 on arrival. Patient was worked up for his cardiac type symptoms, found to have elevated WBC and CRP with no explanation. D-Dimer was elevated with CT showing no sign of PE. Patient was sent home from the ED with instructions to follow up with primary care and/or return if s/s worsen. 1/24/21 1705- patient is returned to the ED via ambulance after becoming unresponsive and some seizure like activity. Patient was intubated. Head CT showed large brain bleed that was irreparable and not compatible with life. Patient was also found with positive blood cultures x2 with gram positive cocci in clusters growing after 9 hours.
VAERS ID: 974855 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-25
Onset: 2021-01-25
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL 3249 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Hypoxia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: pantoprazole, levothyroxine, lisinopril, lamotrigine, atenolol, mirtazapine, furosemide, dronabinol
Current Illness: hypothyroid, hypertension
Preexisting Conditions: same
Allergies: No Known Allergies
Diagnostic Lab Data: sent to the Medical Examiner office for Autopsy
CDC Split Type:

Write-up: decedent had shortness of breath and hypoxia, cardiac arrested in front of the EMS crew, ACLS initiated, arrived in the Hospital ED asystole and pronounced dead
VAERS ID: 974960 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-05
Onset: 2021-01-14
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Culture urine, Full blood count, Muscle rigidity, Pyrexia, Urinary tract infection, Urine analysis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: JEVITY, FAMOTIDINE, VALIUM, ATROPINE, LABETALOL, PROSCAR, LASIX, DUONEB, KEPPRA, GUIAFENESIN, ERYTHROMYCIN ETHYLSUCCINATE
Current Illness: UTI
Preexisting Conditions: TRAUMATIC BRAIN INJURY, VEGETATIVE STATE, HYPERTENSION, HEART FAILURE, POST TRAUMATIC SEIZURES, CHRONIC RESPIRATORY FAILURE, FLACCID HEMIPLEGIA, GASTROPARESIS, APHASIA
Allergies: AMOXIL
Diagnostic Lab Data: 1/14/2021- URINALYSIS WITH CULTURE, CBC
CDC Split Type:

Write-up: ON 1/14/2021 TYPICAL UTI SYMPTOMS FOR RESIDENT DEVELOPED INCLUDING FEVER AND RIGIDITY. RESIDENT IS NON-VERBAL. IV ANTIBIOTICS WERE STARTED. FREQUENT UTI''S ARE COMMON FOR THIS RESIDENT.
VAERS ID: 975002 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027C20A / 1 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Balance disorder, Computerised tomogram head abnormal, Death, Diarrhoea, Fall, Headache, Subdural haematoma, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Pseudomembranous colitis (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), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: Influenza vaccine 10/06/2020, age 88, fever, chills, vomiting, malaise
Other Medications: Cholecalciferol 1000 ius daily, Magnesium Oxide 400mg BID, Vi
Current Illness: Stable
Preexisting Conditions: Chronic atrial fibrillation (on warfarin), coronary artery disease, chronic heart failure with preserved ejection
Allergies: Bee venum, shellfish, adhesive tape, cardizem, primidone
Diagnostic Lab Data: 1/13/2021 CT scan head
CDC Split Type:

Write-up: on 1/13/2021 at 3:40am Cliff called for assistance. He lost his balance and had fallen. Cliff refused vitals, refused emergency department, denied hitting his head. As the day progressed patient developed a headache, diarrhea, and vomiting. He again declined the offer for the emergency room. At supper time wife and staff found Cliff unresponsive, 911 was called and he was taken to the emergency department. The ER did a CT scan and found an acute subdural hematoma. Patient was placed on comfort cares and expired at 3pm on 01/14/2021. Cliff did not have a history of falls.
VAERS ID: 975023 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-25
Onset: 2021-01-25
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Respiratory syncytial virus test negative, SARS-CoV-2 test negative, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: ATORVASTATIN 20MG DAILY, GABAPENTIN 300MG TWICE DAILY, HYDRALAZINE 10MG 3 TIMES DAILY, LANTUS 30UNITS AT BEDTIME, LUMIGAN OPHTHALMIC SOLN BOTH EYES EVERY EVENING, METOLAZONE 2.5MG DAILY, OMPERAZOLE 20MG DAILY, PREDNISONE 15MG DAILY, TORSEMI
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, HYPERTENSION, DIABETES MELLITUS, COPD, TOBACCO USE, ALCOHOL INTAKE, RESPIRATORY FAILURE, PVD, PROTEINURIA, PERICARDITIS, HYPERLIPIDEMIA, OBESITY, ILD, HYPONATREMIA, CKD STAGE 3, BPH, ANEMIA, BILATERAL HEARING LOSS, GERD, HYPERSENSITIVITY PNEUMONITIS, DIASTOLIC CONGESTIVE HEART FAILURE, SOLITARY PULMONARY NODULE
Allergies: SULFA, IODINE-BASED CONTRAST MEDIA
Diagnostic Lab Data: SARS-CoV-2 by PCR - NEGATIVE, FLU-A./B/RSV NEGATIVE
CDC Split Type:

Write-up: CARDIAC ARREST THAT LEAD TO DEATH - IT WAS REPORTED BY EMS THAT THE PT HAD RECEIVED THE VACCINE ABOUT 30 MINS PRIOR. HE ARRIVED HOME, BECAME SHORT OF BREATH & COLLAPSED. 911 WAS CALLED AND HE WAS TRANSPORTED VIA EMS TO HOSPITAL (16:17) WHERE HE LATER EXPIRED (23:01).
VAERS ID: 975184 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-14
Onset: 2021-01-19
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Pharmacy       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: 2021-01-19
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: none
Preexisting Conditions: Heart disease Mild stroke about a year ago
Allergies: none
Diagnostic Lab Data: unknown
CDC Split Type: unknown

Write-up: The patient had a heart attack and died at a local hospital morning of 1/19/2021.
VAERS ID: 975206 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 2021-01-22
   Days after vaccination: 31
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray normal, Culture urine positive, Escherichia infection, Fall, Full blood count normal, Metabolic function test normal, Urinary tract infection
SMQs:, Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: Aricept 10 mg at bedtime; Cerovite Sr, Tablet 1 tablet daily; Coreg 6.25 mg two times a day; Ferrous Sulfate 325 mg two times a day; Folidc Acid 1 mg daily; Lexapro 5 mg daily; Lisinopril Hydrochlorothizide 20-12.5 mg daily; Methimazole 5 m
Current Illness: 11/30/2020 positive for Covid-19
Preexisting Conditions: Alzheimer''s Dementio; Esential hypertension; major depressive disorder, recurrent; osteoarthritis bilateral knees; Hyperlipidemia; specified diorders of thyroid; Vit D deficiency; Impulse control disorder; Unspecified dementia with behavioral disturbance; Hypertensive retinopathy; unspecified abnormalities of gait and mobility; feeding difficulties; other dysphagia.
Allergies: No known allergies
Diagnostic Lab Data: CBC & BMP on 1/8/21 Routine labs Chest X-ray on 1/18/21- no acute pathology Urine culture 1/18/21 final results on 1/21/21 E. Coli infection
CDC Split Type:

Write-up: 1 fall after first dose on 1/8/2021 at 1930; no injuries; 4 falls after second dose on 1/14/21 at 1545, 1/15/21 at 1700, 1/21/21/at 1220 and 1/21/21 at 1330 all falls with no injuries. Started Ceftriaxone 1 GM IM daily for 5 dyas on 1/21/21 for UTI: E. Coli
VAERS ID: 975223 (history)  
Form: Version 2.0  
Age: 105.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-13
Onset: 2021-01-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Headache
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: Azithromycin and Sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Headache-Severe, Systemic: Other- Death 8 days after receiving the vaccine-Severe
VAERS ID: 975382 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-20
Onset: 2021-01-22
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood urea increased, Brain natriuretic peptide increased, Chest X-ray abnormal, Death, Eye movement disorder, Lung opacity, Pneumonia, Pulse absent, Respiratory arrest, Staring, Unresponsive to stimuli, Vomiting, White blood cell count increased
SMQs:, Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 4 hou
Current Illness: Anemia, Dementia, COPD
Preexisting Conditions: Anemia, Dementia, COPD
Allergies: none
Diagnostic Lab Data: 01/20/21-Routine labs ordered, BUN elevated and BNP at 55, 01/22/21-Stat labs ordered-WBC-23, BNP-1426, Xray- 01/22/21-Right lung opacities
CDC Split Type:

Write-up: 01/22/20When transferring resident from bed to W/C Resident became unresponsive to voice with eyes fix open and point up to the right. Placed resident back in bed found 82% o2 sats B/P 110/106 pulse 110 resp below 16 placed o2 via non rebreather with 20 l/min 02 up to 90% then stabilized at 89% Resident following all commands encouraged to take do breathing exercises, with some compliance, continues ABT/pneumonia , no s/s adverse 1/23/2021 16:48 Discharge Summary Note Text: Resident found unresponsive with no pulse or respirations in bed with emesis on gown. Time of death verified at 1645 with LPN. Funeral Home called at 1900 and body released at 2000.
VAERS ID: 975421 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-07
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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 medications for COPD, nebulizers, inhalers
Current Illness: Patient had reported on 8/8/2019 having arthritis, leg wounds, COPD, asthma, incontinence of bladder. Resident may also have had blood clots in his legs, per his sister.
Preexisting Conditions: Same as in Item 11.
Allergies: none known
Diagnostic Lab Data: Unknown by this reporter
CDC Split Type:

Write-up: Resident was discovered deceased in his apartment on 1/23/2021. Family had
VAERS ID: 975434 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-02
Onset: 2021-01-07
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Abnormal behaviour, Blood glucose normal, Cardio-respiratory arrest, Computerised tomogram, Death, Disorientation, Grunting, Oxygen saturation decreased, Pneumonia, Pyrexia, Respiratory failure, Sepsis, Throat clearing, Tremor, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Dementia (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-09
   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: Renvela, Clopidogrel, Coreg, Aceteminophen, amLODIPine Besylate, Atorvastatin Calcium, Benzonatate, Calcium Acetate, Citalopram Hydrobromide, cloNIDine, Cozaar, Diclofenac, Docusate Sodium, Fluticasone-Umeclidin-Vilant Aerosol Powder Breath
Current Illness: OTHER INJURY OF UNSPECIFIED BODY REGION, SUBSEQUENT ENCOUNTER , LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED , CELLULITIS OF LEFT LOWER LIMB, CELLULITIS OF RIGHT LOWER LIMB , END STAGE RENAL DISEASE , DEPENDENCE ON RENAL DIALYSIS , TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE,UNSTEADINESS ON FEET , CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED , MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE , COGNITIVE COMMUNICATION DEFICIT, REPEATED FALLS, OTHER LACK OF COORDINATION, SPINAL STENOSIS, LUMBAR REGION WITH NEUROGENIC CLAUDICATION, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION, ESSENTIAL (PRIMARY) HYPERTENSION
Preexisting Conditions: listed in Item 11
Allergies: No Known Allergies
Diagnostic Lab Data: Spoke to RN at ER. Resident had fever of 102.9 upon arrival to the ER. He coded on the way back from his CT scan. He was diagnosed with right sided pnuemonia, respiratory failure and sepsis. Resident just passed away in ER and was not even admitted. Family was there with him
CDC Split Type:

Write-up: vomiting x3 1/8/21 1/9/21 00:34 - called to resident room by CNAs, staff stated resident was "different". Vitals taken and 02 sat was low, O2 in room and applied via NC @3L, O2 sat returned to 98 and all other vitals WNL including BS. Resident asked how he felt, stated he felt "okay". Resident exhibiting some shakey movements and clearing throat, states he does not have any phlegm or drainage or trouble swallowing. MD called and updated on situation, voicemail left. 1/9/21 11am- resident has been making a "growling" noise this shift. resident also has tremors. resident alert and answers questions appropriately. when asked if resident wants to go to hospital, resident firmly states "no". vitals wnl. no emesis noted. will continue to monitor resident. 1/9/21 12p- resident not answering questions appropriately. resident only answering yes or no. resident cannot tell me name, or the year, resident cannot state where he is currently or birthdate.
VAERS ID: 975689 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-06
Onset: 2021-01-20
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: IBUPROFEN, VITAMIN D, ZINC, TRAMADOL, CRANBERRY, DULOXETINE, MIRALAX, ACIDOPHYLIS, ATIVAN, ASA, GUAUFENISEN
Current Illness: COVID 19 01/10/2021 HYPEROSMOLOTY AND HYPERNATREMIA HERNIA HYPERGLYCEMIA LOW BACK PAIN ANEMIA OSTEOPOROSIS DEMENTIA WITH BEHAVIORS CONSTIPATION CARDIAC MURMUR/HEART DISEASE POLYNEUROPATHY HX OF BREAST CANCER HTN DEPRESSION
Preexisting Conditions:
Allergies: PCN and NKFA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident vaccinated on 01/06/21 she acquired COVID 19 on 01/10/2021. Resident had multiple co morbidities and was declining prior to the vaccine. Resident expired on 01/20/2021
VAERS ID: 975735 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-06
Onset: 2021-01-25
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Death
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: zinc, acidophylis, albuterol inhaler, vitamin d, mirtazapine, Pepcid, vitamin c, Lasix, magnesium oxide, Depakote, cranberry, melatonin, Zoloft, folic acid, pericolace, simethicone, xarelto, asa, mvi with mineral, synthroid, evista,
Current Illness: COVID 19 01-10-2021 GERD DELUSIONS VASCULAR DEMENTIA WITH BEHAVIORS INSOMNIA CHRONIC DVT LEFT LOWER EXTREMITY HEMOCHROMATOSIS PSYCHOSIS MAJOR DEPRESSIVE DISORDER WITH ANXITY IMPULSE DISORDER VITAMIN DEFICIENCY EDEMA CONSTIPATION HALLUCINATIONS HYPOTHYROIDISM HX OF SKIN CANCER CARPAL TUNNEL LT HAND DYSTHYMIC HTN
Preexisting Conditions: ALZHEIMERS CONTRACTURE OF LEFT HAND
Allergies: Aricept, codeine, hydrocodone, sulfa abx
Diagnostic Lab Data:
CDC Split Type:

Write-up: VACCINE ADMINISTERED 01/06/21 ACQUIRED COVID 19 01/10/21 RESIDENT HAD MULTIPLE CO MORBIDITIES AND WAS DECLINING PRIOR TO VACCINE. RESIDENT EXPIRED ON 01/25/2021
VAERS ID: 975744 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-15
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-26
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, Dyspnoea, Full blood count abnormal, General physical health deterioration, Metabolic function test abnormal, Pyrexia, SARS-CoV-2 test negative, Tachycardia, Urinary tract infection, Urine analysis
SMQs:, Anaphylactic reaction (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Atorvastatin Calcium 10mg, Ceftriaxone 1GM, Famotidine, Hydrocodone-Acetaminophen 5-325mg, Levothyroxine 25mcg, Senna, ASA, Docusate
Current Illness: The resident was febrile on 1/9/2021 after receiving the Pfizer vaccine on 1/7/2021. On 1/9/2021 UA, CBC, and CMP ordered indicating she had UTI. SARS-CoV-2 testing was performed using POCT GeneXpert on 1/9/2021. No SARS-CoV-2 was detected. The resident continued to decline and on 1/15/2021 she became tachycardiac and was having trouble breathing. She was transferred to ER where she later died.
Preexisting Conditions: Dementia, Hyperlipidemia, HTN, Hypothyroidism, left femur fracture, hx of COVID-19
Allergies: NKA
Diagnostic Lab Data: UA, CBC, CMP
CDC Split Type:

Write-up: See initial report
VAERS ID: 975762 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Idaho  
Vaccinated: 2021-01-20
Onset: 2021-01-24
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: N/A
Preexisting Conditions: - Hx of aortic dissection - Hx of mitral valve repair - Ascending aortic aneurysm (HCC) - Hearing loss of right year - Scoliosis of thoracolumbar spine - Fatigue - Overweight
Allergies: - Fish containing products - Kale - PCN
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt deceased
VAERS ID: 975918 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-12
Onset: 2021-01-17
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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 Narrative:
VAERS ID: 975952 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-15
Onset: 2021-01-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 2
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: Narrative:
VAERS ID: 976032 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-22
Onset: 2021-01-26
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Asthenia, Constipation, Death, Decreased appetite, Dyspepsia, Hypoxia, Lethargy, Malaise, Multiple organ dysfunction syndrome
SMQs:, Acute pancreatitis (broad), Asthma/bronchospasm (broad), Retroperitoneal fibrosis (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 (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific dysfunction (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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, Aspirin, Sinemet, Docusate, Eliquis, Finasteride, Fluticasone, Furosemide, Klor-con, Melatonin, Nortriptyline, Pantoprazole, Simvastatin, EMU muscle and joint relief cream, Synthroid, Tamsulosin, Vitamin B12, Vitamin D3, TUMS
Current Illness: CHF exacerbation in November 2020
Preexisting Conditions: CHF, CAD w/CABG, Pacemaker, CKD IV, HTN, Hyperlipidemia, Hypothyroidism, Osteoarthritis
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient stated he wasn''t feeling well on January 25, 2021, wasn''t eating and complained of abdominal pain. Patient noted to have indigestion and was constipated. Meds provided and labs ordered. On morning of January 26, 2021, patient became weak, lethargic and hypoxic and was sent to emergency department around 0700 hours on January 26, 2021. At approximately 1100 hours, emergency physician notified this writer that patient was not going to overcome his illness and would be placed on comfort care. At approximately 1130 hours, this writer was notified that patient had passed away from multi-organ failure.
VAERS ID: 976111 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-23
Onset: 2021-01-24
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Cardioversion, Death, Dyspnoea, Pulseless electrical activity, Resuscitation, Somnolence, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: warfarin (COUMADIN) 2.5 mg tablet zinc sulfate 220 (50) mg capsule nutritional supplements (NUTREN 1.5) 0.07 gram-1.5 kcal/mL liqd acetaminophen (TYLENOL) 325 mg tablet senna (SENOKOT) 8.6 mg tab furosemide (LASIX) 40 mg tablet spironolacto
Current Illness: Pt admitted with closed-loop bowel obstruction with subsequent surgery for ex-lap, SBR ~160cm jejunem and ileum, left with open abdomen with Abthera wound vac 12/22. Now s/p Exploratory laparotomy, primary stapled small bowel anastomosis, abdominal fascial and skin closure on 12/24.
Preexisting Conditions: Neurology Myalgia Secondary hypothyroidism ? Cardiovascular Coronary atherosclerosis of native coronary artery Postsurgical aortocoronary bypass status Chronic atrial fibrillation (HCC) Aortic insufficiency RBBB Essential hypertension, benign Pure hypercholesterolemia Bradycardia Typical atrial flutter (HCC) Severe aortic stenosis History of acute anterolateral myocardial infarction Thoracic aortic aneurysm without rupture (HCC) Ischemic cardiomyopathy Coronary artery disease involving autologous vein coronary bypass graft without angina pectoris Acute on chronic systolic heart failure (HCC) Acute on chronic systolic (congestive) heart failure (HCC) Chronic systolic congestive heart failure (HCC) ? Gastrointestinal Malnutrition of moderate degree (HCC) ? Nephrology BPH with obstruction/lower urinary tract symptoms Stage 3 chronic kidney disease (HCC) ? Endocrinology Acquired hypothyroidism ? Genetics/Metabolics Chronic gout of ankle ? Ophthalmology Nuclear sclerotic cataract of right eye Pseudophakia of left eye Exudative age-related macular degeneration of left eye with active choroidal neovascularization (HCC) Ocular trauma of right eye ? Rheumatology Primary localized osteoarthrosis, pelvic region and thigh ? Musculoskeletal Left leg swelling ? Psychiatry Delirium ? Other Statin intolerance Transient global amnesia CVA, ?Possible lacunar infarct right cerebellar Long term current use of anticoagulant therapy
Allergies: Statins (muscle weakness)
Diagnostic Lab Data:
CDC Split Type:

Write-up: CC:full arrest HPI:HPI and ROS limited due to patient''s condition. History is via EMS, medical record, and son. Per Son patient had Covid vaccine on Saturday morning. Slept all day Sunday. Woke up Sunday night a bit "like coming out of a deep sleep per son, around 10 pm. Shortly after that patient was having a hard time breathing. Emergency called. Arrested around the time EMS arrived. King airway, I/O and CPR initiated. Patient has been in v fib. Was shocked multiple times, given 4 rounds of epi, bicarb and amiodarone. ACLS continued on arrival. Multiple rounds of epi, and attempted defib. Patient given epi, bicarb. Rhythms included fine v fib, asystole, and PEA. Unrecoverable with no cardiac motion. Time of death 11:50 pm.
VAERS ID: 976112 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-10
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol Tartrate Tablet 25 MG BID Norvasc Tablet 10 MG (amLODIPine Besylate) QD Namenda Tablet 5 MG (Memantine HCl) BID Cozaar Tablet 100 MG (Losartan Potassium) QD hydrALAZINE HCl Tablet 25 MG TID Amiodarone HCl Tablet 200 MG QD CloNID
Current Illness: Resident started manifesting loss of appetite and body weakness on January 10,2021 a few days after vaccination. She expired in our facility 1/21/2021.
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING OTHER NONTRAUMATIC 10/28/2020 Principal Diagnosis INTRACRANIAL HEMORRHAGE AFFECTING LEFT DOMINANT SIDE TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE UNSPECIFIED ATRIAL FIBRILLATION ENTIAL (PRIMARY) HYPERTENSION 10/28/2020 Diagnosis 4 Admission HISTORY OF FALLING 10/28/2020 Diagnosis 5 Admission OTHER ABNORMALITIES OF GAIT AND MOBILITY 01/13/2021 Other Diagnosis During Stay COVID-19
Allergies: ASPIRIN PENICILLIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired on january 21, 2021
VAERS ID: 976146 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-21
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asymptomatic COVID-19
SMQs:, COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Multivitamin Liquid (Multiple Vitamins-Minerals) Give 5 ml via G-Tube one time a day for (SUPPLEMENT) Aspirin Tablet Chewable 81 MG Give 1 tablet via G-Tube one time a day for (CVA PROPHYLAXIS) Norvasc Tablet 5 MG (amLODIPine Besylate) G
Current Illness: No symptoms after COVID vaccinations
Preexisting Conditions: ENCOUNTER FOR SURGICAL AFTERCARE FOLLOWING SURGERY ON THE DIGESTIVE SYSTEM ENCOUNTER FOR ATTENTION TO GASTROSTOMY CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER VIRAL COMMUNICABLE DISEASES UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DEGENERATIVE DISEASE OF NERVOUS SYSTEM, UNSPECIFIED ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS UNSPECIFIED SEQUELAE OF UNSPECIFIED CEREBROVASCULAR DISEASE PAROXYSMAL ATRIAL FIBRILLATION UNSPECIFIED CIRRHOSIS OF LIVER ESSENTIAL (PRIMARY) HYPERTENSION UNSPECIFIED VIRAL HEPATITIS B WITHOUT HEPATIC COMA HYPERLIPIDEMIA, UNSPECIFIED GASTRITIS, UNSPECIFIED, WITHOUT BLEEDING UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident is asymptomatic
VAERS ID: 976166 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-18
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Gabapentin Capsule 100 MG, Give 1 capsule orally one time a day for (NEURALGIA) Losartan Potassium Tablet 50 MG, Give 1 tablet orally one time a day for (HYPERTENSION) HOLD IF SBR<110 OR HR<60 Norvasc Tablet 5 MG (amLODIPine Besylate), Give
Current Illness: NONE
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING NONTRAUMATIC INTRACEREBRAL HEMORRHAGE AFFECTING RIGHT DOMINANT SIDE CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER VIRAL COMMUNICABLE DISEASES ACIDOSIS ANEMIA UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF LARGE INTESTINE ACUTE KIDNEY FAILURE, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE NEURALGIA AND NEURITIS, UNSPECIFIED ESSENTIAL (PRIMARY) HYPERTENSION
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: ASYMPTOMATIC
VAERS ID: 976280 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 0000-00-00
Onset: 2021-01-21
Submitted: 0000-00-00
Entered: 2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: GABAPENTIN; PREGABALIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 21 Jan 2021 - coroner called provider office
VAERS ID: 977319 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2020-12-29
Onset: 2021-01-25
   Days after vaccination: 27
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: N/A
CDC Split Type:

Write-up: Notified by patient''s sister on 1/26/2021 that patient died in his sleep on 1/25/2021. She did not know cause of death.
VAERS ID: 977320 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Dyspnoea, Intensive care, Life support, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: acute pancreatitis, gerd, ibs, OA, rheumatoid arthritis, HTN, H/o falls, osteoporosis, pre-diabetes, hyperlipidemia, diverticulosis, interstitial lung disease, permatomyoitis
Preexisting Conditions: acute pancreatitis, gerd, ibs, OA, rheumatoid arthritis, HTN, H/o falls, osteoporosis, pre-diabetes, hyperlipidemia, diverticulosis, interstitial lung disease, permatomyoitis
Allergies: azathioprine (Imuran)
Diagnostic Lab Data:
CDC Split Type:

Write-up: about 20+ hours after vaccination resident was having hard time breathing, 911 was called. Resident coded multiple times at the facility after CPR she was taken to ICU. She coded again and was placed on life support. Due to her choice to not be on life support she passed on 11/26/2021.
VAERS ID: 977358 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-08
Onset: 2021-01-12
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac failure congestive, Chest X-ray, Cough, Death, Full blood count, Laboratory test, SARS-CoV-2 test, Ultrasound chest
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Cardiomyopathy (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, ASA, Paxil, Amlodipine
Current Illness:
Preexisting Conditions: anemia, mild renal insufficiency, hypertension
Allergies: none
Diagnostic Lab Data: CBC, SMA6 Jan 18, Jan20 Covid 19 test Jan 20 Chest X Ray Jan 20 Chest ultrasound Jan 20
CDC Split Type:

Write-up: cough congestive heart failure death
VAERS ID: 977426 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Seizure, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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: Tramadol, Dexamethasone, Pantoprazole, Dilatin, Plaxis, Aspirin, VImpat, Keppra, Clopidogrel
Current Illness: 1. Melanoma with brain metastasis 2. Seizure disorder
Preexisting Conditions: 1. Melanoma with brain metastasis 2. Seizure disorder
Allergies: None
Diagnostic Lab Data: None. He was under hospice care.
CDC Split Type:

Write-up: Patient has a history of advanced melanoma with brain metastasis. He developed seizure disorder as well and had some mild seizures at home over the prior month. He received the vaccine at 4pm and was monitored in the office for 15 minutes. He then went home with his daughter whom he lives with. He ate dinner with her and read until 8pm when he went to his room. She found him in his room at 9pm unresponsive with seizures. Hospice was alerted and recommend oral valium. He continued to be unresponsive and expired the following day at 7:30 pm.
VAERS ID: 977963 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Alabama  
Vaccinated: 2021-01-26
Onset: 2021-01-26
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 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? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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
CDC Split Type:

Write-up: (Report per patients wife ) Patient took his usual nap around 12pm. She found him lying in the bed unresponsvie at 2pm. EMS was not called. Patient''s wife called the Funeral home.
VAERS ID: 978199 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-06
Onset: 2021-01-07
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Pain in extremity, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tendinopathies and ligament disorders (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Heart disease
Preexisting Conditions: Sleep apnea
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Arm hurting used his oxygen at time of bed appeared vomited.
VAERS ID: 978529 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: West Virginia  
Vaccinated: 2020-12-31
Onset: 2021-01-15
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chest X-ray, Computerised tomogram abdomen, Computerised tomogram thorax, Death
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

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? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lasix 20 mg daily, KCL ER 20 MEQ daily, Eliquis 2.5 mg twice daily, allopurinol 300 mg daily, Lyrica 50 mg daily, Metoprolol Succinate ER 50 mg daily, Amlodipine 5 mg daily, Pravstatin 20mg daily, Vit d3 25mcg daily
Current Illness: None
Preexisting Conditions: Diabetes
Allergies: Bee Stings, Statins, Flecinide
Diagnostic Lab Data: Chest XR 1/15/21 CT chest/abdomen 1/15/21
CDC Split Type:

Write-up: Patient developed Covid pneumonia dx 1/15/21, patient expired
VAERS ID: 978567 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-12
Onset: 2021-01-24
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Metformin 500mg PO BID for DM Phenobarbital 97.2mg QD for Seizure Dilantin 100mg, 2 caps, QHS for Seizure Eliquis 5mg BID for DVT Lipitor 10mg QHS for Hyperlipidemia
Current Illness: None
Preexisting Conditions: DM2, Seizure, HTN, Hyperlipidemia, PVD, History of CVA, Contractures of both knees, Dysphagia.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident received the first dose of Moderna Vaccine on 01/12/2021 and Tested for COVID-19 on 01/12/2021. Resident tested positive on 01/13/2021. Resident was transferred to acute hospital on 01/19/2021 due to desaturation. Resident expired at Hospital on 01/24/2021.
VAERS ID: 978754 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Colorado  
Vaccinated: 2021-01-26
Onset: 2021-01-26
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: B12 vitamin 1 tab po daily Triamcinolone acetonide cream 0.5% apply 2-3 times per day Tylenol 500 mg as needed- Had not taken at all in January Loperamide 2 mg as needed-Had not taken at all in January
Current Illness: Hospice client Some diarrhea with colostomy bag in place general decline
Preexisting Conditions: Hypertension, Dyspnea, Primary Pulmonary hypertension, Muscle weakness, pulmonary fibrosis, intraductal carcinoma breast, dizziness
Allergies: Fosamax, Codeine derivatives
Diagnostic Lab Data: Body released to funeral home
CDC Split Type:

Write-up: No symptoms appeared immediately after vaccination, although patient passed away around 6:00 pm unexpectedly. Staff talked with her last time at 5:30 pm and then found her at 6:00 pm passed away. Unknown at this time if death is directly related to receiving the vaccine.
VAERS ID: 978873 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: California  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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: 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:
Diagnostic Lab Data: Test Date: 202012; Test Name: Covid-19; Test Result: Positive
CDC Split Type: USPFIZER INC2021068689

Write-up: died several hours after receiving a Covid-19 vaccine; This is a spontaneous report from a contactable consumer. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient died several hours after receiving a Covid-19 vaccine on an unspecified date. The patient died on an unspecified date. It was not reported if an autopsy was performed. The person had tested positive for the virus (Covid-19) in late Dec2020. Information on the batch/lot number has been requested.; Reported Cause(s) of Death: died several hours after receiving a Covid-19 vaccine
VAERS ID: 978876 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Autoimmune disorder, Death
SMQs:, Immune-mediated/autoimmune disorders (narrow)

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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021070550

Write-up: Autoimmune disease; This is a spontaneous report from a Pfizer-sponsored program from a contactable nurse. A male patient of an unspecified age received bnt162b2 (BNT162B2, Manufacturer Pfizer-BioNTech), via an unspecified route of administration, on an unspecified date, at single dose, for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. The patient experienced autoimmune disease on an unspecified date. The patient died on an unspecified date due to autoimmune disease. It was unknown if an autopsy was performed. The information on the lot/batch number has been requested.; Sender''s Comments: The information available in this report is limited and does not allow a medically meaningful assessment of the case. The company cannot completely exclude a causal relationship between the fatal autoimmune disease and suspect vaccine BNT162B2. Additional information regarding therapy duration, relevant medical history, underlying conditions, concomitant medications and detailed clinical course around the event onset will aid in comprehensive 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: Autoimmune disease
VAERS ID: 978959 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Dysarthria, Hemiparesis, Neurological symptom, Transient ischaemic attack
SMQs:, Cardiac failure (narrow), Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypoglycaemia (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Presented with stroke like symptoms at 10:30, right sided weakness and slurred speach. 911 was call, patient was transported to hospital. Per ED note, patient experienced TIA which resolved, actue exacerbation of CHF. Patient was admitted. Discharge summary on 1/22 indicates same diagnosis, plan was home with hospice. Family notified hospital on 1/25 that patient had expired on 1/23 at home.
VAERS ID: 979081 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-21
Onset: 2021-01-22
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: Warfarin, Tamsulosin, Metoprolol, Vitamin D3, Lasix
Current Illness: None
Preexisting Conditions: Acute systolic congestive heart failure, Atrial Fibrillation, Coronary Artery Disease, Left Ventricular Hypertrophy, Arteriosclerotic Heart Disease, Carotid Artery Stenosis, Ischemic Cardiomyopathy, Hypertension, Osteoarthritis, Myelodysplasia, COPD, Dyslipidemia, Malignant Neoplasm of Colon, Anemia
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient found dead in home the next morning. May or may not be connected to vaccination. Instructed to report it from our medical director and director of nursing.
VAERS ID: 979101 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-01-22
Onset: 2021-01-25
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac 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), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Allopurinol, Amiodorone, Vitamin C, Budesonide, Chlorhexadine gluconate, Clonidine, Eliquis, Polyethylene glycol, Ipratopium-Albuterol, Lantus, Lasix, Loratadine, Magnesium Oxide, Melatonin, Metolazone, Metoprolol Tartrate, Nepro Carb Stea
Current Illness: none
Preexisting Conditions: Ventilator dependant r/t acute respiratory failure with hypoxia, chronic diastolic heart failure, diabetes, cerebral infarct with hemiplegia
Allergies: Penicillin, Chocolate
Diagnostic Lab Data: none
CDC Split Type:

Write-up: cardiac arrest - no warning signs
VAERS ID: 979155 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-03
Onset: 2021-01-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK RA / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Chills, Headache, Influenza A virus test positive, Neck pain, Vomiting
SMQs:, Acute pancreatitis (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Arthritis (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 19
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Atrovastatin Calcium 80mg, Cholecalclfer0l Tablet 5000 Unit, Clopidogrel Bisulfate Tablet 75 mg, Colace Capsule 100 mg, Cyanocobalamin tablet 1000 Mcg, Famotidine Tablet 20mg, Gilmepiride Tablet 1 mg, Loperamide HCI Capsule 2Mg, Melatonin T
Current Illness:
Preexisting Conditions: Heart Disease, Polyneuropathy, Anemia and chronic Kidney disease, Type 2 Diabetes, hypotension
Allergies:
Diagnostic Lab Data: Jan 9 sent to emergency room, jan 11 tested pos for influneza A
CDC Split Type:

Write-up: Jan 3 vaccine administered, jan 4 started headaches, vomiting, pain in the back of the neck, Headaches, chills, loss of speech,
VAERS ID: 979223 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-05
Onset: 2021-01-12
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / 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: 2021-01-22
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Pravastatin 40 mg, KCL ER 10meq, Metoprolol 25 mg, losartan 100 mg, glyburide 2.5 mg, furosemide 40 mg, ASA 81 mg, amlopidine 10 mg, allopurinol 300 mg
Current Illness: CHF, hypertension, type 2 DM
Preexisting Conditions: same as 11
Allergies: NKA
Diagnostic Lab Data: (ER event)
CDC Split Type:

Write-up: Patient developed SOB but reported good O2Sats. Instructed on going to ER if worsening symptoms. Patient eventually expired on 1/22/21
VAERS ID: 979255 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-18
Onset: 2021-01-18
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, COVID-19 pneumonia, Cardiomyopathy, Cardioversion, Central venous catheterisation, Chest X-ray abnormal, Conduction disorder, Cyanosis, Death, Dyspnoea, Echocardiogram abnormal, Ejection fraction decreased, Electrocardiogram abnormal, Endotracheal intubation, Hiatus hernia, Intensive care, Lung consolidation, Lung opacity, Metabolic acidosis, Myocardial necrosis marker normal, Nodal rhythm, Oesophageal disorder, Pneumonia aspiration, Resuscitation, Scan with contrast abnormal, Sinus arrest, Sinus bradycardia, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Disorders of sinus node function (narrow), Conduction defects (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Malignancy related therapeutic and diagnostic procedures (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: per hospital list: Nitrostat 0.4 mg SL prn, famotidine 10 mg, ASA 81 mg, atorvastatin 20 mg, benazepril 5 mg, carvedilol dose unspecified
Current Illness: unknown; family report pt without symptoms prior to event
Preexisting Conditions: hx of gastric bypass; s/p CABG 3 years ago, HTN, HLD, morbid obesity
Allergies: none; + bee allergy listed in records
Diagnostic Lab Data: Patient had 3 EKGs, which did not show STEMI, but did show nonspecific conduction delay and sinus arrest with junctional escape vs sinus bradycardia (HR 50''s). Laboratory work done indicated that cardiac enzymes were normal, and that the patient had metabolic acidosis. Cardiology was called, but no need for emergent cath noted. Pt. has POCUS echocardiogram, which showed severe cardiomyopathy with LVEF 20%, and no pericardial effusion. Portable CXR read as: Extensive opacity in R upper lobe and diffuse opacities throughout the L hemithorax are nonspecific, but suggestive of multifocal pneumonia, including COVID-19. CTA Chest for PE w/ Contrast: Impression: no evidence of pulmonary embolism; bilateral extensive airspace consolidation, cannot exclude pneumonia, aspiration; follow-up barium series recommended to foreign body/filling defect in esophagus (Mediastinum findings: There is thickening involving esophagus and a small hiatal hernia. Gastric bypass surgery. There is dense artifact from the mid lumen of the esophagus measuring 8mm).
CDC Split Type:

Write-up: Patient received COVID 19 vaccine the morning of 1/18/21 at Public Health COVID-19 vaccine clinic. I (person completing this report) work for PH. Later that night while in bed, patient reported difficulty breathing to his wife, then turned blue, and became unresponsive. Family report pt was without any symptoms prior to event. 911 called; CPR started by family member 15 min. after pt became unresponsive. EMS performed resuscitation for about 30-40 minutes with multiple defibrillation for V-fib. Between EMS and Medical Center ER, pt had 9 rounds of epi, CPR w/ LUCAS machine, given 2 doses of amiodarone (150 mg and 300 mg). Patient had 3 EKGs, which did not show STEMI, but did show nonspecific conduction delay and sinus arrest with junctional escape vs sinus bradycardia (HR 50''s). Pt had return of spontaneous circulation. Pt intubated, and started on Levophed. Pt transferred to ICU, and had central line placed. Family decided to make patient DNR. Pt went into coarse VFib again, and as per wishes of family, code blue not called. Patient expired at 01:53 on 1/19/21.
VAERS ID: 979309 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Nevada  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 OT / 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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: patient had no known medical history per supervisor
VAERS ID: 979495 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Wyoming  
Vaccinated: 0000-00-00
Onset: 2021-01-19
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Budesonide/formoter Fish Oil Aspirin Albuterol Terazosin Potassium Pantoprazole Metoprolol Metolazone Levothyroxine Furosemide Alopurinol Apixaban Lactobacillus Acidophilus
Current Illness:
Preexisting Conditions: MRSA carrier CHF Gout Vitamind deficiency A fib
Allergies: Amiodarone Mild Pulmonary fibrosis
Diagnostic Lab Data: none
CDC Split Type:

Write-up: No adverse events noted Patient past away was notified by Public Health the record is at Vital Statistics
VAERS ID: 979533 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Arizona  
Vaccinated: 2021-01-19
Onset: 2021-01-20
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Chest X-ray normal, Death, Dizziness, Fall, Feeling abnormal, Laboratory test normal, Memory impairment, Oxygen saturation decreased, SARS-CoV-2 test negative, X-ray of pelvis and hip normal
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Depression (excl suicide and self injury) (broad), Vestibular disorders (broad), Respiratory failure (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: dexamethasone, losartan, amlodipine, Ensure supplement drink
Current Illness: chronic copd is stable condition; no illnesses at time of vaccination
Preexisting Conditions: copd hypertension
Allergies: none
Diagnostic Lab Data: labs were fairly normal; chest xray showed no acute changes; hip xrays showed no fractures, covid 19 rapid screen was negative
CDC Split Type:

Write-up: Patient recieved vaccine 1 of covid 19 i 1/19/2021. She felt poorly on 1/20/2021. She felt dizzy and fell at 3 AM on 1/23/2021. She felt poorly and did not know her son''s name which was not normal. She went to ER on 1/24. She was assessed as not having fractures. She was going to be transferred to a skilled nursing facility. She was not having respiratory complaints. She was awaiting transfer when her O2 levels started dropping substantially. She declined aggressive intervention and she died within a few hours.
VAERS ID: 979773 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Texas  
Vaccinated: 2020-12-30
Onset: 2021-01-16
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulmonary embolism
SMQs:, Embolic and thrombotic events, venous (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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 as far as i know
Current Illness: none per care giver
Preexisting Conditions: none that was reported
Allergies: none reported
Diagnostic Lab Data: none that i know of
CDC Split Type:

Write-up: Not sure if it has to do with the COVID vaccine but her caregiver reported to me today (1/27/20201) that she passed away on 01/16/2021 from a pulmonary embolism that was 18 days after vaccine
VAERS ID: 979796 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-08
Onset: 2021-01-10
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: metoprolol, atorvastatin, furosemide, metformin, trulicity, glipizide, omeprazole, gabapentin, loratadine, losartan, amlodipine
Current Illness: not known. I spoke with his wife when he was in the hospital a couple of days after the first dose of Moderna vaccine. She mentioned that he felt ill a few days before and up to the vaccine date. Despite feeling ill, he checked off "no" on the questionnaire section that asked if patients were feeling ill that day.
Preexisting Conditions: Diabetes, hyperlipidemia, hypertension
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient went to hospital with COVID symptoms on 01/10/2021 and passed away on 01/22/2021
VAERS ID: 979818 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Death, Dyspnoea, Resuscitation, SARS-CoV-2 test positive, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Adult one daily multivitamin Vitamin B12 Vitamin D Acetaminophen - Codeine 300-30 prn acyclovir levothyroxine
Current Illness: Malignant neoplasm of colon dx Stage IIB in 2018. Surgery in 2018 to remove mass Inguinal hernia (rt) CT follow up in 12/2020 r/t above found no evidence of metastatic disease in abdomen or pelvis, inguinal hernia still present. Distension in abdomen reported in 11/2020 through 12/2020 at office visit
Preexisting Conditions: Malignant neoplasm of colon dx Stage IIB in 2018. Surgery in 2018 to remove mass Inguinal hernia (rt) CT follow up in 12/2020 r/t above found no evidence of metastatic disease in abdomen or pelvis, inguinal hernia still present.
Allergies: None
Diagnostic Lab Data: Rapid COVID 19 test positive at ED. OF NOTE: Wife tested positive for COVID 2 weeks prior to patient vaccination and subsequent death. It is unclear if patient had symptoms or tested for COVID during that time frame. No other labs collected.
CDC Split Type:

Write-up: Patient arrived at ER with complaints of CPR in progress. Per EMS, patient became short of breath while performing yard work on 1/26/2021. At arrival, patient was in fine v fib with a total of 6 shocks delivered along with 300 mg amiodarone followed by 150 mg amiodarone, 1 amp epinephrine and 2 epinephrine drips adminstered en route to ED. CPR initiated at 1755 and EMS reports asystole at 1829. TOD 1909 pronounced by ED DO Dx: Cardiac arrest
VAERS ID: 979837 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Nevada  
Vaccinated: 2021-01-25
Onset: 2021-01-27
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Death, Hypotension, Presyncope, Pulseless electrical activity, Resuscitation, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: History of benign prostatic hyperplasia, hypertension, urinary tract infection, cerebrovascular accident. 1/25/21 Brought to Hospital ED by EMS from Health District for near syncope and hypotension post Pfizer vaccine administration. 1/27/21 Brought to Hospital ED by EMS from home after wife found.
Preexisting Conditions: History of benign prostatic hyperplasia, hypertension, cerebrovascular accident.
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per EMS, the patient was last seen walking and talking to wife 10 minutes prior to EMS arrival. EMS reports via patients wife, that patient was upstairs to change for his doctor appointment then patient''s wife found him down. The patient received his COVID-19 vaccine on 1/25/21. EMS states they gave 5 rounds of EPI then patient moved into vfib then was shocked once but returned to asystole. In ED, the patient initially in asystole CPR was started immediately. The patient was given 3 rounds EPI, 1 round bicarb. The patient stayed in PEA throughout. Patient was given tPA. Patient continued to be in asystole and time of death was called at 11:35 am.
VAERS ID: 979841 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Montana  
Vaccinated: 2021-01-07
Onset: 2021-01-09
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Death, Intensive care, 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: 2021-01-15
   Days after onset: 6
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:
Current Illness: Evaluated for L flank pain in ED on 1/1/2021, no acute findings on CT. Noted to be in mild CHF, discharged home from local ED.
Preexisting Conditions: HTN, CKD stage 5, hemodialysis dependent, DM type II, hx renal transplant
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt likely presented to vaccine appt with asymptomatic/early infection of COVID-19, as he presented 2 days post-vaccination and tested positive for COVID-19 on rapid and PCR test. He was hospitalized where he eventually died of complications from COVID-19 while in ICU. Date of death was 1/15/2021.
VAERS ID: 979926 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: California  
Vaccinated: 2020-12-30
Onset: 2021-01-02
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Senior Living       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: 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: N/A
Current Illness: Pt was on hospice in LTCF at time of death, but expired 3 days after receiving vaccine. She exhibited shortness of breath the morning of death. 12/7-12/17 covid positive but seemed to be recovering HTN Alzheimer?s
Preexisting Conditions: HTN Health Conditions
Allergies: N/A
Diagnostic Lab Data: Pt was covid positive from 12/7-12/17
CDC Split Type:

Write-up: Pt began experiencing shortness of breath 3 days after vaccine and expired later that day.
VAERS ID: 979990 (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: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac 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), Cardiomyopathy (broad), Respiratory failure (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: none
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: sudden cardiac arrest
VAERS ID: 980107 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Alabama  
Vaccinated: 2021-01-12
Onset: 2021-01-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Lethargy, Livedo reticularis, Mental status changes, Oxygen saturation decreased, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), 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), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient noted to have a change in status at 11:23PM that night. Her oxygen saturation had dropped from normal on room air to 82% and required oxygen. She was also noted to be lethargic with altered mental status and not responding verbally. She then began to mottle. Her oxygen saturation worsened to 51% on 4Liters of oxygen by the next day and she expired on 1/14/21.
VAERS ID: 981938 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-22
Onset: 2021-01-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, Cardiac arrest, Cardio-respiratory arrest, Chest X-ray abnormal, Cyanosis, Death, Lung infiltration, Lung opacity, Pulse absent, Respiratory arrest, Resuscitation, SARS-CoV-2 test negative, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), 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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: Covid negative: 12/27/20, 1/20/21, 1/25/21 Covid Negative 1/11/21
CDC Split Type:

Write-up: UNKNOWN/ASYTOLE Narrative: Please refer to section 6. 68y/o male with h/o severe peripheral vascular disease with previous left AKA 2/3/20, s/p bilateral bypasses in the past. Pt recently underwent right AKA on 1/12/21. Per Hospital remote data 1/10/21 pt c/o shortness of breath, CXR demonstrated right lower lobe opacity & left basilar infiltrate. Pt s/p $g10 days emperic IV abx. Moderna vaccine 0.5ml IM was administered via left deltoid on 1/22/21 around 16:21. On 1/23/21@05:14 code blue was called as pt found to be unresponsive, breathless and pulseless, facial cyanosis noted, CPR started immediately.Pt found to be in asystole. ACLS guideline followed but no return of spontaneous circulation, At 05:32 pt remained pulseless and breathless and was pronounced. Autopsy currently pending.
VAERS ID: 981945 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-08
Onset: 2021-01-13
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, COVID-19, Death, Fall, SARS-CoV-2 test positive
SMQs:, Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: COVID positive on 01/13/21
CDC Split Type:

Write-up: weakness and fallsNarrative: 95 yo male w/ a PMH significant for Afib, legal blindness, Hx of CVA, cognitive impairment, GERD, HTN, pseudogout, BPH, chronic knee infection, and DJD who received his first dose of the Moderna COVID-19 vaccine on 01/08/21. The pt''s COVID-19 screening questionnaire prior to receiving the vaccine was negative. The pt presented to the ED on 01/13/21 for weakness and m PCR test on ultiple recent falls (since receiving his first dose of the COVID-19 vaccine). The pt''s COVID-19 01/13/20 was positive and he was admitted. He was started on treatment with remdesivir + dexamethasone on 1/14. The pt initially required supplemental oxygen via low-flow NC, however his oxygen requirements increased to 100% NRB. On 01/16/21 his MPOA elected for hospice care. The pt passed on 01/17/21. Unclear if the COVID-19 vaccine attributed to the patient''s hospitalization and eventual death, or whether these events occurred from COVID-19 itself, however this case is being reported the FDA since this vaccine is under an emergency use authorization (EUA).
VAERS ID: 983720 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-30
Onset: 2021-01-20
   Days after vaccination: 21
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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 Narrative: Patient had Parkinson''s and advanced Dementia. He was on a palliative care unit and a DNR.
VAERS ID: 983721 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-13
Onset: 2021-01-23
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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 Narrative: Patient with Severe Dementia and on Hospice for end of life care.
VAERS ID: 981061 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-22
Onset: 2021-01-25
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Unsure
Current Illness: None
Preexisting Conditions: Unsure
Allergies: Unsure
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 3 days post Moderna vaccine.
VAERS ID: 981225 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-27
Onset: 2021-01-27
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain, Death, Pulse absent, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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 Suppository Insert 650 mg rectally every 6 hours as needed for pain 1-3 Bisacodyl Suppository 10 MG Insert 1 suppository rectally every 24 hours as needed for constipation COVID-19 mRNA Vaccine (Pfizer) Suspension 30 MCG//0.3M
Current Illness:
Preexisting Conditions: C25.9 MALIGNANT NEOPLASM OF PANCREAS, UNSPECIFIED B19.20 UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA S82.002D UNSPECIFIED FRACTURE OF LEFT PATELLA, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED F03.90 UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE D64.9 ANEMIA, UNSPECIFIED Z91.81 HISTORY OF FALLING E46 UNSPECIFIED PROTEIN-CALORIE MALNUTRITION G31.84 MILD COGNITIVE IMPAIRMENT, SO STATED I10 ESSENTIAL (PRIMARY) HYPERTENSION G40.89 OTHER SEIZURES F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED M62.81 MUSCLE WEAKNESS (GENERALIZED) R26.89 OTHER ABNORMALITIES OF GAIT AND MOBILITY R41.841 COGNITIVE COMMUNICATION DEFICIT Z11
Allergies: Imipenem, Penicillins, Peanut
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient with inoperable pancreatic cancer received second Pfizer vaccine approximately 12:30 pm on 1/27/21. At approximataely 16:30, patient complained of abdominal pain and was given Levsin 0.125mg and morphine 5mg orally. At approximately 19:30 patient was found on the floor covered in a large amount of emesis, unresponsive without a pulse.
VAERS ID: 981406 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-15
Onset: 2021-01-18
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       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: 2021-01-18
   Days after onset: 0
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: multiple, unknown
Current Illness:
Preexisting Conditions: COPD, smoker
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stroke, death
VAERS ID: 981407 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-06
Onset: 2021-01-24
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Expired in sleep on 1/24/21
VAERS ID: 981790 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-26
Onset: 2021-01-26
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 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 listed on form
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Other- Death
VAERS ID: 981849 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-01-13
Onset: 2021-01-16
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: died 01/16/2021
VAERS ID: 981912 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-23
Onset: 2021-01-23
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Cardiac arrest, Chest pain, Cold sweat, Death, Endotracheal intubation, Hypotension, Laboratory test, Pallor, Pulmonary embolism
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: albuterol, fluticasone nasal spray, hydrochlorothiazide, losartan
Current Illness:
Preexisting Conditions: hypertension
Allergies: none
Diagnostic Lab Data: 1/27 in the ED patient underwent a CTA chest to reveal PE, basic labs, alteplase 100 mg, amiodarone 150 mg followed by infusion, was intubated with rocuronium, and placed on a norepinephrine drip.
CDC Split Type:

Write-up: Patient presented to the Emergency Department complaining of chest pain, pale, cool diaphoretic, and hypotensive. The patient was discovered to have a large saddle pulmonary embolism, went into cardiac arrest and expired. Of note, the patient received her second Moderna COVID vaccine on 1/23, which would place her first one approximately 12/25 if she received them at the appropriate interval. This information is from the patient''s daughter and the ED record, the information is not available in CAIR. Per the daughter, the patient started feeling ill on 1/21, improved on 1/25, and then acutely worsened on 1/27, resulting in the ED visit.
VAERS ID: 982218 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-08
Onset: 2021-01-13
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012120A / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

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: On hospice: morphine, ativan, trazodone, tylenol
Current Illness: failure to thrive, pressure ulcer, pneumonitis d/t aspiration, dementia, COPD, alzheimer''s disease,
Preexisting Conditions: HTN, see above
Allergies: aspirin: severe unknown reaction
Diagnostic Lab Data:
CDC Split Type:

Write-up: resident was on hospice, chronically ill w dementia, COPD, HTN, failure to thrive, passed away 1/13/21. Not certain injection related as he was declining already.
VAERS ID: 982354 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-29
Onset: 2021-01-23
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: patient received COVID vaccine on 12/29/2020 and passed away on 1/23/2021
VAERS ID: 982370 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-14
Onset: 2021-01-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Patient fell at home night before vaccination.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died at hospital on j/16/2021 approximately 48 after receiving vaccination. Believe death related to fall at home prior to vaccination.
VAERS ID: 982417 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kansas  
Vaccinated: 2020-12-30
Onset: 2021-01-07
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / 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: 2021-01-14
   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:
Current Illness: This person had been on HOSPICE for Failure to Thrive since November 2019. She was treated for weight loss with nutritional supplements and served meals of her choice. She had noted increase in sleep in weeks prior to death, but would have times she wanted out of bed for meals and to attend some activity.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident tested positive for COVID on 1/7/2021.
VAERS ID: 982472 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: New Jersey  
Vaccinated: 2021-01-19
Onset: 2021-01-20
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory failure
SMQs:, Anaphylactic reaction (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), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 7
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: Eliquis, Lasix, metoprolol
Current Illness: Chf, CKD
Preexisting Conditions: CHF, CKD, DM
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Worsening respiratory failure 1/20/2021 death 1/27/2021
VAERS ID: 982495 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Oklahoma  
Vaccinated: 2021-01-15
Onset: 2021-01-19
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 1 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: diclofenac
Current Illness: none
Preexisting Conditions: none
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Client''s sister called crying and said the family just found out yesterday that Client had died some time last week. The last time any family talked to him was on the 19th of January, missed calls show on the phone on the 21st. His last internet search was sternum pain. . She will also call the Agency and report this. The vaccine isn''t in Registery at this time, do I don''t know the lot number but she said he was due back in one month. She said he was very healthy and ran triathalons.
VAERS ID: 982517 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-11
Onset: 2021-01-25
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: patient received COVID vaccine on 1/11/2021 and passed away on 1/25/2021
VAERS ID: 982541 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-22
Onset: 2021-01-24
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Endotracheal intubation, General physical health deterioration, Hypotension, Lethargy, Mechanical ventilation, Mental status changes, Respiratory distress
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: COVID pneumonia 12/2020
Preexisting Conditions: Coronary artery disease s/p PCI prxima and mid left circumflex in July 2011, carotid stenosis, peripheral vascular disease, dyslipidemia, hypertension
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 36 hours after vaccination, the patient had increased respiratory distress. He was placed on high flow nasal cannula oxygen with mild improvement. He then continued to be hypotensive requiring IV fluids and subsequently IV vasopressors. Patient''s BP was stabilized with vasopresor, however he continued to deteriorate clinically with altered mental status and lethargy, concerned for bowel peroration based on physical exam by MD. He was then emergency intubated and placed on mechanical ventilation. He was then transferred to acute care hospital near by.
VAERS ID: 982826 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Nevada  
Vaccinated: 2021-01-21
Onset: 2021-01-26
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Resuscitation, 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: 2021-01-26
   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: immunocompromised with reportable conditions
Preexisting Conditions: immunocompromised with reportable conditions, positive for COVID-19 September 2020
Allergies: unknown
Diagnostic Lab Data: not available
CDC Split Type:

Write-up: Was at work on 1/26/21 and collapsed, no known complaints a the time. CRP was initiated immediately, transported to ER and pronounced dead
VAERS ID: 982890 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Mississippi  
Vaccinated: 2021-01-22
Onset: 2021-01-25
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Death, Endotracheal intubation, Pulse absent, Resuscitation, SARS-CoV-2 test positive, Troponin increased, White blood cell count increased
SMQs:, Angioedema (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Respiratory failure (broad), 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: 2021-01-25
   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: Crestor 10 mg po daily Norvasc 10 mg po daily benazepril 20 mg po daily Gabapentin 600 mg po daily Toprol XL 100 mg po daily
Current Illness: GI Bleed and Anemia- DX: 1/31/2021
Preexisting Conditions: ASCVD, HTN, Blindness, Diverticulous
Allergies: No Known Drug Allergies
Diagnostic Lab Data: 1/25/2021- Troponin 3.010; WBC 19.6
CDC Split Type:

Write-up: Pt presented to ER via EMS at 1556 3 days after receiving vaccine. pt was breathing approximately 50 times a minutes and o2 sats in the 70''s upon arrival. NP decided to intubate, Rocuronium and Versed given. Pt became bradycardic and 1 amp of Atropine was given without improvement. No pulse felt, CPR started per ACLS protocol. 7 Epi''s given. Time of death- 1632. After TOD pt was swabbed for COVID-19 and the results were positive.
VAERS ID: 982891 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2020-12-30
Onset: 2020-12-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Apnoea, Blood glucose increased, Death, Exposure to SARS-CoV-2, Fall, Mental status changes, Respiration abnormal, SARS-CoV-2 test negative, SARS-CoV-2 test positive, Skin laceration, Unresponsive to stimuli, Wound closure
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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:
Current Illness:
Preexisting Conditions: Heart Failure, unspecified, Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity with Aveolar Hypoventilation, Essential Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism, Obstructive Sleep Apnea
Allergies: NKDA
Diagnostic Lab Data: Rapid COVID tests with negative results 1/11, 1/13 and 1/15/21. PCR COVID testing with negative results 12/29/2020, 1/6/2021 and 1/13/2021. COVID swab obtained upon death1/16/2021 resulted positive.
CDC Split Type:

Write-up: All residents had been in isolation due to multiple cases of COVID in the facility. Resident voiced no health related complaints. He continued to visit with staff and required moderate assist with toileting. Resident had fall 0130 on 1-15-2021, which resulted in laceration with surgical repair. Resident was noted to change in mental status and respirations on morning of 1-16-2021 during morning blood sugar check. Resident had O2 @1.5l/m via n/c and respirations of 10 with periods of apnea and unresponsive to verbal stimuli. Blood sugar was 583. Resident deceased upon re-check after calling PCP to report status change.
VAERS ID: 982929 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2020-12-30
Onset: 2021-01-27
   Days after vaccination: 28
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 AR / IM

Administered by: Work       Purchased by: ?
Symptoms: Cardiac arrest, Condition aggravated, Death, Diverticulitis, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Gastrointestinal nonspecific inflammation (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Cetirizine 10 mg, Haloperidol 5 mg, Sertraline 50 mg, Albuterol HFA 90 mcg (PRN), Diphenhydran 25 mg (PRN), Fluticasone 50cg PRN, Lactulose 10 gm/15 (PRN), Polyeth Glycol 17 gm (PRN), Neomycin/Polymyxin drop, Amoxicillan 500 mg, Methyldredn
Current Illness: Ongoing Sinus and ear infections being treated by PCP
Preexisting Conditions: COPD, Hypothyrodism, non-alcoholic fatty liver, diabetes type 2, hypertension, diverticulitis
Allergies: Quetiapine, Zyprexa
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Client was being treated with antibiotics by her PCP for diverticulitis flare up. It had not been resolved on the date of her death which occurred 01/27/21, She was found unresponsive by staff, 911 contacted, and paramedics pronounced her deceased at 7:48 AM. After consultation with PCP manner of death was noted as cardiac arrest. PCP was to sign off on death certificate.
VAERS ID: 982942 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-21
Onset: 2021-01-21
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Illness
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: peanuts
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: per recipient spouse - vaccine recipient became ill during the night of 1/21/21 or early morning of 1/22/21 and was deceased in the morning of 1/22/21.
VAERS ID: 983169 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-08
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
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), 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: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel, Lexapro, Gabapentin, Synthroid, Prilosec, Zinc, Vitamin C, Vitamin D, Tuberculin Skin Test
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, AAA, PVD, Neuropathy, RLS, Hypothyroidism HTN, GERD
Allergies: Olanzapine, Risperidone, Aggrenox
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client received the COVID-19 vaccine on 1/5/21 by the Vaccine clinic. Plans were for Hospice services. Client tested positive for COVID-19 by rapid testing on 1/8/21. On 1/10/21 at 0900 Client was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.
VAERS ID: 983173 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-21
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Diarrhoea, Hypophagia, Pain, SARS-CoV-2 test positive, Speech disorder, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Losartan-HCTZ, Memantine, Metformin, Macrobid, Prilosec, Risperidone, Zocor, Detrol, Benedryl, Aspirin, Centrum, Donepezil, Farxiga, Gabapentin, Vitamin B-12, Vitamin D3, Tylenol
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Anemia, DM type 2, Hyperlipidemia, HTN, GERD
Allergies: Avandia
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client recevied the COVID-19 vaccine on 1/5/21 by the Vaccine clinic. Client tested positive for COVID-19 by rapid testing on 1/21/21, with c/o hurting all over and loose stools. She became non-verbal on 1/23/21 with poor intake. On 1/24/21 at 0537 Client was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.
VAERS ID: 983184 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-11
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Airway secretion clearance therapy, Dyspnoea, SARS-CoV-2 test positive, Salivary hypersecretion, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   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: Norco, Morphine Sulfate, Levsin
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, Anxiety, Ischemic Heart Disease, Hypertension, Hypercholesterolemia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient has been under Hospice services for almost a year. She began to demonstrate a large amount of oral secretions on 1/10/21 at 2130. She was suctioned and a Rapid COVID-19 test was performed, which was negative. The COVID-19 Rapid test was repeated on 1/11/21 and was positive. Oxygen saturation was noted to be 78% on 1/12/21, and oxygen was initiated at 1133 at 3L per nasal cannula. Oxygen was increased to 4L at 1635 d/t shortness of breath. On 1/15/21 @ 0645 patient was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.
VAERS ID: 983187 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-09
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Apnoea, Cough, Oxygen saturation decreased, Oxygen therapy, Rales, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol, Eliquis, Allegra, Synthroid, Sodium Chloride, Trazadone, Zinc, Vitamin C, Vitamin D, Dexamethasone, Tylenol
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, Encephalopathy, Syndrome of Inappropriate Secretion of Antidiuretic hormone
Allergies: Risperidone, Memantine, Haldol
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client tested positive for COVID-19 by rapid test on 1/8/21. On 1/9/21 at 1405 his oxygen saturation dropped to 86% and oxygen was initiated at 2L per nasal cannula. A non-productive cough was noted on 1/10/21 and oxygen was increased to 3L. On 1/12/21 Client became non-responsive with 30 second periods of apnea. Dexamethasone was initiated on 1/13/21. Lung sounds were noted with crackles on 1/15/21 at 1158 and at 2120 Client was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.
VAERS ID: 983189 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-11
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Oxygen saturation decreased, SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), 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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alprazolam, Amlodipine, Lexapro, Cozaar, Metoprolol, Tylenol
Current Illness: COVID-19
Preexisting Conditions: ASHD, Hyperlipidemia, Hypertension, Dementia, Anxiety, Dysphagia
Allergies: Fosomax
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient tested positive for COVID-19 by rapid test on 1/6/21. She began to demonstrate a dry cough on 1/11/21. On 1/12/21 at 1723 her oxygen saturation dropped to 79% and oxygen was applied at 4L per nasal cannula. On 1/19/21 at 2130 Patient was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.
VAERS ID: 983192 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Decreased appetite, Dyspnoea, Fluid intake reduced, Hypophagia, SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 16
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: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Dysphagia, Dementia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient recevied the COVID-19 vaccine on 1/5/21 by the Vaccine clinic #1. Patient tested positive for COVID-19 by rapid testing on 1/6/21. She demonstrated poor appetite and fluid/food intake and an IV of Normal Saline was initiated on 1/7/21. Oxygen saturation was initiated on 1/12/21 at 4L per nasal cannula. for shortness of breath. On 1/22/21 at 0310 Patient was unresponsive and without vital signs. Orders were for DNR and CPR was not initiated.
VAERS ID: 983193 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Decreased appetite, Dyspnoea exertional, Hypophagia, Lethargy, Oxygen saturation decreased, SARS-CoV-2 test positive, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Citalopram, Divalproex, Levothyroxine
Current Illness: COVID-19
Preexisting Conditions: Dementia, Atrial Fibrillation, Hypothyroidism, Dysphagia
Allergies: Atorvastatin, Donepezil, Corticosteroids
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient began to demonstrate a cough the evening of 1/5/2021, after receiving the COVID-19 vaccine earlier in the afternoon. A rapid COVID-19 test was performed and was positive. She began to demonstrate shortness of breath with exertion on 1/7/21, and lethargy on 1/12/21. Appetite and oral intake began to decline on 1/12/21, and Oxygen saturation dropped on 1/16/21 to 82%, and oxygen was initiated at 3L per nasal cannula. On 1/19/21 at 0414 patient was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.
VAERS ID: 983428 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Nebraska  
Vaccinated: 2020-12-24
Onset: 2021-01-06
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Anaemia, Aortic stenosis, Asthenia, Atelectasis, Atrioventricular block complete, Blood creatinine increased, Blood potassium decreased, Blood pressure fluctuation, Blood sodium decreased, Blood urea increased, C-reactive protein increased, Cardiomegaly, Chest X-ray abnormal, Condition aggravated, Death, Dehydration, Fatigue, Haemoglobin decreased, Hypertension, Lung infiltration, Procalcitonin increased, Sepsis, Staphylococcal bacteraemia, Vomiting, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Conduction defects (narrow), Retroperitoneal fibrosis (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), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (narrow), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Bystolic - started on 12/21/20, Crestor started on 11/09/2020, Qzemoic subq weekly, Advair diskus, Fish oil, ASA, Vitamin E, Multivitamin
Current Illness: Denied any illness at time of the vaccination. November 2020 was diagnosed with Covid-19. Admitted to Hospital on 01/6/2021 with c/o weakness. Reported that her weakness was over her entire body. Reports having episodes of vomiting once or twice a week.
Preexisting Conditions: Erysipelas, Aphthous pharyngitis, Sixth nerve palsy, Heart mumur, Acute renal insufficiency, Hypertension, Diabetes Mellitus
Allergies: NKA to medications
Diagnostic Lab Data: See above for further inform. 1/8/2021 WBC - 14.4, Hgb - 9.2, K+ - 2.9, BUN - 34, Creatitine -1.8, C-Reactive Protein - 12.8, Procalcitonin - 0.64, CXR - 01/07/2021 - Mild increased bibasilar atelectasis or infiltrate. No pleural effusion, no pneumothorax, stable mild cardiomegaly.
CDC Split Type:

Write-up: Pt. was admitted to hospital on 1/6/21 with fatigue, weakness. Pt. was Covid positive in November of 2020. Impression upon admission was fatigue may be due to her aortic stenosis and some hypertensive issues with blood pressure changes. She was anemic. WBC was elevated to 19.2, HBG 10.5, NA-131, K+ - 3.1, Rule out bacterial infection. Potential source could be her heart valve. Also noted to have acute renal failure with BUN of 47 and Creatinine of 2.2 noted. Pt. was transferred to Hospital on 1/8/2021 with dx of aortic stenosis, bacteremia, ARF, Dehydration and anemia. Discharged with dx. of sepsis. Pt. expired on 1/18/21 with dx. of severe sepsis, complete heart block, staphylococcus epidermidis bacteremia.
VAERS ID: 983766 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-16
Onset: 2021-01-21
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood pH decreased, Cardiac failure acute, Chest discomfort, Death, Dyspnoea, International normalised ratio increased, N-terminal prohormone brain natriuretic peptide increased, SARS-CoV-2 test negative
SMQs:, Cardiac failure (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide 20mg 2poBID, Warfarin 5mgQD, Omeprazole 20mg BID, Propanolol 10mg BID, atorvastatin 40mg QD, vitamin D 1000IUQD
Current Illness: Heart failure with reduced EF, history of moderate pulmonary hypertension, history of moderate mitral valve regurgitation and moderate pulmonary valve regurgitation. History of A. fib.
Preexisting Conditions: Heart failure with reduced EF, history of moderate pulmonary hypertension, history of moderate mitral valve regurgitation and moderate pulmonary valve regurgitation. History of A.fib.
Allergies: No known allergies to drugs or food
Diagnostic Lab Data: ProBNP: 5000 on 1/21/21 Covid-19 test: negative on 1/21/21 INR: 3.2 on 1/21/21 pH: 7.33 on 1/21/21
CDC Split Type:

Write-up: Pt started complaining of chest heaviness and shortness of breath on the afternoon of 1/21/21. EMS was called to the patients home and she was found to have an O2 sat in the 70''s. She was admitted to hospital and found to have a proBNP of 5000. She tested negative for Covid-19. She was determined to be in acute-on-chronic heart failure and was referred for hospice care. She passed away on the evening of 1/24/21.
VAERS ID: 983919 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-21
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy       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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death
VAERS ID: 1296823 (history)  
Form: Version 1.0  
Age: 50.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-01-26
Onset: 2021-01-27
   Days after vaccination: 1
Submitted: 2021-01-28
   Days after onset: 1
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 LA / -

Administered by: Other       Purchased by: Other
Symptoms: Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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:
Diagnostic Lab Data: NOT APPLICABLE
CDC Split Type:

Write-up: According to facility representative on 1/27/2021 at approximately 7:15 am, pt was discovered not breathing with no pulse. Resident was pronounced dead at 7:44 am on 1/27/2021. Resident was previously tested positive for COVID-19 on 12/9/2020.
VAERS ID: 984617 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-16
Onset: 2021-01-17
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cholecystitis, Death, Malaise, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Infectious biliary disorders (narrow), Gallbladder related disorders (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021063974

Write-up: Patient passed su hospital on 23Jan2021 stopped breathing; complained of not feeling well; had an inflamed gall bladder; This is a spontaneous report from a contactable consumer. A 98-year-old female patient received bnt162b2 (BNT162B2, PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL8982 and expiry date unknown), via an unspecified route of administration on 16Jan2021 at single dose for covid-19 immunisation. The patient medical history was not reported. The patient concomitant medication reported as has received other medications (unspecified) within 2 weeks. The patient passed in hospital on 23Jan2021 with stopped breathing. Day after vaccine on 17Jan2021, the patient complained of not feeling well, went to hospital where was told she had an inflamed gall bladder. The events caused patient hospitalization for 4 days. The cause of death reported as stopped breathing. It was unknown if autopsy done. Prior to vaccination, the patient not diagnosed with COVID-19. The outcome of the event breathing arrested was fatal, outcome of the other events was unknown.; Reported Cause(s) of Death: Stopped breathing
VAERS ID: 985004 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-08
Onset: 2021-01-27
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Constipation, Death, Fatigue, Hyperhidrosis, Impaired work ability, Resuscitation, Unresponsive to stimuli
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Cardiac Issues. Hx of cardiac Stent but unknown in-depth.
Allergies: Codeine Penicillin V
Diagnostic Lab Data:
CDC Split Type:

Write-up: The week of 1/18/2021 The patient complained of Abdominal pain and called off work (we are also her employer) She was seen for constipation on 1/20/2021. Employee returned to work on 1/25/2021 Had occasional episodes during work where she would sweat and become tired but would rest until she felt better. On the Night of 1/27/2021 she was feeling fine no issues, later in the shift a co worker found her unresponsive, CPR was initiated but unsuccessful.
VAERS ID: 985205 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dizziness, Malaise
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Yes, but caller does not know what they are.
Current Illness: No
Preexisting Conditions: None
Allergies: No
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient was feeling dizzy and under the weather after the vaccination. The following day he died in his sleep during a nap.
VAERS ID: 985367 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-06
Onset: 2021-01-18
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 UN / IM

Administered by: Senior Living       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: 2021-01-25
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Mucinex Tablet Extended Release 12 Hour 600 MG (guaiFENesin ER) Acetaminophen Tablet 500 MG cloZAPine Tablet 25 MG Remeron Tablet (Mirtazapine) Aspercreme Lidocaine Patch 4 % (Lidocaine) Cyanocobalamin Tablet 500 MCG Cholecalciferol
Current Illness: COVID-19 + DAY AFTER THE FIRST DOSE OF THE VACCINE
Preexisting Conditions: PARKINSON''S DISEASE HTN BPH CROHN''S DEMENTIA ANXIETY OA DDD ALLERGIC RHINITIS VITAMIN D DEFICIENCY
Allergies: ATIVAN GEODON
Diagnostic Lab Data:
CDC Split Type:

Write-up: TESTED POSITIVE FOR COVID-19 1-7-2021, TRANFERRED TO HOSPITAL ON 1-18-2021. HE READMITTED TO THE FACILITY ON 1-21-2021 WITH HOSPICE SERVICES AND EXPIRED ON 1-25-2021.
VAERS ID: 985449 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-27
Onset: 2021-01-28
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Computerised tomogram abdomen abnormal, Death, Intestinal dilatation, Large intestinal obstruction, Pupil fixed, Septic shock, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Toxic-septic shock conditions (narrow), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific dysfunction (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: colonic obstruction with dilatation of large and small bowel
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was an 87 y/o female admitted for septic shock. She was started on and eventually maxed on 3 pressors. CT abd showed colonic obstruction with dilatation of large and small bowel. Patient was made DNR in the ED. Palliative care consulted on case. Family opted for comfort care. Patient was asystole on monitor. No spontaneous breath/cardiac sounds ausculted. Patient did not withdraw to pain. Pupils fixed and dilated. She was pronounced and 1230 on 1/28/21
VAERS ID: 985451 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-06
Onset: 2021-01-24
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 UN / 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: 2021-01-24
   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: predniSONE Tablet 20 MG Mucinex Tablet Extended Release 12 Hour 600 MG (guaiFENesin ER) Acetaminophen Tablet 500 MG RisaQuad Capsule (Probiotic Product) BISACODYL 10MG SUPPOSITORY Morphine Sulfate (Concentrate) Solution 100 MG/5ML H
Current Illness:
Preexisting Conditions: VASCULAR DEMENTIA HEART FAILURE BULLOUS PEMPHIGOID
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: COVID-19 + 1/11/2021, EXPIRED ON 1-24-2021
VAERS ID: 985501 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-18
Onset: 2021-01-22
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Fatigue, Nausea, Respiratory arrest, Resuscitation, Sluggishness
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fish oil Aspirin Calcium + D Lisinopryl 10 mg methimazole 5 mg colase 100 mg Hydrochlorathiazide 25 mg amlodipine 5 mg atenolol 25 mg trazadone 50 mg
Current Illness: none
Preexisting Conditions: hypertension, hyperlipidemia, hyperthyroidism, thyroid nodules, constipation, osteopenia, insomnia, incontinence
Allergies: none
Diagnostic Lab Data: none, no autopsy
CDC Split Type:

Write-up: family states seemed short of breath since after the covid vaccine. Staff said beginning on 1/22/21 the patient seemed sluggish, more tired, and nausea noted. She stayed in her room more after the vaccine because worried about giving/getting COVID to others. was talking on the phone at 11:30 PM on 1/26/21 to staff person about temperature of room. at 12:15 AM on 1/27/21 staff noted not breathing, started CPR and called EMS. When EMS arrived they stopped the code because she was too long deceased.
VAERS ID: 985527 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-06
Onset: 2021-01-23
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Full blood count, Hyponatraemia, Metabolic function test
SMQs:, Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 12
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: ALLOPURINOL CHOLECALCIFEROL DEBROX DOCUSATE SODIUM FLOMAX FLONASE GABAPENTIN KONSYL PACKET LASIX LORATIDINE MELATONIN MIRALAX SENNA
Current Illness:
Preexisting Conditions: NEUROPATHY HYPONATREMIA HTN BPH CKD ANEMIA GOUT
Allergies: ROCEPHIN
Diagnostic Lab Data: CBC, BMP 1-23-2021
CDC Split Type:

Write-up: COVID-19 + ON 1-13-2021, TRANFERRED TO HOSPITAL ON 1-23-2021 DUE TO HYPONATREMIA
VAERS ID: 985715 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-29
Onset: 2021-01-02
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, General physical health deterioration, Malaise
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: metoprolol 25mg vitamin D3 1000IU furosemide 80mg Norvasc 5mg aspirin 81mg Renvela 800mg atorvastatin 20mg vitamin B12 1000mcg
Current Illness: high blood pressure dialysis GI bleed/ symptomatic anemia
Preexisting Conditions:
Allergies: no known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received the vaccine on 12/29/20 and presented at the ER at the Hospital on 12/30/20 stating that he wasn''t feeling well. It is stated that his health had declined over the past few weeks and currently on hospice. Visit was unremarkable. Patient stated that wanted to stop dialysis. Patient passed away on 01/02/2021.
VAERS ID: 985814 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-20
Onset: 2021-01-21
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Aspiration, Asthenia, Blood creatinine increased, Blood glucose normal, Blood potassium increased, Blood urea increased, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Cough, Dyspnoea, Echocardiogram abnormal, Ejection fraction decreased, Emphysema, Endotracheal intubation, Fatigue, Haematocrit decreased, Haemoglobin decreased, Left atrial dilatation, Lung consolidation, Lung opacity, Nausea, Oropharyngeal pain, Pulmonary granuloma, Pulmonary hilum mass, Pulmonary mass, Red blood cell count decreased, Respiratory tract congestion, SARS-CoV-2 test negative, Vomiting, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 500 mg amoxicillin 1 gm aspirin furosemids 40 mg glucosamine-chondroitin 1 tab cozaar 25 mg multivitamin potassium chloride 20 meq tamsulosin 0.4 mg furosemide 40 mg zofran 4 mg
Current Illness: started with a sore throat the day before vaccination
Preexisting Conditions: anemia, BPH with obstruction, cervical neuritis, cervical spondylosis, cervicalgia, enlarged prostate, HLD, HTN, left sciatic nerve pain, low back pain, lumbar spinal stenosis, osteoarthritis, pacemaker, pancytopenia
Allergies: morphine, oxycodone, hydrocodone, hydromorphone, coumadin
Diagnostic Lab Data: 1/25/21 had CBC which showed WBC at 0.1, RBC 2.52, Hgb 8.8, Hct 27.2, Chem profile done showed high potassium, high glucose of 129, elevated BUN and Creatinine. Was negative for SARS-CoV 2 on 1/25/21. CXR showed right perihilar masslike opacity which may reflect infiltrate or neoplasm. Did CT of the chest which showed bilateral upper lobe chronic emphysematous lung changes, dense right upper lobe airspace disease, left lower lobe bronchial filling defects suggesting aspiration, scattered bilateral upper lobe nodular densities, scattered left lower lobe calcified granulomas, and left hilar calcified granuloma
CDC Split Type:

Write-up: started having generalized weakness on 1/21/21, fatigued., nausea/vomiting. went to doctor on 1/25/21 with complaint of sore throat, cough, and felt congested. Went to ER on 1/25/21 with complaints of increased shortness of breath, worsening nausea and vomiting. started on oxygen for sats of 87%. admitted on 1/25/21. On 1/26/21 needed intubated, CXR showed worsening consolidative change right lung at right hilar level. Echocardiogram showed ejection fraction 35-40%, left atrium is moderately dilated.
VAERS ID: 985933 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-29
Onset: 2020-12-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Chest X-ray abnormal, Death, Dyspnoea, Erythema, Influenza virus test negative, Leukocytosis, Lung infiltration, Pulmonary congestion, Pyrexia, Respiratory rate increased, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Dementia; Walking disability
Allergies:
Diagnostic Lab Data: Test Date: 20201231; Test Name: creatinine; Test Result: Inconclusive ; Test Date: 20201231; Test Name: BUN; Test Date: 20201231; Test Name: Temperature; Result Unstructured Data: ?F; Test Date: 20201231; Test Name: CXR; Test Result: Inconclusive ; Result Unstructured Data: mild left lower lung infiltrate; Test Date: 20201231; Test Name: Pulse; Test Result: Inconclusive ; Result Unstructured Data: Heart beats per minute; Test Date: 20201231; Test Name: Flu swab; Test Result: Negative ; Result Unstructured Data: negative; Test Date: 20201231; Test Name: O2; Test Result: Inconclusive ; Result Unstructured Data: Percent Room air; Test Date: 20201231; Test Name: WBC
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died; Increased respirations (22 and labored at times); Pulse 105; 94% O2 on RA; Labored breathing at times; leukocytosis; elevated BUN; left lower lung congestion; elevated creatinine; Temperature of 102.0F; Redness on face; A spontaneous report was received from a nurse concerning a 92-year-old, female patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced redness on face, increased respirations, labored breathing at times, temperature of 102F, pulse of 105, 94 percent O2, leukocytosis, elevated BUN, left lower lung congestion, elevated creatinine, and death. The patient''s medical history, as provided by the reporter, included dementia and reduced mobility. No relevant concomitant medications were reported. On 29 Dec 2020, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 30 Dec 2020, the patient began to experience redness on her face, increased respirations (reported as 22 and labored at times), pulse of 105, and 94 percent oxygen saturation on room air. The patient had a fever of 102 degrees Fahrenheit. Laboratory tests revealed a negative influenza swab, elevated white blood cell count of 14.1, elevated BUN at 113, and creatinine 2.7. Chest x-ray showed mild, left lower lung infiltrate. On 31 Dec 2020, the patient went under hospice care per her family request.. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 01 Jan 2021, the cause of death was unknown.; Reporter''s Comments: This case concerns a 92-year-old, female subject with medical history of dementia and reduced mobility, who experienced the serious unexpected events of death, respiratory rate increased, heart rate increased, oxygen saturation decreased, elevated BUN, elevated creatinine, left lung congestion and dyspnoea and the non-serious events of erythema and pyrexia. The events of respiratory rate increased, heart rate increased, oxygen saturation decreased, dyspnoea, erythema and pyrexia occurred 2 days after the first dose of the study medication administration, and the event of death occurred 4 days after the first dose of the study medication administration. Very limited information regarding the events is available at this time and no definite diagnosis or autopsy report have been provided. Additional information has been requested.; Reported Cause(s) of Death: Died
VAERS ID: 986063 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Utah  
Vaccinated: 2021-01-12
Onset: 2021-01-16
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Cholestyramine, Duloxetine, Fiber, Haloperidol, Hyoscyamine, Lisinopril, Lorazepam, Metoprolol, Morphine, Nystatin powder, Pepto Bismol, Seroquel, Spiriva, Symbicort, Tramadol, Tylenol, Vistaril, Zolpidem
Current Illness: COPD, CHF, Major Depressive Disorder, Anxiety, Respiratory Failure, Insomnia, OsteoArthritis, Hypertension, Irritable Bowel Syndrome, Atrial Fibrillation, COVID recovered
Preexisting Conditions: Resident was a Hospice Patient as of: 11/17/2020
Allergies: No Known Allergies
Diagnostic Lab Data: No tests/results pertaining to this incident.
CDC Split Type:

Write-up: Resident was vaccinated on 1/13/21. Resident passed away on 1/16/21
VAERS ID: 986123 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-19
Onset: 2021-01-24
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       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: 2021-01-24
   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: USPFIZER INC2021072348

Write-up: passed away-heart attack; This is a spontaneous report from a contactable consumer, the daughter of the patient from a Pfizer Sponsored program Pfizer First Connect. A male patient of an unspecified age received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Lot Number: UNKNOWN), via an unspecified route of administration on 19Jan2021 as a single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. On 24Jan2021, the patient passed away due to a heart attack. It was not reported if an autopsy was performed. The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.; Reported Cause(s) of Death: passed away-heart attack
VAERS ID: 986200 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: New Mexico  
Vaccinated: 2020-12-30
Onset: 2021-01-15
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

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: Atorvastatin, Metformin and Atenolol.
Current Illness: None.
Preexisting Conditions: Uncontrolled DMII and HTN.
Allergies: NKA.
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Death
VAERS ID: 986631 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-14
Onset: 2021-01-15
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

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: 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: Hypertension, hyperthyroidism
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Suspected myocardial infarction on 01/15/2021. Patient passed away on 01/15/2021.
VAERS ID: 986672 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-01
Onset: 2021-01-15
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19 pneumonia, Cough, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: 125 MG/5ML Suspension 5 ml in AM and 10 ml in PM Orally thru feeding tube Seroquel 50 MG Tablet 1 tablet Orally Once a day (crush and mix with water and thru feeding tube) Naproxen 125 MG/5ML Suspension 10 ml with food or milk Orally
Current Illness: none
Preexisting Conditions: CVA, seizures, Lung nodule
Allergies: iodine topical betadine
Diagnostic Lab Data: Covid-19 nasal swab
CDC Split Type:

Write-up: Patient tested Covid positive, cough, low oxygen levels, COVID Pneumonia, patient is now deceased
VAERS ID: 986773 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2020-12-31
Onset: 2021-01-14
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute respiratory failure, Bilevel positive airway pressure, COVID-19, Death, Exposure to SARS-CoV-2, Hospice care, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (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), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Acetylcysteine Solution 10 % 3 ml inhale orally two times a day BUDESONIDE 30''S,U-D,SDV UD 0.25MG/2ML AMPUL-NEB 2 ml inhale orally two times a day DIVALPROEX SOD ER 500MG TAB.SR 24H Give 1 tablet by mouth at bedtime IPRATROPIUM-ALBUTEROL O
Current Illness: Intermittent episodes of acute on chronic worsening of multi-factorial chronic respiratory failure with clear goals established through advance care planning. Overall, was stable in the month prior to vaccination.
Preexisting Conditions: 1. Status post TBI as a young child resulting in a cerebral palsy like syndrome w/ ID and spastic quadriparesis, R$gL 2. Seizure disorder 3. OBS/Psychiatric disorder with bipolar aspects and psychosis, better on Lithium. Symptoms well-controlled on Paxil, Risperdal and Lithium. 4. Asthmatic bronchitis w/ poor baseline respiratory function (chronic respiratory failure) and chronic cough, stable on regimen of inhaled budesonide, Duonebs and VEST therapy. 5. Complex Sleep apnea, controlled with Bi-PAP 6. GERD, stable on daily PPI. 7. Hypertension, controlled with spironolactone and terazosin. 8. CHF?, stable on spironolactone. Unable to get more records. 9. Hypothyroidism, stable on levothyroxine. 10. Dysphagia with Recurrent Aspiration (Does not want a Peg tube). Stable on puree diet and thickend liquids.
Allergies: Quinolones, Latex, Natural rubber
Diagnostic Lab Data: Nasal swab sample obtained 1/14/21 and sent for PCR testing was positive for SARS-CoV-2.
CDC Split Type:

Write-up: Resident was vaccinated on 12/31/20. Then on 1/14/21 he tested positive for SARS-CoV-2 on routine surveillance PCR testing. Another resident on the same hall was COVID positive on 1/11/21. Results of the PCR test were obtained on 1/16/21. He appeared asymptomatic at that time. Given his COVID positive status, all aerosol generating procedures had to be stopped. Overnight on 1/16/21 into 1/17/21, he had the onset of acute respiratory failure and was transported to the hospital. Per notes, he was put on BiPAP for several hours, but his CO2 level did not improve. Per prior advance directives completed with the resident and his two brothers, he had DNR/DNI orders. The hospital physician spoke with his brother and the decision was made to move to comfort care. He was discharged to inpatient hospice and died around 4pm on 1/18/21. This outcome does not appear to be vaccine-related, but death from COVID-19 infection is listed as a reportable event following COVID-19 vaccination.
VAERS ID: 986857 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Texas  
Vaccinated: 2020-12-28
Onset: 2020-12-28
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Mental status changes, Nausea
SMQs:, Acute pancreatitis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

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: Tresiba Flextouch Insulin Pen Victoza Pen Gabapentin Symtuza Sertraline HCL Anoro Inhaler Atorvastatin Risperidone Aspirin Men''s Multivitamin Melatonin Pioglitazone
Current Illness: Uncontrolled insulin levels (high glucose)
Preexisting Conditions: HIV COPD Diabetes Mellitus Type II Schizophrenia Psychosis Suprapubic catheter
Allergies: Fish / seafood
Diagnostic Lab Data:
CDC Split Type:

Write-up: Extreme bouts of nausea first few days after vaccine. Estimated that patient died at home within 3-4 days after receiving the vaccine. Last phone call to daughter expressed extreme nausea and seemed to have altered mental status. Found dead by daughter on 01/04/2021.
VAERS ID: 986869 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-03
Onset: 2021-01-10
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELI284 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (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: 2021-01-01
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Prednisone, Miralax, Labetalol, Gas-X, Gabapentin, Folic Acid, Fluconazole, Famotidine, Eliquis, Crestor, Bactrim
Current Illness: Pembro associated pneumonitis and nuronal inflammation, Candida Esophagitis
Preexisting Conditions: HTN, MVP/Mod MR, Prior Renal Ca s/p R nephrectomy, Active Lung Ca (Prior lobectomy/SRT on pembrolizumab)
Allergies: NKA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient noted with respiratory distress on 1/10/2021, transferred to hospital via 911.
VAERS ID: 986901 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-28
Onset: 2021-01-28
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Copaxone
Current Illness:
Preexisting Conditions: Optic neuritis; asthma
Allergies: None
Diagnostic Lab Data: Autopsy pending
CDC Split Type:

Write-up: Patient received vaccine uneventfully with no acute concerns. Left clinic and by report went out with friends. Spoke to father on phone at or around 9:00 pm. Failed to show up to work and was found dead at home. Other details pending
VAERS ID: 986948 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-22
Onset: 2021-01-24
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Private       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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Diltiazem CD, Gabapentin, Hydroxychloroquine, Levothyroxine, Omeprazole, Oritavancin, Potassium Chloride, Propylene Glycol Eye Drops, Sertraline
Current Illness: alcoholic cirrhosis, thrombocytopenia, anemia, lymphedema
Preexisting Conditions: hypertension, hypothyroid, rheumatoid arthritis, depression, GERD
Allergies: acetaminophen, atorvastatin, belsomra, benadryl, benzoin, cefazolin, cephalosporins, codeine, cymbalta, darvocet, dilaudid, duragesic, floxin, guaifenesin, hydrocodone, indocin, lovenox, morphine, nafcillin, oxycodone, paxil, sudafed, sulfa, vancomycin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiac arrest on 1/24/21 in the early morning hours then passed away on 1/25/21 around 1:51am in the hospital
VAERS ID: 987029 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-27
Onset: 2021-01-28
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 2 RA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: Pepcid Aspirin Finasteride Stress Plus Zinc Tab Seroquel Pravastatin Sodium Amlodipine besylate Flomax
Current Illness: PRESSURE ULCER OF RIGHT HEEL, STAGE 2 ATHEROSCLEROSIS OF NATIVE ARTERIES OF LEFT LEG WITH ULCERATION OF OTHER PART OF FOOT ATHEROSCLEROSIS OF NATIVE ARTERIES OF LEFT LEG WITH ULCERATION OF HEEL AND MIDFOOT
Preexisting Conditions: TRAUMATIC SUBDURAL HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, SUBSEQUENT ENCOUNTER MUSCLE WEAKNESS (GENERALIZED) UNSPECIFIED LACK OF COORDINATION FEEDING DIFFICULTIES OTHER REDUCED MOBILITY NEED FOR ASSISTANCE WITH PERSONAL CARE DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED DYSPHAGIA, OROPHARYNGEAL PHASE OTHER SYMBOLIC DYSFUNCTIONS ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ORTHOSTATIC HYPOTENSION HYPERLIPIDEMIA, UNSPECIFIED DEMENTIA WITH LEWY BODIES CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE HYPOKALEMIA PRESSURE ULCER OF LEFT HEEL, UNSTAGEABLE CONSTIPATION, UNSPECIFIED BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS ESSENTIAL (PRIMARY) HYPERTENSION REPEATED FALLS RETENTION OF URINE, UNSPECIFIED PRESENCE OF AORTOCORONARY BYPASS GRAFT PARKINSON''S DISEASE LOCALIZED SWELLING, MASS AND LUMP, RIGHT UPPER LIMB
Allergies: Penicillins Green Food Dye Dust Mites Aricept Namenda
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident passed away at 8:15 am on 1/28/21-found to be without pulse/respirations/DNR order in place.
VAERS ID: 987126 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-01-29
Onset: 2021-01-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Patient died. Patient had been declining in health rapidly prior to receiving the vaccine
VAERS ID: 987301 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2020-12-28
Onset: 2020-12-28
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Cerebrovascular accident, Death, Life support, SARS-CoV-2 test positive, Seizure
SMQs:, Systemic lupus erythematosus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Convulsions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad), 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? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Not Sure! Vaccine was given in a Nursing Facility
Current Illness: Previous Stroke
Preexisting Conditions: Not Sure
Allergies: Not aware
Diagnostic Lab Data: Don''t Know
CDC Split Type:

Write-up: My Mother was given the Covid Vaccine (1st Dose) on 12/28/2020. Later that night we received a call from the nursing facility that my Mother was having uncontrollable seizures and had to be transported to the nearby hospital. The ER doctor confirmed that my Mother had tested positive to Covid. She was treated for Covid and was on life support. A few days later we received a call that my Mother had a major stroke. She passed away on January 4, 2021
VAERS ID: 987469 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-26
Onset: 2021-01-27
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Chest X-ray abnormal, Computerised tomogram abdomen, Computerised tomogram abnormal, Culture negative, Diarrhoea, Lung opacity, Pneumonia aspiration, Respiratory rate increased, Urine analysis normal, Vomiting
SMQs:, Acute pancreatitis (broad), Interstitial lung disease (narrow), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: was being treated with antibiotic prednisone for hand swelling day prior
Preexisting Conditions: history of bowel obstructions and diverticulosis, AFIB, Dementia, PANCYTOPENIA
Allergies:
Diagnostic Lab Data: Per hospital report CXR- aspiration pneumonia, UA C&S - all negative, CT of abdomen and pelvis showing some bibasilar airspace opacities and atelectasis. possible evidence of enterocolitis symptoms may also be secondary to immune response to second COVID 19 vaccination.
CDC Split Type:

Write-up: emesis bright yellow in color, liquid BM, increased respirations
VAERS ID: 987513 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-27
Onset: 2021-01-27
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Oxygen saturation decreased, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: None
Current Illness: UTI And PNA
Preexisting Conditions: COPD , anxiety history of ETOH abuse ,thrombocytopenia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Note Text: Resident oxygen was going down to 74% during change of shift 3-11, oxygen initiated 3liters via nasal canula per standing order want up to 84-86% NP notified, ordered Prednisone 20mg stat, Rocephin 1gram IM stat administered, Per NP statement if pt''s condition worsening sent him to ER, continue monitoring pt and his oxygen going to 82% increasing distress. Notified Nurses supervisor, 911 was called pt left building at 1819 to Hospital alert oriented. Vs bp. 165/60, temp. 98.3,m pulse 109, res 22, 02. 82%. Resident father notified.
VAERS ID: 987533 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Full blood count, Lethargy, Metabolic function test
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Insulin Lispro, Propranolol 120mg, Clopidogrel 75mg, Donepezil 10mg, Memantine 10mg, QUEtiapine Fumarate 100mg, Pantoprazole 40mg, Pramipexole Dihydrochloride 1.5mg, predniSONE 20mg, Aspirin 81mg, Atorvastatin Calcium 40mg, Insulin Glarg
Current Illness: See item 12
Preexisting Conditions: COPD, CHF, DM, Asthma, HTN, Dementia, Depression, GERD, Parkinson
Allergies: Dexamethasone, Versed
Diagnostic Lab Data: Stat CBC & CMP ordered. Labs were drawn but the patient expired before the facility received the results.
CDC Split Type:

Write-up: The patient was observed to be lethargic on 1/29/21 at 1515. BP-80/50, P-75, RR-27, T-100.1. He was given a bolus of NS 150 mlx2. and Rocephin 1 gram IM.
VAERS ID: 988245 (history)  
Form: Version 1.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-16
Onset: 2021-01-17
   Days after vaccination: 1
Submitted: 2021-01-27
   Days after onset: 10
Entered: 2021-01-29
   Days after submission: 2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Cardiac arrest, Sudden 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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: 93 y/o with complex medical history (severe COPD on oxygen, diastolic CHF, CKD3, myelofibrosis, marginal zone lymphoma of spleen with recent progression and no active treatment, chronic anemia, afib, CAD, pulmonary artery hypertension, h/o bladder cancer, hypertension, hypothyroidism, h/o bilateral PE, sick sinus syndrome s/p pacemaker, h/o Hodgkin''s disease). Has had multiple hospitalizations over the last 3 months for dyspnea, most recently in 12/2020. Enrolled in palliative care. Has had multiple transfusions (most recently 01/13/21) for his chronic anemia due to myelofibrosis, and recently started on darbepoetin. No documented history of anaphylaxis to medications or prior vaccinations. He received COVID19 vaccine (Moderna) on 01/16/21. He passed away suddenly at home on 01/17/21. Symptoms: & cardiac arrest Treatment:
VAERS ID: 988246 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-22
Onset: 2021-01-26
   Days after vaccination: 35
Submitted: 2021-01-27
   Days after onset: 1
Entered: 2021-01-29
   Days after submission: 2
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 LA / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 3 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Alanine aminotransferase decreased, Aspartate aminotransferase decreased, Atrial fibrillation, Bilirubin conjugated increased, Blood alkaline phosphatase normal, Blood bilirubin increased, Blood creatinine increased, Blood urea decreased, Blood urea increased, Death, Pneumonia, Protein albumin ratio increased, SARS-CoV-2 antibody test negative, SARS-CoV-2 test negative, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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, albuterol/ipratropium, amlodipine, ascorbic acid, atorvastatin, baclofen, buspirone, calcium carbonate with vitamin D, cholecalciferol, dexmedetomidine, diltiazem, docusate, esomeprazole, famotidine, fentanyl, fluticasone, ga
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Collection DT Spec CoV19BF COVIDIg 01/21/2021 14:10 NASAL Not Detected 01/12/2021 04:00 SERUM 0.03 01/11/2021 12:35 NASAL Not Detected Collection DT Spec WBC BUN Creat Cystn-C 01/25/2021 04:00 BLOOD 15.28 H 01/25/2021 04:00 PLASM 64 H 1.3 2.46 H 01/24/2021 04:00 PLASM 56 H 1.1 01/24/2021 04:00 BLOOD 13.16 H 01/23/2021 04:40 BLOOD 14.02 H 01/23/2021 04:00 PLASM 52 H 0.9 01/23/2021 04:00 BLOOD 7.93 01/22/2021 04:00 BLOOD 10.58 H 01/22/2021 04:00 PLASM 49 H 0.9 01/21/2021 04:00 PLASM 47 H 1.0 01/21/2021 04:00 BLOOD 7.39 01/20/2021 04:00 PLASM 30 H 0.8 01/20/2021 04:00 BLOOD 9.10 01/19/2021 04:00 PLASM 17 0.7 L Collection DT Spec Protein Albumi TotBili DirBili ALT AST AlkPhos 01/25/2021 04:00 PLASM 5.6 L 3.2 L 1.1 1096 H 504 H 51 01/24/2021 04:00 PLASM 6.0 L 3.2 L 0.8 1482 H 699 H 57 01/23/2021 04:00 PLASM 5.5 L 2.9 L 0.6 1778 H 1044 H 53 01/22/2021 04:00 PLASM 5.7 L 2.6 L 0.4 2135 H 1579 H 49 01/21/2021 17:00 PLEUR 1.3 01/14/2021 04:00 PLASM 6.8 3.2 L 0.4 15 21 57 01/13/2021 04:00 PLASM 6.3 L 3.0 L 0.3 14 18 53 01/12/2021 04:00 PLASM 5.8 L 2.7 L 0.3 11 17 55
CDC Split Type:

Write-up: Narrative: See "Other Relevant History" in Section 6 above Symptoms: ElevatedLiverEnzymes & death, pneumonia, afib Treatment:
VAERS ID: 987636 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-18
Onset: 2021-01-21
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure decreased, Dyspnoea, Fluid retention, Multiple organ dysfunction syndrome, Peripheral swelling, Pulmonary oedema, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (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 (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: Insulin, blood pressure medication
Current Illness: Diabetes
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Legs started swelling and shortness of breath Thursday January 21 2021 Was rushed to hospital with kidney failure and fluid build up around lungs and entire body Blood pressure dropped and had multiple organ failure
VAERS ID: 987663 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-31
Onset: 2021-01-10
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
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: Prescription blood pressure medication
Current Illness: None
Preexisting Conditions: For a year he had a catheter as part of treatment of a prostrate issue without surgery.
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died
VAERS ID: 987789 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-22
Onset: 2021-01-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Dizziness, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: REC''D CALL FROM PT''S DAUGHTER, HER FATHER WAS VACCINATED ON 1/22/21, WOKE UP 1/23/21 WAS SHORT OF BREATH AND DIZZY. PT PRESENTED TO ED OF LOCAL HOSPITAL AND WAS ADMITTED, PT PASSED ON 1/25/21. DAUGHTER STATES THAT FAMILY AND DOCTORS AGREE THAT THE VACCINE DID NOT CONTRIBUTE TOWARDS PT''S DEATH, BUT FELT IT NEEDED TO BE REPORTED. PT''S DAUGHTER CONTACTED THIS RN AT LOCAL HEALTH DEPARTMENT TO REPORT TO VAERS.
VAERS ID: 987877 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-14
Onset: 2021-01-26
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: PT WAS ON HOSPICE CARE AT TIME OF VACCINATION
Preexisting Conditions: UNKNOWN
Allergies: PCN
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: REC''D CALL FROM PT''S SON, PT HAS BEEN ON HOSPICE CARE AND PASSED 1/26/21. DOES NOT BELIEVE THIS IS RELATED TO VACCINE ADMINISTRATION, BUT WANTED TO REPORT TO US.
VAERS ID: 988270 (history)  
Form: Version 1.0  
Age: 90.0  
Sex: Male  
Location: Tennessee  
Vaccinated: 2020-12-28
Onset: 2021-01-14
   Days after vaccination: 17
Submitted: 2021-01-29
   Days after onset: 15
Entered: 2021-01-30
   Days after submission: 1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD039K20A / UNK RA / -

Administered by: Other       Purchased by: Other
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: & death Treatment:
VAERS ID: 988369 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-19
Onset: 2021-01-21
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Pneumonia aspiration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   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: Carvedilol Citalopram Phenytion Olanzapine
Current Illness:
Preexisting Conditions: diabetes gastroparesis MitraClip
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: aspiration pneumonia/death
VAERS ID: 991450 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-01-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Muscle spasms, Muscle tightness, Myalgia, Neck pain
SMQs:, Rhabdomyolysis/myopathy (broad), Dystonia (broad), Eosinophilic pneumonia (broad), Arthritis (broad), Tendinopathies and ligament disorders (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: Lisinopril, furosemide, omeprazole, amlodipine, meclizine, loratadine
Current Illness:
Preexisting Conditions: Coronary artery disease (CAD); Hypertension (HTN); Renal Disease (e.g. CKD, HD, ESRF)
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient developed left sided neck and trapezoid tightness and pain after receiving the moderna covid vaccine in her left shoulder. The injection site is non tender and does not show any erythema or tenderness. The tenderness is over the left trapezius and left lateral neck area. It also feel tight like a muscle spasm.
VAERS ID: 989006 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Virginia  
Vaccinated: 2021-01-30
Onset: 2021-01-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-01-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9263 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Airway secretion clearance therapy, Breath sounds abnormal, Cardiac arrest, Cardioversion, Death, Dyspnoea, Endotracheal intubation, Mobility decreased, Pulseless electrical activity, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (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), Parkinson-like events (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Per reviewed on medical records: metformin, gabapentin, glipizide
Current Illness: unknown
Preexisting Conditions: diabetes obesity hypoventilation syndrome
Allergies: penicillin latex
Diagnostic Lab Data:
CDC Split Type:

Write-up: After being observed for approximately 20 minutes and patient walked to her car without assistance I was called to assess the patient in the parking lot for troubles breathing. EMS was called as I made my way outside. Upon my arrival patient was leaning out of the car and stating that she could not breath. She was able to tell me that she was allergic to penicillin. Oxygen was immediately placed on the patient with minimal relief. Lung sounds were coarse throughout. She then began to vomit about every 20-30 seconds. Epipen was administered in the right leg with no relief. Patient continued to complain of troubles breathing and vomiting. A second epipen was administered in the patients right arm again with no relief. A few minutes later patient was given racemic epinephrine through the oxygen mask. There appeared to be mild improvement in her breathing as she appeared more comfortable, but still complaining of shortness of breath and vomiting. When EMS arrived patient was unable to transport herself to the stretcher. When EMS and clinical staff transferred patient to the stretcher she became unresponsive. She appeared to still be breathing. She did not respond to verbal stimuli. Per ED report large amount of fluid was suctioned from the patients lungs following intubation in the ambulance. When patient arrived to the ED she was extubated and re-intubated without difficulty and further fluid was suctioned. At that time patient was found to be in PEA, shock was delivered. Shortly thereafter no cardiac activity was found and patient pronounced dead.
VAERS ID: 989015 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Connecticut  
Vaccinated: 2021-01-26
Onset: 2021-01-27
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-01-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: End Stage Renal Disease, NON ST Elevation (NSTEM) Myocardial Infarction,, Type II Diabetes Mellitus, Cardiac Arrest cause unspecified, Paroxysmal atrial fibrillation, acute embolism and thrombosis of unspecified deep veins of right lower extremity, Alzheimer''s disease, Chronis systolic heart failure,
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Myocardial Infarction
VAERS ID: 990034 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-17
Onset: 2021-01-31
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-01-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Rheumatoid arthritis
SMQs:, Arthritis (narrow), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Rheumatoid arthritis, diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: I helped facilitate scheduling for his COVID vaccine and received notification from his wife that he passed away unexpectedly this morning. She reported he had been experiencing a rheumatoid arthritis flare and was on steroids. His diabetes was not well controlled as a result. He did not have any reactions in the days immediately after the vaccine.
VAERS ID: 990780 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-25
Onset: 2021-01-28
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: Marko Cell Carcinoma Matasisized
Preexisting Conditions: was in hospice since 8/11/20 had cancer
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed
VAERS ID: 990956 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-12
Onset: 2021-01-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Other- Patient passed away
VAERS ID: 991060 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-27
Onset: 2021-01-28
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Anaemia, Cardiac failure congestive, Condition aggravated, Death, Packed red blood cell transfusion, Pyrexia, Unresponsive to stimuli
SMQs:, Cardiac failure (narrow), Haematopoietic erythropenia (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Myelodysplastic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril 10mg daily, Lasix 40 mg daily, Simvastatin 40 mg daily, Senna 8.6/50mg twice daily, Namenda XR 28mg daily, Protonix 40mg daily, ASA 81 mg daily, Potassium Chloride ER 10 meq daily, Amiodarone 100mg daily, metoprolol 25 mg daily.
Current Illness: Dementia, heart failure, paroxysmal atrial fib.. BHP, HTN, thorasic aortic aneurysm, polyosteoarthritis, history of falls, anemia
Preexisting Conditions: as above Resident was transferred to hospital on 1/28/21. Returned to nursing facility on 1/30 and passed away on 1/31/21.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever 101.1, unresponsive episode. Transferred to Hospital on 1/28. Diagnosis there was anemia and CHF, aware that he had vaccine day prior. Transfused with 2 units pRBC''s. Transferred back to Nursing Home on 1/30 and passed away 0140 1/31/2021
VAERS ID: 991080 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Massachusetts  
Vaccinated: 2020-12-28
Onset: 2021-01-06
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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 sudden death reported by family. No further details available at this time.
VAERS ID: 991117 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-28
Onset: 2021-01-28
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen saturation decreased
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Other- pt had history of copd and DNR on file. approx 3 1/2hr after vaccine pt had sob and lowo2 sat, emergency services called, pt passed on their arrival.staff felt due to pt existing condition
VAERS ID: 991216 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2021-01-26
Onset: 2021-01-28
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 1 LA / IM

Administered by: Private       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: 2021-01-28
   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:
Preexisting Conditions: History of Heart Condition
Allergies: NKDA
Diagnostic Lab Data: Unknown
CDC Split Type: 921134 WebIZ #

Write-up: Vaccine given on 01-25-2021. Wife reported on 01-29-2021 that patient had a ran a fever on 01-26-2021, Was better on 01-27-2021. She found him dead when she came home work on the evening of 01-28-2021.
VAERS ID: 991622 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: 81 mg Aspirin Prevident 5000 Pepcid 20 mg Propafenone 150 mg Biscodyl Suppository Milk of Magnesia Acetaminophen 325 mg Miralax Powder Ferrous Sulfate 325 mg
Current Illness: Cerebral Infarction due to embolism Crohn''s Disease Gastric Reflux Hyperlipidemia HTN SENILE DEGENERATION OF BRAIN, NOT ELSEWHERE CLASSIFIED PRIMARY GENERALIZED (OSTEO)ARTHRITIS
Preexisting Conditions: See Item 11
Allergies: Adhesive Tape (intolerance) Procaine (intolerance)
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Death
VAERS ID: 991677 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-01-21
Onset: 2021-01-30
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Public       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: 2021-01-31
   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: diagnosed with Covid on 12/03/2020
Preexisting Conditions: hypertension, hyperlipidemia, diabetes, GERD
Allergies: Sulfa, Flexeril, trimethoprim
Diagnostic Lab Data:
CDC Split Type:

Write-up: got up in the night and stated that she couldn''t breath, ambulance was called, pt expired in route to hospital. *relayed to me by Facility staff RN.
VAERS ID: 991849 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-25
Onset: 2021-01-27
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041620A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Dyspnoea, Hypoxia, Respiratory tract congestion, Tachycardia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: clonazepam, Flomax, Flunisolide Soln., Melatonin, Omeprazole, Miralax, Sertraline, Milk of Mag, Tylenol
Current Illness:
Preexisting Conditions: Epilepsy, HTN, BPH, ASHD, GERD, Alzheimer''s Disease, Depression, OCD
Allergies: NKA
Diagnostic Lab Data: nonne
CDC Split Type:

Write-up: Congestion, Hypoxia, SOB, Tachycardia, Weakness. Started on O2 @ 3L, HOB elevated, Tylenol supp
VAERS ID: 991859 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-29
Onset: 2021-01-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Food refusal, Memory impairment, Mobility decreased, Somnolence, Urine output decreased, Visual impairment
SMQs:, Acute renal failure (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Depression (excl suicide and self injury) (broad), Chronic kidney disease (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: hospice patient for 1 year
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per granddaughter''s report, pt became very weak within hours of receiving the first dose of the Moderna COVID-19 vaccine and could not get out of bed the next morning without assistance, reported difficulty seeing, and did not recognize some family members. By Sunday, 1/31, pt was unable to be awakened, would not eat, and had low urinary output. Granddaughter reports that the morning of 2/1 he was awake and ate a small amount and seemed to be improving although still weak and unable to get out of bed. Granddaughter reported he died 2/1 around 10am in the morning.
VAERS ID: 991927 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: North Dakota  
Vaccinated: 2021-01-05
Onset: 2021-01-12
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-12
   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: Diphenhydramine HCl, atorvastatin, furosemide, gabapentin, Healthy Eyes (vitamin A, C, & E with lutein minerals), Imodium, Isosorbide mononitrate, Jantoven, Potassium Cl, Metoprolol succinate, Nitroglycerin.
Current Illness:
Preexisting Conditions: Constipation, acute exacerbation of chronic congestive heart failure , osteoarthritis, mitral and aortic incompetence, abnormal renal function, hernia of abdominal cavity, polyp of colon, coronary arteriosclerosis, atrial fibrillation, aortic valve stenosis, aortic valve disorder, cerebrovascular disease, long term current use of anticoagulant, sick sinus syndrome, edema, gout, angina co-occurrent and due to coronary arteripolyneuropathy, essential hypertension, mixed hyperlipidemia, chronic kidney disease stage 3, chronic systolic heart failure, angina, prosthetic cardiac paravalvular leak, prosthetic heart valve in situ, aortic stenosis-non-rheumatic, macrocytic anemia, diarrhea-occasionally, heart disease, cerebrovascular accident, old MI, Squamous cells carcinoma of skin of face, long QT syndrome- 6/18/2020 PPM placed.
Allergies: No known defined allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found deceased at Nursing Home in his room 01/12/2021 at 5:25 AM.
VAERS ID: 991997 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-28
Onset: 2021-01-30
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose increased, Blood potassium increased, Cardiogenic shock, Cold sweat, Death, Endotracheal intubation, Nausea, Sepsis, Troponin increased, Vomiting, White blood cell count increased
SMQs:, Cardiac failure (narrow), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
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: Tylenol, Levemir, Humalog, Trazodone, Prozac, Metoprolol, Eliquis, Plavix, Atorvastatin, Pantoprazole, Dialyvite, Renagel
Current Illness: COVID + diagnosis (12/17/2020) ASYMPTOMATIC Multiple oral extractions completed by dentist on 1/26/2020 ESRD (on 3x week dialysis-last date of dialysis 1/29/2020)
Preexisting Conditions: ESRD, Diabetic, Heart Disease, Vascular Disease, HTN,
Allergies: Bactrim/Sulfa, Cyclobenzaprine, Fentanyl, Gabapentin, Lisinopril, Metoprolol, Primidone
Diagnostic Lab Data: Multiple test completed during course of ER and hospital stay WBC 16.8, K+ 6.1, Serial Troponins 363, 444, 578
CDC Split Type:

Write-up: Resident c/o nausea evening of 1/29 (nausea common for her post dialysis), had a large emesis at approx 2220, 0030 (unusual for resident to vomit)- received Zofran per order. Skin cool and damp, Blood sugar 147 (checked due to h/o diabetes and poor intake). At approx 230am Blood pressured checked and noted to be 52/29. Resident transferred to ER, intubated and transferred to higher level of care where she passed away on 1/30 at 736pm. Resident''s medical notes indicated likely shock, cardiogenic in nature, sepsis (source unknown) along with a multitude of other co-morbidities that resident has.
VAERS ID: 992063 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-19
Onset: 2021-01-29
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypoxia, Respiratory depression, SARS-CoV-2 test positive, Skin discolouration
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: Tums, folic acid, hydroxychloroquine (pre-existing prescription to pandemic), pain pump, symbicort inhaler, multi-vitamin, albuterol inhaler, duloxetine, nystatin powder, senna-docusate, tofacitinib citrate, probiotic, polyethylene glycol,
Current Illness:
Preexisting Conditions: Vascular dementia, swelling of left lower extremity (chronic), subclinical hypothyroidism, STEMI (2014), rheumatoid arthritis, postinflammatory pulmonary fibrosis, posterior tibial tendon dysfunction, paroxsymal atrial fibrillation, osteoporosis, OSA on CPAP, microscopic colitis, interstitial lung disease, hypertension, hx of squamous cell carcinoma of skin, hx of basal cell carcinoma, hearing loss, gout, GERD, dyspnea on exertion, dyslipidemia, diverticulitis, HX of CVA, COPD, chronic heart failure w. preserved ejection fraction, chronic back pain, carotid artery stenosis, CAD, BPH, Barrett''s esophagus, asthma, anxiety, allergic rhinitis, actinic keratosis.
Allergies: Amoxicillin (N&V), "poison ivy/treatments"
Diagnostic Lab Data: Positive COVID-19 per PCR, 1/29/2021
CDC Split Type:

Write-up: Patient received first dose of the COVID-19 Moderna vaccine on 1/19/2021 at an outside facility (no lot #, route, or site available to me in electronic charting). Pt began having hypoxia, SOB, and a dusky appearance of extremities on 1/29/2021 and was brought by EMS to our hospital. PT is a DNR and family had been looking into a hospice sign up due to dementia and general decline in the weeks prior to hospitalization. Pt tested positive on admission for COVID-19 via PCR test on 1/29/2021. Pt continued to have respiratory decline, was put on comfort care per wishes of family/advanced directives, and he passed away the evening of 1/30.
VAERS ID: 992082 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-24
Onset: 2021-01-25
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EI3249 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Culture urine negative, Death, Full blood count normal, General physical health deterioration, Hemiparesis, Metabolic function test, Metabolic function test normal, Mobility decreased
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Parkinson-like events (broad), Noninfectious encephalitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Rocephin, depakote sprinkles, metoprolol, trazodone, famotidine, certevite, mylanta, vit D, zocor, keppra, aspirin, tylenol, tricor.
Current Illness: None
Preexisting Conditions: Supraventricular Tachycardia, cerebral palsey, epilepsy,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident was noted on 1/25 with an increased functional decline as she would not feed herself with utensils, but would eat finger foods if placed in her hand. She was started on Rocephin IM for possible infections. Labs had been obtained on 1/21/21, unremarkable for CBC and CMP. 75,000 colony count on urine. On 1/26/21 she was noted with right sided weakness and further decline. She was sent to Hospital for further evaluation. We were notified that she expired on 1/28/2021. Resident had been noted with a decline in function about 2 weeks earlier when she would not stand or transfer any longer. She was still responsive, taking meds, and feeding herself until 1/26/21. Further information on admitting diagnoses and progress notes from hospital have not been available to date.
VAERS ID: 992137 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: South Carolina  
Vaccinated: 2021-01-19
Onset: 2021-01-25
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bradycardia, Cardio-respiratory arrest, Death, Diarrhoea haemorrhagic, Hyporesponsive to stimuli, Hypotension, Mechanical ventilation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: oxymorphone ,mertazapine,medical marijuana , duloxetine , lisinopril , monolucast, hydocortisone, simvastatin amlodipine famotidine
Current Illness:
Preexisting Conditions: pan-hypo pituitarism, hypertension, hyperlipidemia chronic pain sleep apnea
Allergies:
Diagnostic Lab Data: See hospital record
CDC Split Type:

Write-up: 6 days after vaccine developed bloody diarrhea. Thought to have ischemic colitis but negative evaluation. became hypotensive bradycardic placed on ventilator. Subsequently was poorly responsive and eventually coded once more and succumbed
VAERS ID: 992154 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-11
Onset: 2021-01-25
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: duo neb, lasix, protonix, prednisone, apap , dulcolax, cough syryp, levsin, MOM, morphine, tums, ativan, flomax, aquaiphor oint, senna, muscle rub
Current Illness: None
Preexisting Conditions: Alzheimers Dementia late onset without behavioral disturbance, Hypotension, benign prostatic hyperplasia, Left inguinal hernia found 2016, Left shoulder lesions, Hypothyroidism, GERD (gastroesophageal reflux disease), Mixed hyperlipidemia, Basal Cell Carcinoma, Kyphosis, Hx of shingles, dysphagia, Legally blind LEFT eye, cataracts both eyes, frality, hard of hearing Hospice- general decline in the past year.
Allergies: NKA
Diagnostic Lab Data: none, pt on hospice, comfort cares
CDC Split Type:

Write-up: No adverse events reported post vaccine. 1 st dose on 1/11/21 by public health. Death 1/31/21 Patient was on hospice for gradual decline.
VAERS ID: 992209 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Alaska  
Vaccinated: 2021-01-08
Onset: 2021-01-30
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: Lorazepam, Haloperidol, Morphine
Current Illness: Hyperlipidemia
Preexisting Conditions: Hyperlipidemia
Allergies: NKDA, NKFA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death
VAERS ID: 992237 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-25
Onset: 2021-01-29
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cardioversion, Chest discomfort, Death, Dyspepsia, Electrocardiogram, Endotracheal intubation, Mechanical ventilation, Palpitations, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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), Gastrointestinal nonspecific dysfunction (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Nebivolol 5mg; Pantoprazole 40 mg; Levocetirizine dehydrochloride 10 mg
Current Illness:
Preexisting Conditions: Hypertension; Hyperlipidemia; decreased GFR. Family history of CAD
Allergies: None
Diagnostic Lab Data: Bag valve mask and intubation prior to arrival to ED. Epi x3 and defibrillation x2.
CDC Split Type:

Write-up: 1/28/2021- Seen by FNP for indigestion, chest pressure and palpitations. EKG reviewed and referral made to Cardiology. 1/29/2021-1800 Presented to ED in cardiac arrest-onset PTA. Patient was found unresponsive by his wife at their home. The last known well was at 1530 when she called him on the phone. The patient was pronounced at ~1850.
VAERS ID: 992238 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2020-12-16
Onset: 2021-01-05
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Private       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: 2021-01-29
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 24 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol sitagliptin/metformin glipizide pioglitazone folic acid rivaroxaban tadalafil aspirin atorvastatin lisinopril nephrocaps omeprazole
Current Illness:
Preexisting Conditions: ischemic heart disease hypertension diabetes mellitus type 2 gastroesophageal reflux disease hyperlipidemia obstructive sleep apnea obesity
Allergies: Plavix
Diagnostic Lab Data:
CDC Split Type:

Write-up: Tested positive for COVID19 on 12-30-2020, Admitted to Hospital on 1/5/2021 with active COVID, Patient died 1/29/2021.
VAERS ID: 992342 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Alabama  
Vaccinated: 2021-01-21
Onset: 2021-01-30
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Arrhythmia, Dyspnoea, Hypertension, Oxygen saturation decreased, Pneumonia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Baby Aspirin
Current Illness: none
Preexisting Conditions: Diabetes Type 2
Allergies: NKDA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Shortness of Breath, decreased oxygen saturation, irregular heart rhythm, hypertension, Positive for COVID, bilateral pneumonia
VAERS ID: 992347 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Oklahoma  
Vaccinated: 2021-02-01
Onset: 2021-02-01
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: hydrocodone, fentanyl, albuterol
Current Illness: none known
Preexisting Conditions: degenerative disc disease, chronic back pain, hypothyroidism, hypertension, GERD, COPD, tobacco dependence
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death
VAERS ID: 992372 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Oregon  
Vaccinated: 2021-01-08
Onset: 2021-01-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011I20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Atrophy, Cerebral haemorrhage, Cerebral small vessel ischaemic disease, Chest X-ray normal, Computerised tomogram head normal, Death, Embolic cerebellar infarction, Embolic cerebral infarction, Erythema, Laboratory test normal, Magnetic resonance imaging brain, Magnetic resonance imaging brain abnormal, Mental status changes, SARS-CoV-2 test negative, Troponin increased, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: (1) Acetaminophen 500mg PO Q4H PRN pain (2) Albuterol inhaler 1 puff Q4H PRN (3) Cyanocobalamin 1000mg PO daily (4) Diazepam 5mg PO daily PRN anxiety (5) Ergocalciferol 48,000 units PO daily (6) Fluoxetine 20mg PO daily (7) Arnicare cream 1
Current Illness:
Preexisting Conditions: (1) Advanced dementia (2) Hypothyroidism (3) Anxiety (4) Hx falls
Allergies: (1) Etodolac (rxn = n/v, diarrhea, SOB) (2) Bee Pollen (3) Escitalopram (rxn = ''intolerance'') (4) Paroxetine (rxn = ''ineffective'') (5) Venlafaxine (rxn = ''ineffective'')
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is a 73 year old female that received her 1st dose with Moderna vaccine on 1/8/21 at approximately 1600. Within one hour, the patient developed altered mental status and increasing weakness. She was transported to the hospital by the staff at her Assisted Living Facility for concern of a vaccine reaction. On admission, oxygen saturation was found to be 89% on room air, BP=137/86, HR=94. Labs were normal, with the exception of WBC=15 (leukocytes normal, chest xray clear, COVID test negative), and a detectable troponin=63. Head CT negative. Physical exam was only notable for ''slight superficial erythema over distal right forearm and dorsal hand. No significant edema.'' The patient was treated for a possible allergic reaction to vaccine with NS bolus, methylprednisolone 125mg, famotidine 20mg, and aspirin 300mg PR. She was admitted for monitoring given continued altered mental status/weakness. The next day, she continued to show no improvement, so a head MRI was ordered. MRI showed " 1. Numerous acute cerebral and cerebellar infarcts involving both anterior and posterior circulations consistent with a central embolic source. 2. Minimal right parietal petechial hemorrhage. 3. Moderate atrophy and moderate nonspecific white matter signal abnormalities compatible with chronic microvascular ischemia " Neurology was consulted, who approved the start of aspirin and to continue DVT prophylaxis. The patient''s advanced dementia and timeline preclude other intervention. The patient''s status was DNR/DNI. The patient was discharged on hospice to her assisted living facility on 1/11/21 (with reports of continued somnolence). It was reported that date of death was 1/24/21.
VAERS ID: 992571 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-29
Onset: 2021-01-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Death, Dyspnoea, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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: 2021-01-30
   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: unknown
Current Illness: He stated he was experiencing some shortness of breath with cold and walking up the steps. The patient did report that they had some bloody stool early in the week but that had resolved.
Preexisting Conditions: PMH: DM, HTN, Obesity, hyperlipidemia, Chronic kidney Disease, polyp?s removal. History of Angioedema secondary Ace Inhibitor
Allergies: ACE inhibitor
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient''s wife called the physician''s office with increasing SOB. MD advised that the patient go to the ED. While dressing, the patient became unresponsive, 911 called. Patient expired in ED.
VAERS ID: 992599 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: California  
Vaccinated: 2020-12-31
Onset: 2021-01-03
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lactobacillus Capsule MULTIVITAMINS TABLET CRANBERRY TABLET
Current Illness: COVID-19 POSITIVE 12/14/20
Preexisting Conditions: COPD, DM TYPE 2, CHF, GERD, HYPERTENSION, HYPERLIPIDEMIA
Allergies: Ciprofloxacin, Codeine, Bactrim, Lactose Intolerant
Diagnostic Lab Data:
CDC Split Type:

Write-up: right arm redness
VAERS ID: 992677 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041620A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Body temperature increased, Vomiting projectile
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Clonazepam, Mirtazapine, Seroquel, Austedo, Risperdal, Senna, Omeprazole
Current Illness:
Preexisting Conditions: Huntington''s Anxiety, Depression, Constipation.
Allergies: Paroxetine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Low Grade Temp, Persistent low back pain, Projectile Vomiting.
VAERS ID: 992734 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-07
Onset: 2021-01-24
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray, Death, Oxygen saturation decreased, SARS-CoV-2 test positive
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: alendronate sodium 70 mg 1 time a day every sunday for arthritis aspirin 81 mg q day Buspirone HCL 5 mg 3 times daily Calcitonin solution 200 units 1 spray via nostril Calcium capsule 250 mg 2 times per day Cardedilol 6.25 tab 2 times per
Current Illness: Rheumatoid Arthritis, overactive bladder, glaucoma, major depressive disorder, Alzheimers Disease, polyneuropathy,
Preexisting Conditions: Rheumatoid Arthritis, overactive bladder, glaucoma, major depressive disorder, Alzheimers Disease, polyneuropathy,
Allergies: codeine, penicillin, enbrel, septra, sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1st COVID immunization 1/7/2021, COIVD positive results on 1/16/21, 1/24/21 O2 sats decreased to 78%, 1/24/21 reveived the Bamlanivimab infusion 50 ml/hr. 1/24/20 chest x ray 1/24/21 She was sent to hospital and admitted. 1/27/2021 Expired
VAERS ID: 992846 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Montana  
Vaccinated: 2021-01-29
Onset: 2021-01-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Coreg 12.5 mg tablet: 12.5 mg PO BID; Hytrin 10 mg capsule po daily; Lasix 20 mg tablet po daily; Lipitor 40 mg tablet daily; Phenobarbital 30 mg tablet po BID; Levothyroxine 100 mcg tablet daily; lisinopril 2.5 mg tablet po daily; pantopra
Current Illness: CRT-P upgrade on 1/7/2021 Pacemaker 0107 on 1/7/2021
Preexisting Conditions: Acute MI; arthritis; atrial fibrillation; bleeding; bronchitis; bypass; cholecystitis; chronic anemia; COPD; CKD; CAD; Heart block Hypercholesteremia; HTN; hypothyroidism; MI
Allergies: CeleBREX-GI Bleed Morphine-urticaria
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient complained to wife of not feeling well in evening after the vaccination and expired at home during the night.
VAERS ID: 992884 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Kansas  
Vaccinated: 2021-01-16
Onset: 2021-01-17
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Fatigue, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: Sulfa Allergy
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: The next morning after vaccine, patient ran a fever, vomited, and was very tired. Mom laid her down to sleep and when she checked later, patient had passed away.
VAERS ID: 992977 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-20
Onset: 2021-01-20
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Pharmacy       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: 2021-01-25
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: pantoprazole, tramadol, duloxetine, vesicare
Current Illness: unsure
Preexisting Conditions: unsure
Allergies: cephalosporins, sulfa, penicillins, opiods,
Diagnostic Lab Data: unsure
CDC Split Type:

Write-up: spoke with patient husband on Saturday 1/23 and he said that she had been in the hospital. that she had had a stroke, the MD''s at the hospital told him that it was not contributed to the vaccine and that they were unsure even if the stroke had occurred prior to the vaccine or after. spoke with him again on 1-29 and he stated that she had passed away on 1/25/21
VAERS ID: 993028 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-06
Onset: 2021-01-09
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Hyperhidrosis, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-11
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: see attached med list
Current Illness: C-diff
Preexisting Conditions: COPD, HTN, DM II, CAD, Acute kidney failure, CHF, GERD, Adult failure to thrive,
Allergies: metoprolol, demerol
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 1/9/21-Diaphoresis, O2 90%, respirations 22, increased weakness, wheezing bilaterally. Send to ER for evaluation and treatment. She was sent to ER, where she was admitted for 2 days, then expired there on 1/11/21
VAERS ID: 993072 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-27
Onset: 2021-01-27
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / SYR

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain, Ascites, Blood alkaline phosphatase increased, Blood chloride decreased, Blood creatinine increased, Blood culture positive, Blood lactic acid increased, Blood potassium decreased, Blood sodium decreased, C-reactive protein increased, Carbon dioxide decreased, Death, Malaise, Omental necrosis, Ovarian necrosis, Peritoneal lavage, Platelet count decreased, Septic shock, Streptococcus test positive, Surgery, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Toxic-septic shock conditions (narrow), Biliary system related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Metoprolol, Lipitor, Lisinopril, Asa,Demedex, Levimir, Jardiance, Metformin
Current Illness: None reported
Preexisting Conditions: Type 2 DM, MGUS, Cardiomyopathy with implanted Defib, Chronic heart failure
Allergies: Environmental and Magnesium succinate
Diagnostic Lab Data: WBC 1.2 with lactic acid 9.3, Plt. 113, Na 128, K 3.3, Cl 92, CO2 16, Cr 2.25, Alk phos 150, CRP 160.6. Blood cultures grew out strep A, Pt. taken to emergent surgery with no intra abdominal pathology. for sepsis found. Had massive ascites. Subsequently had a repeat wash out with necrotic ovaries/omentum noted. Never recovered and subsequently died from her illness.
CDC Split Type:

Write-up: Pt. presented to the ER with abd pain and septic shock. Pt. reported to feel ill shortly after receiving the vaccine.
VAERS ID: 993112 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: California  
Vaccinated: 2020-12-01
Onset: 2021-01-01
   Days after vaccination: 31
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Cardiac arrest, Death, Decreased appetite, Dependence on respirator, SARS-CoV-2 test positive
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), Dementia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 31
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin ec 81mg, xarelto 20 mg, propranolol 40 mg, Vita-B1 100mg Trazodone 50mg, Clonidine HCL 0.1 mg tablet, Divalproex 80D DR 25mg, CHLORPROMAZINE 10mg, folic acid 1 mg ,Benztropine mes 1mg, cetirizine HCL 10mg, SPIriva 18 MCG CP-handihal
Current Illness: Broken ankle
Preexisting Conditions: Mid intellectual Disabilities, Schizoaffective Disorders, Obesity, Unspecified Heart Disease, Unspecified Hypothyroidism, unspecified Allergic rhinitis
Allergies: PCN,Lactose Intol
Diagnostic Lab Data: Hospital would not share any information at all
CDC Split Type:

Write-up: she was injected, sh stopped eating and talking, the doctor watched her for 2 days. had her transported to the hospital. i was told she had tested positive for COVID 2 times once at the home and once at the hospital. with in 2 DAYS at the hospital she wa on a ventilator 2 days later she died. i talked with the rehab center and confirmed she tested negative for COVID on Dec 27th 2020 and was given the Vaccine on the 29th Dec 202 was in the hospital 4 day later, was on a ventilator 4 days after that then died a few day later as her heart stopped beating. all the while i had POA and was not contacted by Hospital staff until after they had made the next step.
VAERS ID: 995147 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-23
Onset: 2021-01-20
   Days after vaccination: 28
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chills, Death, Erythema, Fatigue, General physical health deterioration, Injection site pain, Laboratory test normal, Pain in extremity, Pyrexia, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Lab tests after MODERNA COVID-19 vaccine: ALL NEGATIVE Orders for date: 01/19/2021 Test Urgency Status Lab NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/19/2021 12:43 Orders for date: 01/14/2021 Test Urgency Status Order NASAL SWAB NASAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test Complete 01/14/2021 15:59 Orders for date: 01/11/2021 Test Urgency Status Lab NASAL SWAB NASOPHARYNGEAL CAVITY COVID-19 MONT PANEL (AT BINAX) ROUTINE Test complete 01/11/2021 12:27 Orders for date: 01/07/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/11/2021 17:01 Orders for date: 01/04/2021 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX zzCOVID-19 (M2000)ROUTINE Test Complete 01/08/2021 07:34 Orders for date: 12/28/2020 Test Urgency Status Lab NASOPHARYNGEAL SWAB NASOPHARYNX COVID-19 DIAGNOSTIC PANEL (BIOFIRE) ROUTINE Test Complete 12/28/2020 13:58 PCR 20 1403 Most recent med list prior to patient''s death: INPT ACETAMINOPHEN 650 MG RTL SUPP (Status=Active) 650MG RCT FOUR TIMES A DAY AS NEEDED Fever. Give PR if unable to take PO ORDER LAST ACTION: 12/29/20 16:37 GIVEN ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3 ML INHALE 1 VIAL IN NEBULIZER BY ORAL INHALATION FOUR TIMES DAILY AS NEEDED COPD, MED HAS LARGE SUPPLY INPT BISADODYL 10MG RTL SUPP (Status=Active) 10MG RCT EVERY 72 HOURS AS NEEDED Constipation. Give if MOM ineffective ORDER LAST ACTION: 02/26/20 18:11 GIVEN INPT LORAZEPAM 2MG/ML INJ. 1 ML (Status=Active) 0.5MG(0.25 ML) SUBCUTANEOUSLY EVERY FOUR HOURS AS NEEDED End of life agitation or anxiety INPT MILK OF MAGNESIA 30 ML UD (Status=Active) 30ML BY MOUTH DAILY AS NEEDED CONSTIPATION ORDER LAST ACTION: 01/07/21 15:09 GIVEN INPT MORPHINE SO4 4MG/ML INJ PFS (Status=ACTIVE) 4MG/ML IV EVERY ONE HOUR AS NEEDED if needed for end of life restlessness, air hunger, pain. ORDER LAST ACTION: 01/19/21 11:15 GIVEN POLYETHYLENE GLYCOL 3350 ORAL PWDR TAKE 17 GM (ONE CAPFUL) BY MOUTH DAILY AS NEEDED constipation. MED HAS LARGE SUPPLY
CDC Split Type:

Write-up: Death Narrative: Patient received the first COVID-19 dose on 12/23. Afterwards, patient complained of localized pain on L deltoid area where the vaccine was administered; his temperature was 98.1 F. On 12/26-27, staff reported that patient appeared more fatigued than usual and was shivering on 12/27, which seized after blanket was given. On 12/28, patient presented with fever (Tmax 100.2 F) and acetaminophen was administered for alleviation of fever. ADR was reported for the fever on 12/29. Patient continued to decline and was placed back on hospice care on 12/29; on 12/30. the symptoms reported on nursing note include erythema and pain on whole L arm. Lidocaine was applied. Patient''s family and provider mutually agreed not to administer the second dose of vaccine. He continued to decline and was started on end-of-life care around 1/4 and passed on 1/20 1417.
VAERS ID: 995165 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-27
Onset: 2021-01-30
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Died in sleep
VAERS ID: 993822 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021075824

Write-up: he got both doses then a few days later he died; This is a spontaneous report from a contactable consumer reporting for a friend''s father. A male patient of an unspecified age received the second dose of bnt162b2 (BNT162B2) vaccine , via an unspecified route of administration on an unspecified date at single dose for Covid-19 immunisation . The patient medical history and concomitant medications were not reported. The patient received the first dose on an unknown date. The patient died few days after receiving the second dose of the vaccine on an unspecified date. It was not reported if an autopsy was performed. Information about lot/batch number has been requested.; Reported Cause(s) of Death: he got both doses then a few days later he died
VAERS ID: 993823 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       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: 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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021077709

Write-up: died due to heart attack; This is a spontaneous report from a contactable consumer (reporting for her son-in-law) from the Pfizer-sponsored program Pfizer First Connect. A male patient of an unspecified age received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on an unspecified date at a single dose for COVID-19 immunization. The patients medical history and concomitant medications were not reported. The patient died due to heart attack on an unspecified date. The patient died on an unspecified date. It was unknown if an autopsy was performed. Follow-up (28Jan2021): This follow-up is being submitted to notify that the lot/batch number is not available despite the follow-up attempts made. Follow-up attempts completed. No further information is expected.; Reported Cause(s) of Death: died due to heart attack
VAERS ID: 993828 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-21
Onset: 2021-01-24
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Blood glucose normal, Cardiac arrest, Death, Dysphagia, Fall, Glycosylated haemoglobin increased, Pulse absent, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (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 (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: NOVOLOG
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure abnormal (Verbatim: Blood pressure); Diabetes; Neuropathy; Walker user; Weight abnormal
Allergies:
Diagnostic Lab Data: Test Date: 20210124; Test Name: blood sugar; Result Unstructured Data: Test Result:91; Test Name: blood pressure; Result Unstructured Data: Test Result:fine; Test Name: heart test; Result Unstructured Data: Test Result:perfect; Test Name: A1C; Result Unstructured Data: Test Result:was always high
CDC Split Type: USPFIZER INC2021079922

Write-up: Heart stopped; Could not swallow; This is a spontaneous report from a contactable nurse (patient''s wife). An 85-year-old male patient received the first dose of the bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on 21Jan2021 at a single dose for COVID-19 immunization. Medical history included blood pressure abnormal (verbatim: blood pressure) from an unknown date and unknown if ongoing, neuropathy from an unknown date and unknown if ongoing, weight issue from an unknown date and unknown if ongoing, diabetes from an unknown date and unknown if ongoing, walker user from an unknown date and unknown if ongoing. Concomitant medications included insulin aspart (NOVOLOG) taken for diabetes from an unspecified date to an unspecified date; and he was taking a long acting one as well. The patient previously received the influenza vaccine (MANUFACTURER UNKNOWN) for immunization on unknown dates ("had flu shots before with no reactions and everything, nothing before"). On 24Jan2021, the patient''s heart stopped (death, medically significant), and could not swallow (medically significant). The clinical course was reported as follows: The patient''s wife stated the patient was taking insulin aspart (NOVOLOG) and he was taking a long acting one as well. The reporter, the patient''s wife and a retired registered nurse (RN) stated, her husband (patient) just died and she thought he died from the COVID vaccine (later clarified the reason of death was-heart stopped). The patient had the vaccine on 21Jan2021, which was on a Thursday, and he was fine. On the following Sunday around 1:30 (on 24Jan2021), the patient was feeling a little weak, however, the patient''s wife thought maybe his blood sugar was low. The patient''s wife checked, and the patient''s blood sugar was 91. The patient''s wife went to get some yogurt to feed him in order to get his blood sugar up a little; "which was a normal thing for him, it was not that low for him." Then, suddenly, the patient fell, and the patient''s wife could not get a pulse or anything. The patient''s wife called an unspecified number and she started compressions; however, he was dead. The patient''s wife stated the patient just had his heart test, a three hour long one, and it was "perfect three weeks ago." The patient had just gone to the doctor the other day and his blood pressure was "fine and everything." The patient''s wife stated that other than his diabetes, "which he had for (sentence incomplete)." Regarding lab tests, the patient''s wife stated, "No, he had it before but not in the last two weeks. He was going for one because we just went to the doctor last week and he was going to call yesterday to make the appointment request to get his blood work done. Blood work has been good except his A1C was always high, but other than that everything was good" (as reported). Regarding causality, the patient''s wife stated, "I do, because he was fine until about half an hour before he died. He said to me, I feel a little weak today and then I was talking to him that your upper body strength is really good and then I said, we just have to work on your weight a little more because he did have neuropathy. And then, I went out of the room and all of a sudden I just heard him fall and that is when I just went in to check his blood sugar and it was 91 and I got him yogurt and he started eating that and then that was it, he started spitting it out and he said, I could not swallow and that was it, he just died." The patient''s wife further added, "I just wanted other people to know that things like this happen and I am sure it was from that because he was healthy as could be. He was walking with his walker, the day before outside and he felt fine." The clinical outcome of the event, heart stopped, was fatal. The clinical outcome of the event, could not swallow, was unknown. The patient died on 24Jan2021 due to "heart stopped." An autopsy was not performed. The batch/lot numbers for the vaccine, PFIZER-BIONTECH COVID-19 MRNA VACCINE, were not provided and will be requested during follow up.; Reported Cause(s) of Death: Heart stopped
VAERS ID: 993832 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Maine  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021081901

Write-up: At the end of the conversation, caller stated that recently saw in (place name) that someone passed away 3 hours after receiving the injection.; This is a spontaneous report from a contactable nurse. A patient of unspecified age and gender received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on unspecified date at single dose for COVID-19 immunization. Medical history and concomitant medication were not reported. Caller, calling on behalf of her sister who has pseudocholinesterase imbalance, would like to know if the Covid vaccine has any contraindication or interaction with succinylcholine. Caller stated that her and her sister are scheduled to receive the first dose of the vaccine this weekend. Caller stated that her sister had a severe reaction to succinylcholine and did not wake up for four days. Caller stated that her sister has to wear a medical bracelet because of this condition. Caller reported that her sister''s son has the same severe reaction to succinylcholine. Caller also stated that when she was a director in the lab, she heard of a person passing away in the OR due to the same reaction with succinylcholine. At the end of the conversation, caller stated that recently saw in (state name) that someone passed away 3 hours after receiving the injection. It was unknow if autopsy was done. Information on the lot/Batch number has been requested.; Sender''s Comments: The information currently available does not allow a medically meaningful assessment for the event "passed away" with unknown cause of death. The case will be reassessed should additional information become available. 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: At the end of the conversation, caller stated that recently saw in (place name) that someone passed away 3 hours after receiving the injection.
VAERS ID: 993998 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-13
Onset: 2021-01-13
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Death, Posture abnormal
SMQs:, Anaphylactic reaction (broad), Dystonia (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? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Hospice care (prior to vaccination); Living in nursing home; Oxygen supplementation (few days before vaccine was given oxygen level was low and started on oxygen)
Preexisting Conditions: Medical History/Concurrent Conditions: Congestive heart failure; Sulfonamide allergy
Allergies:
Diagnostic Lab Data: Test Date: 202101; Test Name: oxygen level; Result Unstructured Data: Test Result:gone down; Test Name: Covid-19 test; Test Result: Negative
CDC Split Type: USPFIZER INC2021063617

Write-up: passed away; cough; This is a spontaneous report from a contactable consumer, the patient''s daughter. A 92-year-old female patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Lot Number: UNKNOWN), via an unspecified route of administration in the left arm on 13Jan2021 at 11:00 (at the age of 92-years-old) as a single dose for COVID-19 immunization. Ongoing medical history included nursing home resident, admitted to hospice on 13Jan2021 (prior to vaccination), and oxygen supplementation (due to low oxygen levels) from a few days prior to the vaccine (Jan2021). Other relevant medical history included congestive heart failure from Dec2020 and sulfa allergy. Prior to the vaccination, the patient was tested numerous times (as reported) for COVID-19 and was negative. There were no concomitant medications. The patient did not receive any other vaccines within four weeks prior to the vaccination. A few days before the vaccination, her oxygen level had gone down, and she had been placed on oxygen. Prior to receiving the vaccine, the patient was reported as being ''fine''. On 13Jan2021, the patient received the vaccine at 11:00. The patient coughed maybe 5 or 6 times and then dropped her head. Resuscitation was not performed as patient had a do not resuscitate (DNR) order. The patient passed away on 13Jan2021 at 13:05. The cause of death was not reported. An autopsy was not performed. The clinical outcome of the cough was unknown at the time of death. The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.; Reported Cause(s) of Death: passed away
VAERS ID: 994309 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-15
Onset: 2021-01-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Bedridden, Death, Dyspnoea, Fatigue
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine, 5 mg; Metformin, 500mg (twice a day); Simvastatin, 20mg; Omeprazol Dr, 40mg.
Current Illness:
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Got vaccine on 1/15/21. He was tired right away, bedridden the next 3 days. He couldn''t breathe so he was taken by ambulance on 1/18/21. He was in hospital for several days. put on remdesivir cocktail for 10 days. Slowly getting worse and died in hospital on 1/30/21.
VAERS ID: 994544 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-31
Onset: 2021-01-31
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Autopsy, Cyanosis, Death, Dental discomfort, Diarrhoea haemorrhagic, Dizziness, Nausea, Resuscitation, Toothache, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: The patient went home around 11 am on 1-31-21 after her vaccine and 15 minute observation period. She was eating breakfast after at home and complained to a neighbor that her teeth hurt and she was nauseated after eating. In the afternoon, she felt dizzy and had diarrhea accompanied with blood. Close to 9 PM, her son went to check on her. The patient was found on the floor--she was unresponsive and had purple lips. Her son called an ambulance and started chest compressions. The patient passed away at the hospital. The doctor has ordered an autopsy, and the results are pending.
VAERS ID: 994678 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 0000-00-00
Onset: 2021-01-04
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       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: 2021-01-12
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Diabetes; Heart disorder; Obesity
Allergies:
Diagnostic Lab Data: Test Date: 20201224; Test Name: Nasal Swab; Test Result: Negative ; Test Date: 20201228; Test Name: Nasal Swab; Test Result: Negative ; Test Date: 20201231; Test Name: Nasal Swab; Test Result: Negative ; Test Date: 20210104; Test Name: Nasal Swab; Test Result: Positive
CDC Split Type: USPFIZER INC2021076918

Write-up: patient contracted COVID; patient contracted COVID; This is a spontaneous report from a contactable consumer. A non-pregnant 80-year-old female patient received two doses of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration, the first dose in 2020 and the second dose on 22Dec2020 11:00, both at a single dose for covid-19 immunization. Medical history included heart, diabetes, obesity. There were no concomitant medications. The patient did not have covid prior to vaccination. The patient contracted COVID on 04Jan2021 11:00. The patient was hospitalized for COVID-19 for 8 days. The patient underwent lab tests and procedures which included: Nasal Swab: negative on 24Dec2020, negative on 28Dec2020, negative on 31Dec2020, positive on 04Jan2021. Unspecified therapeutic measures were taken as a result of the event. The outcome of patient contracted COVID was fatal. The patient died on 12Jan2021. It was unknown if an autopsy was performed. The batch/lot number for the vaccine, BNT162B2, was not provided and will be requested during follow-up.; Reported Cause(s) of Death: patient contracted COVID
VAERS ID: 994778 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: South Carolina  
Vaccinated: 2021-01-22
Onset: 2021-01-28
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, COVID-19, Condition aggravated, Death, Decreased appetite, SARS-CoV-2 test positive
SMQs:, Guillain-Barre syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Pepcid, Aspirin, DOK Plus, Miralax, Potassium Chloride ER, Vitamin C, Ensure Clear, Metoprolol Tartrate, Tramadol, Artificial Tears,
Current Illness:
Preexisting Conditions: OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION, Macular Degeneration, Anorexia, Peripheral Vascular Disease, Cardiac Arrhythmia,
Allergies: No known allergies
Diagnostic Lab Data: COVID-19 PCR test positive on 1-28-21
CDC Split Type:

Write-up: Resident received the vaccine on 1-22-21 and she was diagnosed with COVID-19 during routine testing on 1-28-21. She didn''t have any symptoms except feeling weak and she had a decrease in her appetite. She already had a poor appetite prior. She died on 2-2-21.
VAERS ID: 994788 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-25
Onset: 2021-02-01
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Patient was a nursing home resident, please contact the facility for further scheduled medications.
Current Illness: Patient was a nursing home resident, please contact the facility for further diagnosis.
Preexisting Conditions: Patient was a nursing home resident, please contact the facility for further diagnosis.
Allergies: Ativan, Buspar, Cymbalta, Levaquin, Lyrica, Mirapex, Pristiq, Symbicort
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient death on 2/1/2021 at 4:55am at hospital.
VAERS ID: 994790 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-31
Onset: 2021-02-02
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: Prevacid, Hydrocodone, Famotidine, Combivent Respimat, Boniva, Zinc Oxide, Spiriva, Loratadine, Risperdal, Albuterol, Sertraline, Cyanocobalamin, Levothyroxine, Advair, Omega-3 fatty acids, Atorvastatin, Aspirin, Sennoside, Ergocalciferol,
Current Illness: none
Preexisting Conditions: COPD, cad, morbid obesity, depression, bipolar, hypothyroidism, hypertension and gerd.
Allergies: Ibuprofen, ketorolac, morphine,tramadol.
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident found unresponsive in room this am at approx. 9:30 am. Resident was observed eating breakfast around 8:45 am. Housekeeper reported seeing resident between breakfast and time found unresponsive. Resident had voiced no complaints. Code was initiated until EMS arrived and transported resident to hospital. Resident expired.
VAERS ID: 994913 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-30
Onset: 2021-01-31
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Death, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: patient passed away 2 days after vaccine. patient had temperature, nausea, and vomiting after vaccine.
VAERS ID: 994989 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-10
Onset: 2021-01-19
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       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: 2021-01-19
   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: unsure
Current Illness: unsure
Preexisting Conditions: unsure
Allergies: unsure
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Employee was found unresponsive in floor at her home. EMS arrived and person had expired.
VAERS ID: 995146 (history)  
Form: Version 1.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-15
Onset: 2021-01-24
   Days after vaccination: 9
Submitted: 2021-01-29
   Days after onset: 5
Entered: 2021-02-02
   Days after submission: 4
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Arthralgia, Cardiac arrest, Decreased appetite, Dyspepsia, Dyspnoea, Fatigue, Feeling abnormal, Hypophagia, Palpitations, Pulseless electrical activity, Respiratory depression, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Gastrointestinal nonspecific dysfunction (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: Patient experienced cardiac arrest with PEA and a witnessed collapse upon arrival to the emergency department on 1/24/21. Patient received his first dose of the COVID vaccine on 01/15/2021and felt poorly thereafter. He was describing shortness of breath to his wife and requiring 5L of O2 at home to maintain saturations in 80s, while he usually was on 3L to maintain saturations in the mid 90s. He had been oriented but more fatigued than normal and described bilateral shoulder pain (which was not new for him) as well as indigestion. Took Tylenol with some relief. He had decreased PO intake and less appetite. The patient''s wife encouraged him to come to the hospital daily for a week prior to admission, but the patient did not want to because he felt his side effects were secondary to the vaccine. Symptoms:RespDepression, Palpitations, Syncope & cardiac arrest Treatment: EPINEPHRINE 1 MG ONCE 3 rounds given ,CALCIUM CHLORIDE 1000 MG ONCE
VAERS ID: 995224 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-14
Onset: 2021-01-19
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain lower, Axillary pain, Cardiac arrest, Chest pain, Death, Myalgia
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (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), Eosinophilic pneumonia (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Cardiac arrest; Pain on her upper right chest; Lot of pain in lower abdomen; Pain underneath arm; Thought it was muscle aches; A spontaneous report was received from a nurse concerning a 92-year-old, female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed upper right chest pain and underneath the arm, severe abdominal pain, muscle aches and cardiac arrest. The patient''s medical history was not provided Concomitant product use was not provided by the reporter. On 14 Jan 2021, approximately five days prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly in the arm for prophylaxis of COVID-19 infection. On 19 Jan 2021, the patient developed upper right chest pain and pain underneath the arm. They thought it was muscle aches. Sometime later, the patient developed a lot of pain in the lower abdomen. The called emergency services and an ambulance arrived but the patient then suffered cardiac arrest. Treatment for the event included tramadol. Action taken with mRNA-1273 in response to the events was not applicable due to the patient was died. The patient died on 19 Jan 2021. The cause of death was reported as cardiac arrest. Autopsy were not provided.; Reporter''s Comments: Company Comment: This case concerns a 92-year-old female patient who experienced unexpected serious events of cardiac arrest, upper right chest pain and underneath the arm, severe abdominal pain, muscle aches. The event occurred 5 days after the administration of the first dose of the vaccine mRNA-1273 vaccine (Lot #: unknown, expiration date-unknown). Although a temporal association exist between the events and the administration of the vaccine, in the absence of critical details such as the patient''s medical history, any diagnostic test or autopsy result, adequate evaluation and assessment cannot be established. Main field defaults to ?possibly related'' for all events.; Reported Cause(s) of Death: Cardiac arrest
VAERS ID: 995441 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dysstasia, Mobility decreased, Muscular weakness
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Atorvastatin, Eliquis, Donepezil HCL, Aspirin EC, Fluticasone Prop, Losartan Potas, Desonide, Levothyroxine, Melatonin, Potassium Cl, Cerovite Senior, Vitamin B-12, Vitamin D3 5,000 Unit, Docusate Sodium, Latanoprost OS, Torsemide
Current Illness: None
Preexisting Conditions: Mild Cognitive Impairment, Hypothyroidism, Coronary Artery Disease, Hyperlipidemia, Hypertension, Neuropathy, Vertigo, Vitamin B deficiency
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The vaccine was given on Monday. Tuesday afternoon he developed weakness in both legs and could not stand up. This was a new development; he had neuropathy in one leg but he had been able to stand up and walk three hours before. He was helped to the bathroom. He said he felt better and might want to stand up again. He was helped to bed. He was found dead around 5:30 Wednesday morning. He was 94 years old and had a lot of medical conditions. No one has indicated his death had anything to do with the vaccine. I''m sure it''s just a coincidence that he died so soon after receiving the vaccine
VAERS ID: 995460 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-16
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 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: 2021-01-25
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Levothyroxine Sodium Tablet 50 MCG daily Cholecalciferol Tablet 2000 UNIT daily Metoclopramide HCl Tablet 5 MG 4 times a day Tylenol Tablet 325 MG as needed Q4hrs Senokot S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) 2 tabs daily Atorv
Current Illness: N/A Covid positive on 1/10 Hospitalized 1/16 Deceased 1/25
Preexisting Conditions: HEMIPLEGIA AND HEMIPARESIS FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE AFFECTING RIGHT DOMINANT SIDE (I69.951) WEAKNESS (R53.1) UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE (F03.90) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9) UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY (R26.9) HEART FAILURE, UNSPECIFIED (I50.9) CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (J44.9) ENCOUNTER FOR SURGICAL AFTERCARE FOLLOWING SURGERY ON THE DIGESTIVE SYSTEM (Z48.815) ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (I25.10) ESSENTIAL (PRIMARY) HYPERTENSION (I10) ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF RIGHT UPPER EXTREMITY (I82.621) APHASIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE (I69.920) DYSPHAGIA FOLLOWING UNSPECIFIED CEREBROVASCULAR DISEASE (I69.991) FLUID OVERLOAD, UNSPECIFIED (E87.70) DYSPHAGIA, OROPHARYNGEAL PHASE (R13.12) COVID-19 (U07.1) SPONDYLOLYSIS, CERVICAL REGION (M43.02) HYPERLIPIDEMIA, UNSPECIFIED (E78.5) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9) VITAMIN D DEFICIENCY, UNSPECIFIED (E55.9) CELLULITIS OF RIGHT UPPER LIMB (L03.113) ENCOUNTER FOR ATTENTION TO COLOSTOMY (Z43.3) INCONTINENCE WITHOUT SENSORY AWARENESS (N39.42) OTHER PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (I26.99) OTHER SPECIFIED SOFT TISSUE DISORDERS (M79.89) OTHER SPECIFIED SYMPTOMS AND SIGNS INVOLVING THE DIGESTIVE SYSTEM AND ABDOMEN (R19.8) VASCULAR DISORDER OF INTESTINE, UNSPECIFIED (K55.9) DYSPHAGIA, UNSPECIFIED (R13.10) HYPOKALEMIA (E87.6) GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9) OTHER DYSPHAGIA (R13.19) VERTEBRO-BASILAR ARTERY SYNDROME (G45.0) ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOTIONS AND CONDUCT (F43.25) BENIGN NEOPLASM OF COLON, UNSPECIFIED (D12.6) CEREBROVASCULAR DISEASE, UNSPECIFIED (I67.9) DISORDER OF KIDNEY AND URETER, UNSPECIFIED (N28.9) HEMATEMESIS (K92.0) HYPOTHYROIDISM, UNSPECIFIED (E03.9) LONG TERM (CURRENT) USE OF ANTICOAGULANTS (Z79.01) METABOLIC ENCEPHALOPATHY (G93.41) OTHER HYPERLIPIDEMIA (E78.4) OTHER SPECIFIED MENTAL DISORDERS DUE TO KNOWN PHYSIOLOGICAL CONDITION (F06.8) PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM (Z86.718) PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS (Z86.73) RESPIRATORY FAILURE, UNSPECIFIED, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA (J96.90) DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED (R26.2) PNEUMONIA, UNSPECIFIED ORGANISM (J18.9)
Allergies: Vancomycin
Diagnostic Lab Data: Positive Covid swab on 1/10
CDC Split Type:

Write-up: Vaccine-1/7 Covid positive-1/10 Hospitalized-1/17 Deceased-1/25
VAERS ID: 995520 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
Vaccinated: 2021-01-07
Onset: 2021-01-22
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Angina pectoris, Back pain, Blood pH increased, Blood pressure increased, Confusional state, Discomfort, Insomnia, Pollakiuria, Urine analysis, White blood cell count increased
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Other ischaemic heart disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Clopidogrel 75 mg daily, Depakote 125 mg Twice daily, Imdur, Lexapro20 mg daily, lisinopril 10 mg daily, metoprolol succinate 25 mg daily, proscar 5mg daily, seroquel 50 mg daily, seroquel XR 150 mg daily, trazadone 50 mg daily, flomax 0.4
Current Illness: No illness at time of vaccination or one month prior.
Preexisting Conditions: Atherosclerotic heart disease, Hypertension, Borderline personality disorder, Dysthymic, Chronic ischemic heart
Allergies: NKA
Diagnostic Lab Data: Urinalysis Dipstick: Symptoms Confusion,Frequency,urgency, back pain Leukocytes 3+ Lg Ph 8.5
CDC Split Type:

Write-up: 1-12-21 Resident is complaining of heart pain. Resident blood pressure is 228/105. 1-22-21 Dx UTI 1-13-21 His nurse called MD at approximately 0645, reported to him that it was reported to this nurse that resident has not slept in 2 days and night, has an increased blood pressure, reports severe pain in lower back, and appears to be uncomfortable Resident is able to verbalize his pain and where it is at, but is unable to explain the quality of the pain or give a number on the 0/10 pain scale.
VAERS ID: 995641 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
Vaccinated: 2021-01-06
Onset: 2021-01-31
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute myocardial infarction, Asthenia, Blood test, Computerised tomogram, Condition aggravated, Confusional state, Death, Hypotension, Urinary tract infection
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lipitor 40mg po QD, Baclofen 10mg po BID, Tylenol ES 500mg po BID, Senna-S 50/8.6mg po BID, Vitamin D3 5000 IU po QD, Multivitamin tablet po QD, Garlic Oil 1000mg po QD, Lasix 40mg po QD, Aspirin EC 81mg po QD, Metformin 500mg po QD, Lisino
Current Illness: No active illnesses at time of vaccination or 1 month prior to vaccination; was diagnosed with UTI between vaccination and date of death.
Preexisting Conditions: Malignant neoplasm of prostate, Hypothyroidism, Type 2 Diabetes Mellitus, Hyperlipidemia, Multiple Sclerosis, Neuropathy, Essential primary hypertension, Atrial Fibrillation, Heart Failure, Peripheral Vascular Disease, Constipation, Weakness, Dry mouth, Personal history of Urinary Tract Infections
Allergies: NKA
Diagnostic Lab Data: Non contrast CT Multiple different laboratory blood tests
CDC Split Type:

Write-up: Resident was hospitalized for confusion, and hypotension and increased weakness; resident proceeded to have a NSTEMI and died on 5th day in hospital on 1/31/2021.
VAERS ID: 995649 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-25
Onset: 2021-01-29
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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
Preexisting Conditions: Thyroid disorder, HTN, Peripheral neuropathy, anxiety
Allergies: Augmentin, sulfa
Diagnostic Lab Data: Hospitalization, EMS reports
CDC Split Type:

Write-up: Cardiac arrest; Patient transported by EMS to hospital 11:00pm on 01/29/2021. Patient received vaccine on 01/25/2021. Patient expired 01/30/2021 within the hour into the new day after midnight on 01/30/2021. Patient was feeling well prior to and any chronic health conditions were well controlled. Sudden cardiac arrest 4 days after receiving the vaccine. Details given by patients husband/POA.
VAERS ID: 995789 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-28
Onset: 2021-01-31
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 1 LA / IM

Administered by: Other       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: Unknown
Current Illness: Unknown
Preexisting Conditions: Diabetes Heart Condition
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The patient received the vaccine on the afternoon of Thursday, 1/28/21. He was observed for at least 30 minutes following administration of the vaccine with no reactions noted. He was found dead in his car on Sunday, 1/31/21. It is unknown if the vaccine contributed to his death.
VAERS ID: 995825 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-06
Onset: 2021-01-13
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Delirium, Gastrointestinal haemorrhage, Sudden cardiac death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Gastrointestinal haemorrhage (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Noninfectious meningitis (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (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: Calcium carbonate Cholecalciferol Ezetimibe Insulin (Lantus) Levothyroxine Olanzapine melatonin pantoprazole Senokot-S Sitagliptin Preservision AREDS
Current Illness: Acute lower GI bleed (diverticular bleed) occurred in 12/21/2020 and hospitalization from 12/21-12/31/20 complicated by delirium
Preexisting Conditions: Type 2 DM HLD Macular degeneration Hearing loss HTN Hypothyroidism Osteopenia
Allergies: Statins, ace inhibitors, hydrocodone, metformin, codeine, metoprolol XL
Diagnostic Lab Data: N/A. Client had a DNR order and therefore resuscitation was not attempted.
CDC Split Type:

Write-up: Client unexpectedly collapsed and passed away on 1/13/21 from suspected sudden cardiac death. Prior to her death, she was in skilled care for rehabilitation following hospitalization from 12/21-12/31/20 for an acute lower GI bleed. Her hospitalization and skilled care stay were complicated by delirium and she was being treated for delirium with olanzapine (Zyprexa) at time of death.
VAERS ID: 995977 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-19
Onset: 2021-01-25
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Altered state of consciousness, Hypercapnia, Imaging procedure, Laboratory test, Lethargy, SARS-CoV-2 test negative, Sinusitis
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Latest medication list available to us 12/18/19, due to record being deleted after death: CORN STARCH POWDER RED AREA BETWEEN 3RD AND 4TH FINGER RIGHT HAND - APPLY CORN STARCH FOUR TIMES DAILY - FACILITY TO SUPPLY ACYCLOVIR 200MG CAPSULE 1
Current Illness: N/A
Preexisting Conditions: 0 Profound intellectual disability (F73) secondary to Angelman''s Syndrome with microcephaly (Q38.2); Macroglossia (750.15), rumination (307.53) and aerophagia, S|P aspiration pneumonia 9/98(507.0), history of coagulopathy (286.9); finger clubbing probably secondary to chronic pulmonary disorder; surgery 12/70 for undescended testes; Nissen fundoplication w/pyloroplasty 5/2/88; H/o Acne Vulgaris (L70.0) 31 Inability to monitor own health care needs. Frequent urinary tract infections. 39 Gastroesophageal reflux (K21.9) 56 Megacolon and tendency to fecal impaction (K59.3, K56.4) 57 Hand mouthing secondary to Angelman''s syndrome 59 Chronic recurrent herpes simplex (B00.9) 60 Recurrent cyanosis (R23.0), secondary to mucus plugging 61 Maintain optimal nutritional status altered by severe dysphagia (R13.10) 62 Osteoporosis probably secondary to immobility (M81.0) 63 Needs to maintain optimal musculoskeletal status 64 Optic atrophy(H47.20)secondary to Angelman?s syndrome, myopia(H52.10) 77 Prone to dehydration 83 Hiatal hernia (K44.9) 84 Peripheral vascular disease, poor circulation of bilateral ankles and feet. ?? Frequent UTIs. Small bilateral renal stones.
Allergies: Aspirin, NSAIDs.
Diagnostic Lab Data: Multiple imaging studies and lab tests while hospitalized. Covid negative 1/25/21.
CDC Split Type:

Write-up: Lethargy/altered level of consciousness lead to hospital admission. Multiple interventions during hospitalization. Final hospital diagnoses: Acute respiratory failure with hypercapnia, acute pansinusitis.
VAERS ID: 996086 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-19
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Acute kidney injury, Acute myocardial infarction, Acute respiratory distress syndrome, COVID-19 pneumonia, Cardiac failure acute, Cough, Death, Intensive care, Myalgia, Oropharyngeal pain, Pyrexia, Renal replacement therapy, Rhabdomyolysis, SARS-CoV-2 test positive
SMQs:, Rhabdomyolysis/myopathy (narrow), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (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), Embolic and thrombotic events, arterial (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: h.o HTN, elevated BMI
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt received vaccine on 7 jan. 2021 Twelve days later, on 19 January 2021, Pt developed symptoms of COVID (cough, sore throat, fever, myalgias), on 20 Jan, pt admitted to hospital for worsening symptoms. Pt tested positive for COVID 19. Pt admitted to ICU where pt had complicated hospital course to include ARDS secondary to COVID pneumonia, nonSTEMI, with biventricular heart failure, on multiple pressor, rhabdomyolysis with acute kidney injury, requiring CRRT. Pt was in hospital for 10 days; he passed away on 31 Jan 2021.
VAERS ID: 996105 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-23
Onset: 2021-01-24
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Levothyroxine, senna, multivitamins, aspirin and possible hospice medications
Current Illness: Dementia, hypothyroidism, coronary artery disease, patient was already on hospice, so unclear if vaccine related . Pt was at her baseline until she passed away
Preexisting Conditions: Dementia, hypothyroidism, coronary artery disease, HTN, multiple other medical issues
Allergies: Egg, co-trimoxazole, Sulfa
Diagnostic Lab Data: None
CDC Split Type:

Write-up: patient received vaccine on Jan 23, 2021 passed away on Jan 24, she was already on hospice, so unclear if due to vaccine or other issues. Was at her baseline before and after vaccine per facility, had b''fast and passed away at noon on Jan 24
VAERS ID: 996156 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-02-01
Onset: 2021-02-01
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arthralgia, Death, Impaired work ability, Injection site pain, Malaise, Pain
SMQs:, Extravasation events (injections, infusions and implants) (broad), Arthritis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Hypertension
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client came to nursing station about 2pm to report she "was not feeling well". Nurses took vital signs, then referred her to the vaccination clinic that was onsite. She was observed by vaccination team for a period of time. She reported shoulder pain radiating into shoulder blade in arm vaccine was received. Vaccination team offered ice pack to her, observed for a period of time, and released back to work. About 10pm that evening, she sent a text to another coworker that her pain was "off the charts" and that she had pain covering her whole left side of her body. She did not come to work in the morning and did not contact work. Well being check was performed at approximately 9am on 2/2/2021 and she was found dead in her home. 911 was immediately called and authorities took over the scene.
VAERS ID: 996259 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-19
Onset: 2021-01-25
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Fluoxetine HCL, 20 mg, Magnesium Oxide, 400 mg, Atrovastatin/Calcium, 10 mg, Omprazole, 20 mg, Lisinoprilm 2.5.mg, Lyrica, 200mg, Metoprolol Tartrate, 25 mg , Potassium Chloride 20 meq,
Current Illness: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation, OSA on CPAP
Preexisting Conditions: COPD, Chronic Hypoxemic respiratory failure, Chronic bronchitis, Atrial Fibrillation,
Allergies: Wellbutrin, Niaspan
Diagnostic Lab Data: Reported by hospital patient was COVID negative. Dr. office did not receive any additional lab information or treatment to her office.
CDC Split Type:

Write-up: Unknown. Was informed that the patient went to E/R on 1/25/21 (6 days after receiving vaccine. Died 1/29/21 ( 10 days after receiving vaccine).
VAERS ID: 996291 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Alaska  
Vaccinated: 2021-01-07
Onset: 2021-01-29
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Haloperidol, Morphine, Lorazepam
Current Illness: HTN, Cerebral Infarction, Anxiety, Hx breast neoplasm
Preexisting Conditions: HTN, Cerebral Infarction, Anxiety, Hx breast neoplasm
Allergies: Codeine, Tramadol, Valsartan, Keflex, Penicillins
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Death
VAERS ID: 996423 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: West Virginia  
Vaccinated: 2021-01-04
Onset: 2021-01-10
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cerebrovascular accident, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), 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), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
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:
Current Illness:
Preexisting Conditions: Wife reported patient had diabetes and high blood pressure.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had a CVA and passed away suddenly 1/10/21
VAERS ID: 996591 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-23
Onset: 2021-01-25
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Hypotension, Hypoxia, Mental status changes
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Dementia (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), Eosinophilic pneumonia (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: citalopram, Wellbutrin, docusate, Seroquel, acetaminophen, senna, may have received hospice medications
Current Illness: Dementia, depression, arthritis, IBS, atherosclerosis of aorta, hyperlipidemia, osteoporosis
Preexisting Conditions: Dementia, depression, arthritis, IBS, atherosclerosis of aorta, hyperlipidemia, osteoporosis
Allergies: Codeine Penicillin simvastatin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: patient received vaccine on Jan 23, 2021. developed weakness on Jan 25, 2021. Sent to ED on Jan 27, 2021 with hypoxia requiring 6 L O2, low Bp, declining mental status. Per family request transitioned to hospice and passed away on Jan 30, 2021
VAERS ID: 996959 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-01
Onset: 2021-02-01
   Days after vaccination: 31
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 59267-1000-01 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Lasix, Morphine, Ernesto, Oxycodone, omeprazole Gabapentin
Current Illness: CHF. COPD Chronic Pain
Preexisting Conditions: CHF, COPD, Polio as a child
Allergies: None
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Vaccine was administered Thursday and my father Died early Monday morning unexpectedly
VAERS ID: 997145 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-21
Onset: 2021-02-01
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Cerebral infarction, Computerised tomogram abnormal, Death, Pulseless electrical activity
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: diabetes, cancer, COPD, hypertension
Allergies:
Diagnostic Lab Data: CT 1/29/21 showed brain infarcts
CDC Split Type:

Write-up: 85 year old patient with multiple medical problems. PEA/asystolic arrest 5 days after receiving vaccine, hospitalized. Patient died on 2/1/2021. It is not clear whether the vaccine administration led to the patient''s death or not. "...healthcare professionals are encouraged to report any clinically significant or unexpected events (even if not certain the vaccine caused the event)"
VAERS ID: 997297 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Tennessee  
Vaccinated: 2021-01-04
Onset: 2021-01-17
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chronic kidney disease, Death, Pneumonia, Septic shock, Urinary tract infection
SMQs:, Rhabdomyolysis/myopathy (broad), Toxic-septic shock conditions (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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 on 1/17/21. Death certificate reports: Septic Shock, UTI, Pneumonia, Chronic Renal Failure
VAERS ID: 997553 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-26
Onset: 2021-02-01
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Fatigue
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: nexium, isosorbide, metoprolol, norvasc, lipitor, trospium; baby asa, paracalcitrol, vitamin b, mutli vitamin, sodium bicarbonate, tums prn, vit d3, mealatonin prn, pepcid, nitrostat prn, ativan prn
Current Illness: none
Preexisting Conditions: hypertension, CAD, CRF, hyperlipidemia
Allergies: isoniazid, diltiazem,versed
Diagnostic Lab Data:
CDC Split Type:

Write-up: fatigue x 5 days, including day of vaccination, death the night of day 5/early morning of day 6
VAERS ID: 997571 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-06
Onset: 2021-01-07
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebral haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-15
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: BRAIN BLEED
VAERS ID: 997642 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Montana  
Vaccinated: 2021-01-19
Onset: 2021-02-02
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: possible blood clots, not disclosed at time of vaccination
Preexisting Conditions: chronic back pain
Allergies: vibramyacin
Diagnostic Lab Data:
CDC Split Type:

Write-up: We were notified 02/02/2021 of patient''s death. Unknown cause at this time.
VAERS ID: 997677 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-02-01
Onset: 2021-02-01
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure increased, Cerebrovascular accident, Coma scale abnormal, Death, General physical health deterioration, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), 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), Embolic and thrombotic events, venous (narrow), Dystonia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC Split Type:

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21
VAERS ID: 997783 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-02-01
Onset: 2021-02-03
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: unknown
Current Illness: unknown
Preexisting Conditions: pt lived in long term care facility, unknown health conditions
Allergies: none known
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away subsequent to receiving dose on 02/01. Staff does not have reason to believe vaccine was involved.
VAERS ID: 998108 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-31
Onset: 2021-02-01
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute left ventricular failure, Acute myocardial infarction, Atrial fibrillation, Cardiac failure congestive, Chronic left ventricular failure, Essential hypertension, Hyperlipidaemia
SMQs:, Cardiac failure (narrow), Dyslipidaemia (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Myocardial infarction (narrow), Supraventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Hypertension (narrow), Cardiomyopathy (broad), Lipodystrophy (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Acute on chronic systolic heart failure; Atrial fibrillation with RVR; CHF (congestive heart failure); Essential hypertension; Hyperlipidemia, unspecified hyperlipidemia type; NSTEMI (non-ST elevated myocardial infarction); New onset a-fib
VAERS ID: 998138 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arthralgia, Back pain, Chills, Headache, Neck pain, Pain, Pain in extremity
SMQs:, Retroperitoneal fibrosis (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Daughter unaware of prescriptions
Current Illness: Was hospitalized in December for testing positive for COVID 12/18/2020 - hospitalized for 4 days then released back to nursing home facility.
Preexisting Conditions: Type 2 diabetes; high blood pressure
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Same day as vaccination given, developed pain went from arm up to shoulder, to back, to neck to head - right side of body; chills/body aches
VAERS ID: 998175 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-16
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Death, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 4
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: Metoprolol succinate ER tab ER 24hr 100mg PO daily Milk of Magnesia Suspension 400mg/5l 30ml PRN Mirtazapine 45mg tab at bedtime Clonazepam tab 0.5mg BID D-Mannose Capsule 500 MG 1 capsule daily Cranberry Tablet 450 MG 1 tablet twice daily
Current Illness: No
Preexisting Conditions: MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION MILD COGNITIVE IMPAIRMENT, SO STATED GENERALIZED ANXIETY DISORDER ESSENTIAL (PRIMARY) HYPERTENSION TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OTHER ALLERGIC RHINITIS OTHER IRRITABLE BOWEL SYNDROME PNEUMONIA DUE TO CORONAVIRUS DISEASE 2019 COVID-19 BACTERIAL INTESTINAL INFECTION, UNSPECIFIED HYPOKALEMIA UNSPECIFIED SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND AWARENESS OTHER SEBORRHEIC KERATOSIS HYPERLIPIDEMIA, UNSPECIFIED AGORAPHOBIA WITH PANIC DISORDER PRESENCE OF RIGHT ARTIFICIAL HIP JOINT ACQUIRED ABSENCE OF BOTH CERVIX AND UTERUS ACQUIRED ABSENCE OF OTHER ORGANS CYST OF KIDNEY, ACQUIRED NEOPLASM OF UNCERTAIN BEHAVIOR OF LIVER, GALLBLADDER AND BILE DUCTS OTHER SLEEP DISORDERS PURE HYPERGLYCERIDEMIA SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY, SITE UNSPECIFIED
Allergies: Penicillin, Pravastatin
Diagnostic Lab Data: See Above-please contact for any further questions
CDC Split Type:

Write-up: Resident vaccinated-1/7/21 Resident covid positive 1/11/21 Resident covid PNA-1/12/21 Resident hospitalized 1/16/21 Resident deceased 1/20/21
VAERS ID: 998228 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-29
Onset: 2021-02-03
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: 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: 2021-02-03
   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: ALBUTEROL HFA (8.5GM) 90 MCG INHA TAKE 1-2 PUFFS INHALATION EVERY 4 TO 6 HOURS AS NEEDED APAP 325MG TABS one (1) to two (2) tabs By Mouth two times daily as needed CALCIUM CARB (150) 500 MG CHEW TAKE 1-2 TABS BY MOUTH THREE TIMES DAILY AS
Current Illness: COPD Gastro-espohageal reflux Osteoarthritis Essential Hypertension Dermatitis COVID-19
Preexisting Conditions:
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Found unresponsive
VAERS ID: 998419 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-08
Onset: 2021-01-16
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / 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: Artificial Tears Solution 0.4 % (Hypromellose) Instill 1 drop in both eyes as needed for dry eyes QID Aspirin Tablet 81 MG Give 1 tablet by mouth one time a day Lasix Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for CHF T
Current Illness: See below
Preexisting Conditions: HEART FAILURE, UNSPECIFIED TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED NTA (2 pts) ANXIETY DISORDER, UNSPECIFIED BORDERLINE PERSONALITY DISORDER ESSENTIAL (PRIMARY) HYPERTENSION LEGAL BLINDNESS, AS DEFINED IN USA MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE PERSONAL HISTORY OF COVID-19 DYSPHAGIA, OROPHARYNGEAL PHASE PNEUMONIA, UNSPECIFIED ORGANISM TINEA UNGUIUM ONYCHOGRYPHOSIS UNSPECIFIED OPEN-ANGLE GLAUCOMA, INDETERMINATE STAGE UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION CHONDROCOSTAL JUNCTION SYNDROME [TIETZE] DEPENDENCE ON SUPPLEMENTAL OXYGEN UNSPECIFIED SEQUELAE OF UNSPECIFIED CEREBROVASCULAR DISEASE SLP OTHER SYMBOLIC DYSFUNCTIONS EDEMA, UNSPECIFIED HYPERLIPIDEMIA, UNSPECIFIED IRON DEFICIENCY ANEMIA, UNSPECIFIED ANEMIA, UNSPECIFIED PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED
Allergies: Brimonidine, Metformin, Bactrim, tape
Diagnostic Lab Data: N/A-contact facility for any questions or concerns
CDC Split Type:

Write-up: Resident vaccinated-1/8 Resident deceased-1/16
VAERS ID: 998421 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-06
Onset: 2021-01-27
   Days after vaccination: 21
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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 aspirin- 81mg calcium carbonate carbidopa-levodopa cholecalciferol fenofibrate fluorouracil cream fluticasone nasal spray folic acid nitroglycerin PRN miralax
Current Illness: Basal cell carcinoma of right ear
Preexisting Conditions: Parkinson''s CAD Labile HTN Renal artery stenosis HLD Basal cell carcinoma Squamous cell carcinoma BPH Prostate CA Urge incontinence Mild cognitive impairment
Allergies: Verapamil Amlodipine Morphine Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away unexpectedly on 1/27/21 from presumed sudden cardiac death.
VAERS ID: 998422 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-30
Onset: 2021-01-31
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Aspartate aminotransferase normal, Blood albumin, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium, Blood chloride normal, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase normal, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood lactic acid normal, Blood potassium normal, Blood sodium decreased, Blood urea increased, Blood urine absent, Brain natriuretic peptide normal, Carbon dioxide decreased, Cerebral atrophy, Chest X-ray normal, Computerised tomogram head normal, Dehydration, Full blood count normal, Haematocrit normal, Haemoglobin decreased, Hypophagia, Hyporesponsive to stimuli, Immunology test, Mental status changes, Metabolic function test, Muscular weakness, Platelet count normal, Procalcitonin normal, Protein urine, Pyrexia, SARS-CoV-2 test negative, Somnolence, Specific gravity urine normal, Troponin I normal, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic erythropenia (broad), Peripheral neuropathy (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Proteinuria (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-21
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg daily; cimetidine 300 mg 4 times a day; donepezil 10 mg daily; fluticasone nasal spray daily; gabapentin 600 mg 3 times a day; glipizide 2.5 mg daily; losartan 100 mg daily; memantine10 mg twice a day; metformin 500 mg twice
Current Illness: None
Preexisting Conditions: Type II diabetes, hypertension, hypothyroidism, GERD, hyperlipidemia, early dementia.
Allergies: None
Diagnostic Lab Data: 2/2: WBC 8.7, H/H 13.6/40.5; Plt 185,000; Glucose 173, BUN 23, creatinine 1.5, Na 135, K 4.7, Cl 102, CO2 22, Ca 8.3, Tot protein 6.1, albumin 3.5, ALP 71, AST, 20, ALT 12, Tot bili 0.30, BNP 24, CPK 131, CKMB 1.8, troponin i <0.06. SARS FIA negative. UA: sp gr 1.025, pH 7.0 1+ protein, neg blood o/w normal. 2/3: WBC 8.4, H/H 12.4/36; BUN 18, creat1.1 CT head normal for age; CXR no evidence of infection.
CDC Split Type:

Write-up: patient developed progressive diffuse muscle weakness, altered mental status including excessive drowsiness, decreased oral intake starting on 1/31/2021. Symptoms continued to worsen overnight and he was evaluated in the emergency room on 2/2/2021 and admitted with dehydration and altered mental status. He was aggressively hydrated overnight, but showed persistent diffuse muscle weakness, altered mental status with decreased responsiveness progressing, but no focal neurological findings noted. CT scan of the head on 3/3/2021 showed no findings other than age-related diffuse cerebral atrophy. The patient did spike a fever to 103 on the morning of 2/3/2021. CBC, CMP, procalcitonin and lactic acid levels remained normal. He remains hospitalized in stable condition as of 2/3/2021 @1300.
VAERS ID: 998463 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-06
Onset: 2021-01-19
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute coronary syndrome, Death, Endotracheal intubation, Laboratory test, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Myocardial infarction (narrow), 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), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   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 amlodipine calcium carbonate + vitamin D3 Celebrex (PRN) Irbesartan lidocaine patch loratadine polyethylene glycol pravastatin
Current Illness: pneumonia, acute hypoxic respiratory failure
Preexisting Conditions: HTN HLD Osteoarthritis osteoporosis impaired mobility secondary to avascular necrosis or right humeral head, and s/p ankle fusions, bilateral knee replacements Sciatica open angle glaucoma
Allergies: horse chesnut seed extract
Diagnostic Lab Data: Tests/ results were performed in hospital, outside of our setting (nursing home).
CDC Split Type:

Write-up: Resident passed away unexpectedly on 01/19/21 after developing acute hypoxic respiratory failure on morning of 01/19/21. She was transferred to hospital via EMS where she was intubated, coded, and ultimately expired with uncertain underlying cause, potentially ACS.
VAERS ID: 998544 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-13
Onset: 2021-01-25
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Multiple medication
Current Illness: diabetes, heart trouble, dementia
Preexisting Conditions: as above
Allergies: Morphine and iodine
Diagnostic Lab Data: Stents placed.
CDC Split Type:

Write-up: Patient had heart attack. Spoke with spouse on 2/3/2021 stated had multiple health issues including heart and lung issues.
VAERS ID: 998576 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Washington  
Vaccinated: 2021-01-27
Onset: 2021-01-27
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Blood creatinine increased, Blood culture negative, Blood potassium increased, Blood urine present, Brain natriuretic peptide increased, Cardiac telemetry, Chest X-ray abnormal, Electrocardiogram abnormal, Full blood count normal, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Metabolic function test, Pleural effusion, Protein urine present, Pulmonary oedema, Pyrexia, Respiratory distress, SARS-CoV-2 test negative, Sinus tachycardia, Troponin increased, Urine analysis
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Med List @ time vaccine # 2: PRN acetaminophen Bisacodyl PRN TUMS Clotrimazole Flonase Loratadine Lorazepam Melatonin Bengay Nitrostat Zofran oxycodone Miralax Scheduled: acetaminophen 500 md QID amlodipine 5mg BID Metoprolol 50 mg BID Pra
Current Illness: NSTEMI after COVID vaccine #1
Preexisting Conditions: CAD, CKD4, Hypertension, Anemia, dementia
Allergies: DIPYRIDAMOLE, ERYTHROMYCIN, TERAZOSIN
Diagnostic Lab Data: 1/1/2021 CMP remarkable for Potassium 5.8, creatinine 3.20, HS troponin 2.2, 310 BNP 12.7, CBC unremarkable, UA++ protein 1+ blood, Blood Cx No growth x5 days, COVID RNA rapid (-), 1/2/21 COVID PCR (-), Influenza A+B (-), No EKG, Partial CXR no acute cardio pulmonary process, no pneumonia, Telemetry Strip (12/31 22:00 atrial fib normal rate. 1/27/21 CMP remarkable for potassium 6.1, Serum Creatinine 4.46, BNP 1080, HS troponin 13.2, CBC with diff unremarkable, COVID PCR (-), EKG sinus tachycardia, QRS algorithm, left axis deviation rate 107 borderline criteria arterial infarct, CXR Bilateral + alveolar opacities compatible with pulmonary edema, small (L) pleural effusion, (L) basilar air space likely atelectasis
CDC Split Type:

Write-up: Had acute respiratory failure, dysuria NSTEMI after Dose #1 Lot # 025L20A (Moderna) hospitalized same day 12/31/20 administered @ 1040 back to baseline. 2nd Dose on 1/27/21 0950 Lot as above. Unknown exact onset same day, ED by EMS @ 1745, respiratory distress, febrile 39.4 degrees C BP 150/105 RR 29
VAERS ID: 998579 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-25
Onset: 2021-02-02
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / 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: Patient is a nursing home resident please notify facility.
Current Illness: Patient is a nursing home resident please notify facility.
Preexisting Conditions: Patient is a nursing home resident please notify facility.
Allergies: Iodine, ACE Inhibitors
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away 2/2/2021.
VAERS ID: 998637 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-13
Onset: 2021-01-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Irregular breathing, Resuscitation, Somnolence
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad), Hypoglycaemia (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? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: No known acute illness
Preexisting Conditions: Macular degeneration Dislipidemia
Allergies: None noted
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient noted to have irregular breathing in bed and unable to arouse. Provided life saving measures in the field x 30 minutes and transferred to hospital. Noted to have heart arrhythmia which suspected to cause cardiac arrest.
VAERS ID: 998770 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Dyspnoea, Hypopnoea, Palpitations
SMQs:, Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: OTC APAP prn Tradjenta 5mg daily amlodipine 10mg daily naproxen 500mg BID trazodone 100mg HS atorvastatin 20mg daily gabapentin 100mg TID timolol 0.5% eye drops 1 drop each eye BID metformin ER 500mg daily glipizide 10mg BID lisinopril 20m
Current Illness:
Preexisting Conditions: High blood pressure High Cholesterol Diabetes Restless Legs syndrome depression/anxiety
Allergies: NKA
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient had no symptoms or adverse events until the next evening after shot (1/29/21) where daughter reported her having heart palpitations. Family told her to rest and did not seek medical attention. Saturday afternoon (1/30/2021), patient started experiencing labored breathing. Daughter called 911 and before the ambulance arrived, the patient''s breathing became more and more shallow. Patient was taken to the local hospital and passed away Saturday evening around 5:30 pm.
VAERS ID: 1002931 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-21
Onset: 2021-01-24
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Absence of immediate treatment response, Cardiac arrest, Cardio-respiratory arrest, Death, Electrocardiogram ST segment elevation, Endotracheal intubation, Pulseless electrical activity, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Lack of efficacy/effect (narrow), Myocardial infarction (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), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: CARDIAC ARREST, DEATH Narrative: The patient presents to the emergency department in cardiopulmonary arrest. CPR was continued upon arrival. The Combi tube was removed and an endotracheal tube was placed without complications. ROSC was obtained multiple times but the patient continued to go into PEA. The patient was seen in the emergency department by both critical care and Cardiology. EKG shows ST elevations, but the patient was unstable to go to catheterization. The patient had 1 episode of asystole. Despite best efforts and multiple attempts we were unable to resuscitate the patient. Time of death 1253 on 1/24/21.
VAERS ID: 1002937 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-01
Onset: 2021-02-01
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Autopsy, 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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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 Narrative: Pt attended arthritis clinic appt 0900; labs shortly after; rec''d vaccine in clinic ~ 1113; seen on surveillance camera walking to parking garage ~ 1145; medical center rec''d call from wife ~ 1900 that pt never returned home; police found vehicle running in parking garage, code called, pt obviously deceased by that time 1930, body sent to medical examiner for autopsy.
VAERS ID: 1000226 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-19
Onset: 2021-01-27
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Ischaemia, Surgery, Volvulus
SMQs:, Gastrointestinal obstruction (narrow)

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? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021085163

Write-up: volvulus; volvulus and needed surgery followed by further ischemia; This is a spontaneous report from a contactable physician. An 86-year-old female patient received her first single dose of BNT162B2 (Pfizer-BioNTech Covid-19 vaccine) intramuscularly on 19Jan2021 for Covid-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient had no known allergies. The patient developed volvulus and needed surgery followed by further ischemia and at end of life. The events onset date reported as 27Jan2021. Patient had 3days hospitalization and died eventually. It was unknown if an autopsy was performed. Information about lot/batch number has been requested.; Sender''s Comments: Very limited information was provided in this report. No relevant information regarding the clinical course of the events, the patient''s underlying medical conditions were mentioned. Based on the information currently available, lacking any other alternative explanations as so far, the reported volvulus and Intestinal ischaemia are managed as related to COVID-19 vaccine, BNT162B2, for reporting purpose, only. 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 RA, IEC, as appropriate.; Reported Cause(s) of Death: volvulus; ischemia
VAERS ID: 1000228 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Nevada  
Vaccinated: 2021-01-21
Onset: 2021-01-21
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: Death, Resuscitation, 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: 2021-01-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19; Immunocompromised
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021085790

Write-up: dead; Collapsed; bnt162b2 was given to patient with immunocompromised w/ reportable conditions; bnt162b2 was given to patient with immunocompromised w/ reportable conditions; This is a spontaneous report from a contactable nurse. A 40-year-old male patient receive first dose of bnt162b2 (Lot number: EK9231, Brand: Pfizer), intramuscular in left arm on 21Jan2021 15:15 at single dose for COVID-19 immunization. Medical history included immunocompromised w/ reportable conditions from an unknown date and unknown if ongoing, positive for Covid in September from Sep2020 to an unknown date. The patient''s concomitant medications were not reported. The patient experienced dead, collapsed on 26Jan2021. Therapeutic measures were taken as a result of collapsed. The outcome of collapsed was unknown. The patient died on 26Jan2021. It was not reported if an autopsy was performed. Received Covid vaccine here on 21Jan2021, was at work on 26Jan2021 and collapsed, no known complaints at the time, CPR (cardiopulmonary resuscitation) was initiated immediately, transported to ER (Emergency room) and pronounced dead. Unknown if other vaccine in four weeks. The patient had COVID prior vaccination. Unknown If COVID tested post vaccination.; Sender''s Comments: Based on the information currently provided, the patient was immunocompromised and had prior COVID infection. The death and syncope more likely are associated with the patient underlying medical conditions. More information such medical history, concomitant medications, treatment indication and event term details especially death cause and autopsy results are needed for fully medical assessment. 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: Dead
VAERS ID: 1000233 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021098743

Write-up: just died; This is a Spontaneous report from a Pfizer Sponsored Program from a contactable consumer. A male patient of an unspecified age received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient just died on an unspecified date. It was not reported if an autopsy was performed. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: just died
VAERS ID: 1000624 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021064098

Write-up: Pneumonia; This is a spontaneous report from a Pfizer-sponsored program via a contactable consumer (patient). A male patient of unspecified age (Age: 63; Unit: Unknown) received the first dose and second dose of BNT162B2, via unspecified routes of administration on unspecified dates at single dose for COVID-19 immunization. Medical history and concomitant medications were not reported. After receiving both vaccines, patient still got pneumonia and he had seen many elderly died from pneumonia even after receiving the vaccine. Outcome of the event was not resolved. No follow-up attempts are possible; information about lot/batch number cannot be obtained.
VAERS ID: 1000665 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-18
Onset: 2021-01-20
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: GLIPIZIDE; WARFARIN; METFORMIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Atrial fibrillation; Macular degeneration; Prostate cancer; Type 2 diabetes mellitus
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021092300

Write-up: Death 2 days later; This is a spontaneous report from a contactable Other HCP. A 97-year-old male patient received the 1st dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EL0140) via intramuscular in the left arm on 18Jan2021 12:00 PM at single dose for covid-19 immunisation. Medical history included prostate cancer, macular degeneration, type 2 diabetes, atrial fibrillation. No known allergies. Concomitant medications included glipizide, warfarin and metformin in two weeks. The patient had no other vaccine in four weeks. The patient experienced death on 20Jan2021 at 09:00 PM. Death cause was undetermined. No autopsy was performed. No treatment was received for AE. The patient had no covid prior vaccination, no covid tested post vaccination. Outcome of the event was fatal.; Sender''s Comments: Event unknown cause of death is assessed as Related until sufficient information is available to confirm an unrelated cause of death or if there is sufficient information to allow an unrelated causality assessment. Case will be reassessed when follow-up information is received. 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: Death 2 days later
VAERS ID: 1000670 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Alabama  
Vaccinated: 2021-01-19
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain, Death, Myocardial infarction, Pain in extremity, SARS-CoV-2 test negative, Stent placement, Thrombosis
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 25
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:
Preexisting Conditions: Medical History/Concurrent Conditions: Diabetes
Allergies:
Diagnostic Lab Data: Test Name: Covid-19; Test Result: Negative
CDC Split Type: USPFIZER INC2021094694

Write-up: she was hurting at her chest/ Chest pain; on her left arm hurt real bad that''s what the clot on her left arm; on her left arm hurt real bad that''s what the clot on her left arm; She passed away; heart attack; This is a spontaneous report from a contactable consumer. An 87-years-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 19Jan2021 at single dose for COVID-19 immunisation. Medical history included diabetes mellitus, for which she was taking a pill like an hour before she would take her meal. On Monday (Jan2021) the patient experienced was hurting at her chest/ chest pain, her left arm hurt real bad as she had a blockage in her left arm/clot on her left arm, and they wanted to put in a stent and after the surgery it went well and she all go home in two days. The patient was hospitalized in Jan2021 due to the events. She had a heart attack and that the chamber between the dividers had a hole in it and her heart tissue was too thin so much thin she couldn''t repair it. The patient passed away on 26Jan2021. The patient was tested negative for COVID-19 on unknown date. Information on the lot/batch number has been requested.; Reported Cause(s) of Death: She passed away
VAERS ID: 1000709 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-18
Onset: 2021-02-01
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH 9899 / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Pleural effusion
SMQs:, Systemic lupus erythematosus (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: amiodarone, ASA, calcitriol, coreg, folvite, apresoline, synth
Current Illness: see below
Preexisting Conditions: see below
Allergies: Heparin, Amoxcillin
Diagnostic Lab Data: Patient was hospitalized related to multiple chronic diagnoses.
CDC Split Type:

Write-up: Patient with past medical history of CAD, CKD, sCHF, LGL Leukemia admitted to Hospital on 1/19 with pleural effusion. Pt expired on 2/1/2021. Hs of essential HTN, complete heart block, T2Diabetes,thyroid issues, stroke, papillary CA of thyroid, dyslipidemia, anemia, hypercalcemia, pulmonary nodule, hypoparathyroidism, pacemaker, bilat carotid stenosis, afib, pleural effusion, pancytopenia, cardiomyopathy, severe aortic stenosis, sick sinus syndrome, Dressler syndrome, empyema, ESRD
VAERS ID: 1000711 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-08
Onset: 2021-01-27
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Blood test abnormal, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: rocaltrol, iron, folvite, neurontin, proamatine, zifaxan
Current Illness: chronic liver disease, hypoganadism, alcoholic cirrhosis, cont
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: multiple from prior records not related to vaccine
CDC Split Type:

Write-up: in addition to above, pt had the following diagnosis: portal HTN, abnormal blood chem, essential tremor, depressive disorder, abnormal glucose tolerance test, hyperlipidemia, hypothyroidism, insomnia, localized osteoarthrosis, calculus of kidney, pancytopenia, odule on liver, hepatocellular CA, hyotension, hypovolemia, hepatorenal syndrome additional meds: zoloft, aldactone, thiamine,demadex, ultram, kenalog, vitamins, bactroban ung
VAERS ID: 1000739 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-05
Onset: 2021-01-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH PK9231 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Dyskinesia, General physical health deterioration, Influenza virus test, Laboratory test, Muscle twitching, Pallor, SARS-CoV-2 test negative, Seizure, Skin discolouration, Staring
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Dyskinesia (narrow), Dystonia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-19
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dermaseptin, Eucerin, Listerine, Ophthalmic Care, Periguard, Acetaminophen, Aspirin, Atorvastatin, Bisacodyl, Chlorhexidine, Memantine, MVA, Rivastigmine Patch, Trileptal Suspension, Vitamin B-50, Vitamin C, Vitamin D, zINC
Current Illness: NKA
Preexisting Conditions: Frontotemporal Dementia, Dysphagia, Tinea Unguium, Peripheral Vascular Diseases, Difficulty Walking, Primary Hypertension, Hypercholesterolemia, Hyperlipidemia, Personality Change dur to known physiological condition, History of other mental and Behavioral Disorders, Constipation, Atherosclerotic Heart Disease of Native Coronary Artery, Nail Dystrophy, Dermatitis, Idiopathic Epilepsy and Epileptic Syndromes with Seizures of Localized Onset, Protein Caloria Malnutrition, Muscle Weakness
Allergies: nka
Diagnostic Lab Data: STAT Labs ordered 1/6/21 1/6/21 Rapid Covid completed, Negative 1/15/21 Rapid Flu completed, Negative
CDC Split Type:

Write-up: Approximately 10 minutes after receiving the COVID- 19 vaccine resident displayed seizure activity, staring straight ahead and strong allover muscle jerking of both the up and lower extremities, color became gray, activity lasted approximately 3 minutes, resident then became relaxed, color returned to normal, BP-140/80, 97.8, 60, 16, sleeping the remainder of the shift,. Resident continued to decline until resident CTB on 1/19/21
VAERS ID: 1000752 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-01-17
Onset: 2021-01-31
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Feeling abnormal, Nasopharyngitis, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant 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: 2021-02-01
   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: citalopram, atorvastatin, felodipine, avalide, metoprolol, omeprazole
Current Illness: none that I''m aware of
Preexisting Conditions: aortic atherosclerosis, essential hypertension, depression, type 2 diabetes with stage 4 chronic kidney disease
Allergies: penicillin, procain
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt son, reports patient passed away on 2/1/21 in the early hours. Pt wife, told Pt''s son that patient started feeling "bad" with common cold like symptoms on 1/31/21, had a temp of 99.0. Pt''s wife went to take a shower, when she got out patient was unresponsive. She called EMS, they pronounced patient deceased upon arrival. Pt''s son also reports patient and Pt''s wife both had their 1st COVID-19 vaccine 13 days prior. He was told by EMT on sight to notify the facility where they received their vaccines. He did contact them and was told to notify PCP.
VAERS ID: 1000784 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-01-29
Onset: 2021-01-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Foaming at mouth, Mechanical ventilation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: T.C. from sister to communicate the hospitalization of her sister. She reported that on Friday patient collapsed and started foaming at the mouth and was rushed to hospital. She stated that patient is on a ventilator and at 5PM today they are going to take her off. Sister was very upset and I was uncomfortable asking more questions. She will call me with more information at a later time. She did say that the hospital staff was not sure of what caused her collapse.
VAERS ID: 1000856 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-30
Onset: 2021-01-30
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Fall, Myocardial infarction, Pulse absent, Resuscitation
SMQs:, Myocardial infarction (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Accidents and injuries (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: Myocardial infarction Narrative: PMH significant for aortic valve stenosis, mitral valve stenosis, CKD, CHF, DM, HTN, obesity, hypothyroidism and dyslipidemia. Per report from primary care - the patients wife reports that the patient went on Saturday (1/30/21 - about 1050) morning to receive his COVID vaccine. He returned home and told her about the experience and denied any side effects. He then proceeded to sit in his easy chair for a while and around 1:30, she asked him if he wanted any lunch. The patient''s wife reports he "grumbled" at her, and then got up to go to the bathroom. She then heard a loud crash and found him lying on the floor of the bathroom, with his head knocking hole in the wall as he fell. She could not detect a pulse. She called 911 and began compressions. First responders to the scene likewise tried to revive him but were not successful in her efforts. Per primary care documentation - Uncertain if related to Pfizer vaccine; vaccine administered on 1/30/21 and approximately 3 hours later suffered fatal MI at home.
VAERS ID: 1001488 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-18
Onset: 2021-01-31
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: COVID infection November 2020
Preexisting Conditions: HTN, Afib, atherosclerotic cardiovascular disease;
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died several days after receiving the second dose of the vaccine. See additional information sent. An autopsy has been performed and results are pending.
VAERS ID: 1001567 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: ascorbic acid 500 mg, carbidopa-levodopa 25-100 mg, clopidogrel 75 mg, entacapone 200 mg, finasteride 5 mg, multivitamin, pravastatin, Prevident 5000 Plus 1.1%, propranolol 40 mg, rivaroxaban 20 mg, tamsulosin 0.4 mg.
Current Illness:
Preexisting Conditions: Left anterior fascicular block, hyperlipidemia, hypertension, allergic rhinitis, dysphagia, gastroesophageal reflux disease, benign prostatic hyperplasia, equinovarus deformity, toe amputation, stroke, essential tremor, parkinson''s disease, hemiplegia due to old stroke, neuropathy, spasticity.
Allergies: Hay fever
Diagnostic Lab Data: None. Coroner opted against autopsy due to age and significant comorbidities
CDC Split Type:

Write-up: Death

VAERS ID: 1001713 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data: Test Name: temperature; Result Unstructured Data: 98
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; A spontaneous report was received from a consumer concerning a patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unknown date, approximately 2 hours prior to the onset of the event, the patient received a dose of mRNA-1273 intramuscularly in the for prophylaxis of COVID-19 infection. They were not feeling sick or experiencing any adverse events. Vital signs included temperature 98 degrees Fahrenheit. Approximately two hours after receiving the vaccine, the patient passed away. No treatment information was provided. Action taken with the drug in response to the event was not applicable. The patient died on an undisclosed date. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a patient of unknown age and gender. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately two hours after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1002052 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-19
Onset: 2021-01-20
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away yesterday, found deceased in her apartment; This spontaneous report was received from a consumer which refers to a 91-year-old female patient who received the Moderna COVID-19 vaccine (mRNA-1273) and next day the patient passed away. The patient''s medical history was not provided. Concomitant medications were not reported. On 19 Jan 2021, the patient received her first of two planned doses of mRNA-1273 intramuscularly (Lot number: not provided) for prophylaxis of COVID-19 infection. On 20 Jan 2021, the patient passed away and she was found deceased in her apartment. No treatment medication was provided. Action taken with mRNA-1273 in response to the events was not applicable as the patient passed away. On 20 Jan 2021, the patient died, cause of death was unknown. Autopsy result was unknown. The reporter assessed the causality as related between the event and Moderna COVID-19 vaccine.; Reporter''s Comments: This case concerns a 91-year old female patient. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the onset of the event, a causal relationship cannot be excluded and the event is considered possibly related to the vaccine.; Reported Cause(s) of Death: Unknown Cause of Death
VAERS ID: 1002057 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-03
Onset: 2021-02-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK 9231 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Percocet 5/325 mg, Vitamin B12, Ventolin HFA, Amiodarone, Apixaban, Atorvastatin, Carvedilol, Iron sulfate, Lasix, Gabapentin, Insulin Glargine, Insulin Lispro, Levothyroxine, Lidocaine patch, Protonix, Sertraline,
Current Illness: 1) Deconditioning 2) Osteoporosis with acute T4 compression fracture from coughing in 12/15/20 3) Chest wall pain 4) Anemia due to GI bleed 5) HTN 6) DM 2 7) HFrEF 8) Hyperlipidemia 9) Paroxysmal atrial fibrillation 10) PVD 11) CAD 12) Aortic stenosis 13) Hypothyroidism 14) Anxiety disorder
Preexisting Conditions: See above
Allergies: Baclofen, Sulfa antibiotic
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Sudden death
VAERS ID: 1002187 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Tennessee  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Resuscitation
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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: PATIENT WAS IN CLINIC FOR 1ST CLINIC. WAS DISCHARGED BEFORE OUR 2ND CLINIC. HE CAME BACK TO OBTAIN HIS 2ND SHOT. WE WENT OUT TO THE CAR GAVE SHOT. THE NEXT DAY TO MY KNOWLEDGE, HE STARTED CODING AT HOME. AMBULANCE WAS CALLED AND HE CONTINUED TO CODE. THE AMBULANCE CREW TRIED CPR FOR 30 MINS WITH NO LUCK. PATIENT PASSED 2-3-21.
VAERS ID: 1002229 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-22
Onset: 2021-02-03
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Other       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: 2021-02-03
   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: unknown
Current Illness: none known
Preexisting Conditions: CAD with stent placement 2000
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: spontaneous death, found unresponsive in cell after normal morning activities
VAERS ID: 1002255 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-27
Onset: 2021-01-28
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9263 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 0
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death
VAERS ID: 1002418 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-15
Onset: 2021-02-04
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 2 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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:
CDC Split Type:

Write-up: Patient death
VAERS ID: 1002453 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Indiana  
Vaccinated: 2021-01-26
Onset: 2021-01-29
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 549616 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 0
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none
Preexisting Conditions: coronary artery disease
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reaction at time of vaccination. Reported by family that pt. died on 1/29/2021. Coroner does not believe this was related to vaccine, but requested to report to VAERs
VAERS ID: 1002535 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Herpes zoster, Malaise, Neuralgia, Pain, Rash
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 5
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: On 1/29/21 patient began not feeling well and saw her provider. The doctor gave her fluids and tramadol for pain. They noticed increased confusion, but thought that could have been due to the tramadol. They also increased her gabapentin as she was experiencing nerve pain. Patient also developed a rash and was diagnosed with shingles on 2/1/21. Patient died on 2/3/21
VAERS ID: 1002636 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Washington  
Vaccinated: 2020-12-28
Onset: 2021-01-17
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Angiogram, Angiogram cerebral abnormal, Aphasia, Cerebral artery occlusion, Computerised tomogram abnormal, Computerised tomogram head, Death, Fall, Movement disorder, NIH stroke scale score increased, Nervous system disorder, Thrombectomy
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 6
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ASA 81 mg, allopurinol, potassium chloride, furosemide, diltiazem, metoprolol, tiotropium, albuterol, diclofenac gel topical
Current Illness: None - had exposure to COVID19 + case on 12/18/2020 but tested negative.
Preexisting Conditions: CHF, HTN, hyperlipidemia, atrial fibrillation, COPD (O2 dependent) , CKD Stage 4, type 2 diabetes (diet controlled).
Allergies: Oxycodone, Percodan, atenolol, PCN VK
Diagnostic Lab Data: CT 1/17/21 (no acute hemorrhage but mild hypodensity of greater than 1/3 of the MCA territory) and CT Angiogram on 1/17/21 ( distal L M1/M2 occulsion).
CDC Split Type:

Write-up: On 1/17/2021 patient woke and began her day as usual, was found down by family member 1 hour later conscious but unable to speak and unable to move her R side. She was admitted to the hospital - Initial NIHSS was 26 and CT imaging showed no acute hemorrhage but mild hypodensity of greater than 1/3 of the MCA territory (TPA not recommended). CTA did show distal L M1/M2 occulsion and she was transferred to larger facility for thrombectomy. Unfortunately the patient had persistent severe neurological deficits after thrombectomy. Was discharged home on hospice care and expired on 1/23/21.
VAERS ID: 1002808 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: West Virginia  
Vaccinated: 2021-01-09
Onset: 2021-02-03
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / UNK UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, Ageusia, Anosmia, Asthenia, COVID-19 pneumonia, Death, Decreased appetite, Dyspnoea, Nausea, Respiratory failure
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Taste and smell disorders (narrow), 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), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 20 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Diabetes, hypertension
Preexisting Conditions: IBS, GERD, overweight, scoliosis, Macular degeneration, sciatica, umbilical hernia, RBBB, Others listed
Allergies:
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: According to medical report, Pt presented to the ED on 1/14/21 w/ cc of SOB for 1 day. She received her COVID-19 vaccine on 1/9/21. Pt stated that she developed a dry hacking cough 2 days prior to the vaccine on 1/7/21. Over the last few days prior to admission, she developed generalized weakness, SOB, loss of sense of taste and smell w/ associated decreased appetite and nausea ultimately SOB in the24 hours prior to admission. Final Diagnosis- acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Pt died on 2/3/21. See Medical report for more information.
VAERS ID: 1002813 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-02-03
Onset: 2021-02-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 062G20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure increased, Cardiac arrest, Death, Heart rate increased, Respiratory arrest, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), 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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Alphagan gtts, aricept, colace, D3-50, Depakote, levetiracetam, metoprolol,senna, tylenol
Current Illness: None
Preexisting Conditions: medical diagnosis chronic conditions Epilepsy, alzehimer''s disease, acute resp. failure, non-st MI,encephalopathy, ETOH use, claucoma, anxiety/depression, HTN, macular degeneration, extropia, presbyopia, hearing loss,
Allergies: no allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was seen at 0710 he was sleeping but at normal cognitive behavior Patient was again assessed at 0720 where he was noted to be unresponsive, BP 180/100s, HR 230s, he was a DNR therefore not CPR was administered. EMS arrived at facility patient was noted to be in full cardiac and respiratory arrest. Time of death 0735
VAERS ID: 1002840 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-01-26
Onset: 2021-01-27
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ZTC540693 / 1 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, Malaise
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Tamulosin HCL, HCTZ, Oxybutynin CL ER, Lisinopril, Zetia, Lexapro, Trulicity,
Current Illness: none
Preexisting Conditions: DM II, HTN, Hyperlipidemia
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Client lives alone and had dinner at his home with family members after the 4:40 appointment. Client stated that in general he did not feel well but did not give any specific symptom. Family states they asked the client to go to the ER and the client refused. Family states they helped the client to his chair in the living room and then left to go home. Family states that the client was found in his bedroom the next morning at 7:54 a.m. deceased.
VAERS ID: 1003106 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-04
Onset: 2021-02-04
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pupil fixed, 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: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Enteric Coated Aspirin 81 mg tablet,delayed release 1 Time Daily Eliquis 2.5 mg tablet 2 Times Daily Dulcolax (bisacodyl) 10 mg rectal suppository PRN Fleet Enema 19 gram-7 gram/118 mL PRN acetaminophen 500 mg ta
Current Illness: CARDIOMEGALY; LOW BACK PAIN; MUSCLE WEAKNESS (GENERALIZED); NEED FOR ASSISTANCE WITH PERSONAL CARE; - OTHER ABNORMALITIES OF GAIT AND MOBILITY; LUMBAGO WITH SCIATICA, UNSPECIFIED SIDE; R26.81 - UNSTEADINESS ON FEET; REPEATED FALLS; CERVICAL SPONDYLOSIS; Other Diagnoses PRESENCE OF CARDIAC PACEMAKER; DYSPHAGIA, OROPHARYNGEAL PHASE; HYPERLIPIDEMIA, UNSPECIFIED; CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED ; ATHSCL HEART DISEASE OF NATIVE CORONARY ARTERY W/O ANG PCTRS; ESSENTIAL (PRIMARY) HYPERTENSION; INSOMNIA, UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE;
Preexisting Conditions: On hospice
Allergies: Diltiazem
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Resident received vaccination at 9:12 am, she was monitored and checked at the 15 minute interval 9:27 am, reassessed, vitals were fine. Within 20 (9:32 am) minutes of receiving the vaccine she was unresponsive, pupils were fixed at 9:45 am, no vital signs noted; hospice came out and reported her time of death 10:21 am. This person was on hospice.
VAERS ID: 1003329 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-29
Onset: 2021-02-02
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9263 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Malaise, Unresponsive to stimuli, Vaccination site pain, Vaccination site swelling
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: 2021-02-02
   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: Per medical record: alendronate, amlodipine, aspirin, atorvastatin, benazepril, calcium-Vitamin D, diclofenac, ezetimibe, glimeperide, hydrochlorothiazide, latanoprost opthalmic, topical lidocaine, metformin, Artificial Tears, Lacri-Lube, p
Current Illness: No known recent illnesses per medical record
Preexisting Conditions: Per medical record: type 2 diabetes, hypercholesterolemia, hypertension, non-proliferative diabetic retinopathy, borderline glaucoma, osteoarthritis, obesity
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient''s primary care provider received a death certificate to be signed for this patient. He spoke with the patient''s husband and son, who reported that the patient had pain and swelling at the vaccine administration site after receiving the vaccine and was feeling unwell after receiving the vaccine. The patient''s family reported that they found her unresponsive on 2/2/21 and called 9-1-1. The patient was pronounced dead upon arrival of emergency responders.
VAERS ID: 1003382 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Alabama  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Bradycardia, Chest pain, Condition aggravated, Death, Diarrhoea, Full blood count, Hypotension, Metabolic function test, Seizure, Urine analysis, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Aricept, citalopram,carbamazepine, Atorvastatin, gabapentin, calcium citrate, metoprolol, amlodipine, vitamin D
Current Illness: COVID dx on 1/4/2021
Preexisting Conditions: Dementia, epilepsy, HTN, PVD, osteoporosis,
Allergies: PCN, Sulfa ATB
Diagnostic Lab Data: Did order CBC, carbamazepine level, UA and CMP. Results are pending
CDC Split Type:

Write-up: Began with vomiting and diarrhea. C/O chest pain. Bradycardia. Hypotension. 2 seizures in 45 minutes after not having one in years. We gave fluids. Gave Zofran. Comfort measures. Pt passed at midnight. Was completely fine one day before. Had minimal issues with COVID though did have a pneumonia that was treated w ATB early on and resolved.
VAERS ID: 1003390 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-20
Onset: 2021-01-21
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abdominal pain, Death, Diarrhoea, Injection site pain, Vomiting
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Pseudomembranous colitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 6
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: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 2/1/2021, the patients daughter, who claims is a nurse, reported this incident to me. She stated that the evening after the patient received the vaccine, she felt some mild injection site pain. The morning after, the patient reported severe abdominal pain, diarrhea and vomiting. The patients daughter then called her physician to report these symptoms and attributed them as an adverse reaction to the vaccine at that time. These symptoms were intermittent for one week and no other adverse reactions were noted. In the early morning hours of 1/27/2021, the patient was toileting and had expired while doing so. An ambulance was called and cause of death was not found. An autopsy was not performed.
VAERS ID: 1003494 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-18
Onset: 2021-01-18
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK 5730 / 2 LA / SC

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, 650 mg= 2 tab, Oral, q6hr, PRN amLODIPine, 10 mg= 2 tab, Oral, Daily aspirin, 81 mg= 1 tab, Chewed, Daily atorvastatin, 40 mg= 1 tab, Oral, Q Bedtime Keppra, 1000 mg= 2 tab, Oral, every 12 hr levothyroxine, 75 mcg= 1 tab
Current Illness: Recent hemorrhagic stroke
Preexisting Conditions: Seizure disorder, prior subdural bleed status post cranioplasty, bipolar disorder, hypertension, hyperlipidemia, and vasovagal syncope
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Possible transverse myelitis developing 2 days after vaccine injection. Death on day 9 after vaccination
VAERS ID: 1003587 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-05
Onset: 2021-01-08
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELO140 / 1 AR / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Asthenia, Death, Fatigue, Mobility decreased, Pneumonia aspiration
SMQs:, Parkinson-like events (broad), Guillain-Barre syndrome (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: synthroid, pantoprazole, clonazepam, allopurinol, allbuterol inhaler, Decadron
Current Illness: congestive heart failure
Preexisting Conditions: congestive heart failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: My father was in weak condition to begin with. He didn''t get out of bed for the next few days after receiving the vaccine. The little amount that he ate was consumed in bed. He began aspirating his food which lead to pneumonia. He wasn''t strong enough to fight off the pneumonia even with antibiotics. He died on 1/23/21. While he might have passed soon in any case, I believe that the vaccine may possibly have increased his weakness/exhaustion thereby hastening his demise.
VAERS ID: 1003624 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Hypotension, Oxygen saturation decreased, Peripheral coldness, Pyrexia, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 25
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: cyancobalamin, insulin detemir, potassium chloride, reno caps, sevelemer, sodium polystyrene sulfonate, midodrine, acetaminophen,
Current Illness: PNA
Preexisting Conditions: MSSA, DM, ESRD/HD, HTN
Allergies: metaformin and sulfa
Diagnostic Lab Data: done at hospital
CDC Split Type:

Write-up: Patient awake at 0300. When going into the room to get him ready for dialysis he was cold to touch, unresponsive other than to sound, and nonverbal. O2 sat was 67 via finger probe. Oxygen immediately initiated and a venturi mask retrieved and initiated. When unable to arouse him via sternal rub this RN called 911. Send to ED. Febrile 39.2 and hypotensive 58/43. Admitted. unknown after that as patient expired in hospital.
VAERS ID: 1005533 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-21
Onset: 2021-01-23
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cognitive disorder, Death
SMQs:, Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Narrative: 89yo with type 2 DM, HT, pacemaker and prior COVID+ in Nov 2020. Shortly after administration of 2nd Covid vaccine, patient began to have increased cognitive decline and 2 days after he expired at the facility
VAERS ID: 1004206 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-21
Onset: 2021-01-23
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   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: TYLENOL
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No adverse event was reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a nurse concerning a 91-year-old, female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and died two days later. The patient''s medical history included dementia. Concomitant medications reported included paracetamol. On 21 Jan 2021, approximately two days prior to her death, the patient received the first of two planned doses of mRNA-1273, intramuscularly for prophylaxis of COVID-19 infection. On 23 Jan 2021, the patient died. The nurse reporting the event stated that the patient''s death was considered as due to "natural causes" and that she was not aware of any new-onset symptoms of illness prior to the patient''s death. The patient was described as "fragile" and was under hospice care at the time of her death. An autopsy was not performed. Action taken with the drug in response to the event is not applicable. The patient died on 23 Jan 2021. The cause of death was natural cause of death related to dementia. Autopsy was not performed.; Reporter''s Comments: This case concerns a 91-years-old female patient, with medical history of dementia, who experienced a serious unexpected event of death. This event occurred 2 days after first dose of mRNA-1273, lot # unknown. At the time of death, the subject was very fragile and was in hospice care. Concomitant medication included Tylenol. Treatment details were not provided. The doctor considered that the death was due to natural causes. However, autopsy was not performed. Very limited information regarding this event has been provided at this time. Based on the limited information available, it is difficult to assess a cause and effect relationship. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: Natural cause of death related to dementia
VAERS ID: 1004645 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Florida  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021096325

Write-up: Pfizer vaccine caused the death; This is a spontaneous report from a non-contactable consumer. A patient of unspecified age and gender received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection, lot number and expiration date were not reported), via an unspecified route of administration on an unspecified date at a single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. The reporter claimed that Pfizer vaccine caused the death of the doctor (patient). No further details reported. No follow-up attempts are possible. Information about lot and batch number cannot be obtained. No further information is expected.; Reported Cause(s) of Death: Pfizer vaccine caused the death
VAERS ID: 1004811 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-09
Onset: 2021-01-23
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Autopsy, Bone fragmentation, Computerised tomogram abnormal, Computerised tomogram spine, Death, Headache, Injury, Road traffic accident, Spinal compression fracture, Spinal stenosis, Subdural haematoma, Unresponsive to stimuli
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: unknown
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: CT lumbar spine: L4 compression fracture w/ retropulsion of fragments causing moderate narrowing of spinal canal
CDC Split Type:

Write-up: On 1/23/21 the patient had a single-car accident, slid off icy road into snowbank. She was seen in our ER, diagnosed w/ trauma and L4 compression fracture. She was transported to Hospital for further trauma workup. We believe she was treated and released. On 1/31/21 the patient had a headache but did not seek medical attention. In the morning of 2/1 she became unresponsive and was pronounced dead on the scene when EMS arrived. Autopsy showed a left temporal subdural hematoma.
VAERS ID: 1004864 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Wyoming  
Vaccinated: 2021-01-28
Onset: 2021-02-03
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN9581 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Diabetes mellitus, Endotracheal intubation, Fall, Hypertension, Malaise, Pulse absent, Pulseless electrical activity, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), 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), Accidents and injuries (narrow), Hypertension (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Apixiban 5mg BID Aspirin 81mg daily Atorvastatin 40mg daily gabapentin 600mg TID Soliqua (glargine/lixisenatide) 60 units daily Lisinopril 20mg daily Metformin 1000mg BID Multivitamin 1 tab daily Pioglitazone 30mg daily
Current Illness: n/a
Preexisting Conditions: Atrial fibrillation hypertension hyperlipidemia Type 2 diabetes Heavy drinker
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient expired. Per Emergency MD note: "This is a 72-year-old male with what sounds like diabetes, atrial fibrillation, and hypertension who presents via EMS in cardiac arrest. It sounds like he received his Covid vaccine last week. Initially he had some mild effects from it. However over the last day or so he has felt very unwell. He apparently called his wife today and told her that he was not feeling well and so she returned home. Shortly thereafter he attempted to get up from his chair. He then collapsed and fell forward onto his face. Sounds like his wife had some difficulty rolling him over to perform CPR. When EMS arrived they found him in PEA. He received a total of 5 rounds of epinephrine. At some point they did have return of spontaneous circulation. However just prior to arriving in the emergency department they lost pulses again. The patient was intubated with an 8 oh endotracheal tube prior to arrival."
VAERS ID: 1004956 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-06
Onset: 2021-02-03
   Days after vaccination: 28
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Wife reported patient expired on 2/3/2021
VAERS ID: 1005020 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: No adverse event, Continue: [UNK], Comment: No reported adverse events
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Patient took vaccine and died two weeks later; Spontaneous report s were received from consumers via social media posts concerning an 86 year old male patient who received Moderna''s COVID-19 vaccine and died. There was no medical history provided. There were no concomitant medications provided. On approximately 06 Jan 2021, the patient received the first of two planned doses of mRNA-1273 (Batch # unknown), intramuscularly for prophylaxis of COVID-19 infection. All of the social media posts reported the patients death and, according to one post, the patient took two doses of Moderna''s vaccine and died two weeks later. The patient died on or before 23 Jan 2021. No additional information was provided. Very limited information regarding this event has been provided at this time. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reporter''s Comments: This case concerns a 86-year old male patient. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately two weeks after receiving their second of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the onset of the event, a causal relationship cannot be excluded and the event is considered possibly related to the vaccine. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: unknown cause of death
VAERS ID: 1005022 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 2020-12-26
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Anxiety, Death, Pyrexia, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (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: 2020-12-26
   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: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Respiratory distress; Anxiety; Fever; Passed away; A spontaneous report was received from a consumer concerning a female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed fever, respiratory distress, anxiety and passed away. The patient''s medical history was not provided. Concomitant product use was not provided. On an unknown date, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, within 24 hours of receiving the vaccine, the patient developed a fever, respiratory distress and anxiety. Treatment for the events included oxygen, morphine, and lorazepam. On the evening of 26 Dec 2020, the patient passed away. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 26 Dec 2020. The cause of death was not reported. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a female patient who received their first of two planned doses of mRNA-1273 (Lot unknown), and who experienced the serious unlisted events of death (unknown cause) and respiratory distress, the non-serious listed event of fever, and the non-serious unlisted event of anxiety. The events of respiratory distress, fever, and anxiety occurred within 24 hours of vaccination, while the event of death (unknown cause) occurred an unknown amount of time after vaccination. Very limited information has been provided regarding the circumstances leading to death and additional information has been requested. Based on the current available information and temporal association between the use of the product and the onset of events after vaccination, a causal relationship cannot be excluded.; Reported Cause(s) of Death: unknown cause of death
VAERS ID: 1005130 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-06
Onset: 2021-02-03
   Days after vaccination: 28
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / -

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Report of patient expired on 2/3/2021
VAERS ID: 1005164 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-21
Onset: 2021-01-24
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cognitive disorder, Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant 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? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: unresponsive Narrative: 74yo patient with pacemaker, type 2 DM, parkinson''s and history of syncopal epsisodes presented to emergency dept on Jan 24th. He was observed and discharged on Jan 26th back to the home where he continued to have cognitive decline and later passed away on 2/2/2021
VAERS ID: 1005217 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Indiana  
Vaccinated: 2021-01-27
Onset: 2021-01-28
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: albuteron, gabapentin, levothyroxine, loperamide, pantoprazole, potassium, pravastatin, triamterine, ventolin
Current Illness:
Preexisting Conditions: asthma, CHF, Hypokalemia, hypothyroidism
Allergies: Morphine, penicillin, quinidine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Nursing home called 911 for decline in condition. Patient transported to ER where she was admitted to inpatient care and expired 1/30 at 16:13
VAERS ID: 1005276 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-15
Onset: 2021-01-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chemotherapy, Chills, Death, Malaise, Metastases to bone, Metastases to liver, Prostate cancer metastatic, Prostatic specific antigen increased
SMQs:, Malignancy related therapeutic and diagnostic procedures (narrow), Tumour markers (narrow), Prostate malignant tumours (narrow), Prostate tumours of unspecified malignancy (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 2
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: chills 1 day after vaccine administration; found dead by family 1/18/2021 Narrative: Per patient family report, patient said the next day after vaccination that he didn''t feel well because of chills. Patient was found dead at home by his family on January 18th. He was a 74yo man with castrate resistant prostate cancer and liver and bone metastases with rising PSA, status post intravenous chemotherapy 1/7/21
VAERS ID: 1005301 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-26
Onset: 2021-02-01
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Feeding disorder, SARS-CoV-2 test positive, Tissue injury, Weight decreased, Wound
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Vitamin B-12
Current Illness: COVID-19
Preexisting Conditions: Dementia, Dysphagia, HTN, Diabetes Mellitus Type 2, Hypercholesterolemia
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient tested positive for COVID-19 on 1/8/21. She demonstrated a decline in appetite and the ability to feed herself d/t this illness, but no respiratory or other symptoms. She received COVID-19 vaccine #2 on 1/26/21. She demonstrated an SDTI wound to the Lt. heel on 1/27/21. On 1/31/21 she was noted to have a significant weight loss. She was admitted to services on 2/1/21 with comfort care orders. On 2/2/21 she was observed to be without vital signs. Orders were for DNR, and CPR was not initiated in accordance with that order. She was pronounced dead at 0112 on 2/1/21.
VAERS ID: 1005377 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-05
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   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: Significant other reported patient expired "a week before 2nd vaccine was due".
VAERS ID: 1005455 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-29
Onset: 2021-01-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory arrest, Retching, Withdrawal of life support
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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:
Current Illness: Gallbladder not working, one kidney functioning at 25%
Preexisting Conditions: Rheumatoid arthritis
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: We don''t know what happened. 25 hours after the shot, he started gagging and stopped breathing. He was pronounced at OSF at 8:07pm after we took him off life support.
VAERS ID: 1005499 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-02-02
Onset: 2021-02-02
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Blood lactic acid, Dizziness, Dyspnoea, Endotracheal intubation, Hypotension, Presyncope, Syncope, Tachypnoea, Vomiting, White blood cell count normal
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen calcium carbonate/vitamin D3 fluoxetine ibuprofen cholecalciferol
Current Illness:
Preexisting Conditions: depression, hearing difficulties, osteoporosis, hyperlipidemia, PVD, breast cancer in situ, hypertension, aortic aneurysm
Allergies: Adhesive tape-silicone celecoxib hydrocodone-acetaminophen pravastatin
Diagnostic Lab Data: Lactic Acid 5.6 on admission, WBC 9.2 on admission
CDC Split Type:

Write-up: Moderna Vaccine Lot 029K20A Patient received second dose of vaccine on 2/2/21. Within 30 minutes patient had a near syncopal episode. She felt lightheaded and shortly after had episode of nonbloody vomiting. Hypotensive 81/69 and started on levophed. Alert and orientated. Lungs clear, abdomen benign on admission. Patient had no reaction when received first dose of the vaccine. Patient developed worsening shortness of breath, tachypnea, Afib with RVR, hypotension and required intubation and multiple pressors.
VAERS ID: 1005568 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-05
Onset: 2021-01-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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
CDC Split Type:

Write-up: Pt. deceased.
VAERS ID: 1005686 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2021-02-03
Onset: 2021-02-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 2 - / -

Administered by: Senior Living       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: 2021-02-04
   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: 1. Jardiance 10 mg - take 1 tablet PO QAM 2. Xarelto 20 mg - take 1 tablet PO QAM 3. Metoprolol Succinate ER 25 mg - take 1 tablet PO QAM 4. Potassium Cl ER 20 mEq - take 1 tablet PO (M,W,F) 5. Gabapentin 100 mg - take 1 tablet PO QAM, 2 ta
Current Illness: n/a
Preexisting Conditions: CHF, HTN, HLD, pacemaker, DM, and severe osteoarthritis leading to chronic back pain and the use of a scooter for mobility.
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: death. No known symptoms or complaints. found unresponsive in bed. Released to funeral home as the Medical Examiner will not perform and autopsy. Dr. will sign the DC.
VAERS ID: 1006168 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-26
Onset: 2021-01-26
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute kidney injury, Dyspnoea, Fatigue, General physical health deterioration, Haemodialysis, Hypotension, Hypoxia, Lung infiltration, Mechanical ventilation, Pneumonia, SARS-CoV-2 test negative, Vasopressive therapy
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: none
Allergies: penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient, who was a pharmacist, developed fatigue and shortness of breath hours after receiving vaccine. Two days later, on 01/28/2021, the patient went to local urgent care for worsening shortness of breath and was referred to Hospital for worsening dyspnea and hypoxia. The patient was admitted to the hospital We was found to have bilateral pulmonary infiltrates and treated for pneumonia with Rocephin and azithromycin. He was tested for COVID-19 multiple times, but each of the results were negative. Despite the negative results, there was high clinical suspicion for COVID-19 and the patient was started on Remdesivir and Decadron. The patient''s oxygen requirements continued to worsen and the patient was transferred to another facility for higher level of care. There his hypoxia worsened and he required mechanical ventilation. Patient then developed hypotension and required vasopressors for blood pressure support. Furthermore, patient developed acute renal failure requiring hemodialysis. Despite mechanical ventilation with FiO2 100%, and for vasopressors, patient clinically deteriorated and family decided to palliatively extubate on 02/05/2021.
VAERS ID: 1006216 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: South Carolina  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Medications the resident was currently recieving: AmLODIPine Besylate Tablet 5 MG Losartan Potassium Tablet 50 MG Melatonin Tablet 5 MG Povidone-Iodine Solution 10 % Remeron Tablet 15 MG (Mirtazapine) Tamsulosin HCl Capsule 0.4 MG Lactobaci
Current Illness: None
Preexisting Conditions: ESSENTIAL (PRIMARY) HYPERTENSION ATRIOVENTRICULAR BLOCK, COMPLETE NONRHEUMATIC AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY PAROXYSMAL ATRIAL FIBRILLATION HYPOXEMIA BRADYCARDIA, UNSPECIFIED PRESENCE OF UROGENITAL IMPLANTS
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Notes of the checks/events with resident: 18:36 2/2/21 Resident had no complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 97.2 02:50 2/3/2021 Resident received 2nd COVID vaccine. No complaint of pain, swelling, redness or warmth to vaccine site. No signs and symptoms of fever, chills, tiredness or headache. T 98.1 07:15 2/3/2021 Resident was observed not breathing. 911 was contacted along with the doctor. Resident was confirmed having passed away.
VAERS ID: 1006220 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-24
Onset: 2021-01-31
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Blood creatine phosphokinase, Blood culture, Blood fibrinogen, Blood lactate dehydrogenase, Blood lactic acid, Blood test, C-reactive protein, COVID-19 pneumonia, Chest X-ray, Cough, Differential white blood cell count, Fibrin D dimer, Full blood count, Liver function test increased, Metabolic function test, Mobility decreased, N-terminal prohormone brain natriuretic peptide, Procalcitonin, Productive cough, Prohormone brain natriuretic peptide, Respiratory failure, Respiratory viral panel, Serum ferritin, Troponin, Urine analysis, Wheezing
SMQs:, Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Angioedema (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), Parkinson-like events (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Hime Meds: Tylenol Arthritis tablets, Lipitor, Baclofen, Celexa, Cardizem CD, Claritin-D, Myrbetriq, Remeron and Rhythmol
Current Illness: PMH: Former smoker, paroxysmal atrial fibrillation, sleep apnea, hypertension and osteoarthritis. Admitted to the hospital on 2/3/21 with complaints of non-productive cough for 2-3 days prior to admission and generalized weakness. His O2 sats upon admission was 83% and he was wheezing upon exam. He walks with a walker at baseline and does not use oxygen at home.
Preexisting Conditions: PMH: Former smoker, paroxysmal atrial fibrillation, sleep apnea, hypertension and osteoarthritis
Allergies: NKA
Diagnostic Lab Data: Chest Xray, Blood cxx2, Resp panel, CMP, Ferritin, CRP, Lactate< procalcitonin, D-dimer, Creatinine kinase, Troponin, proBNP, LDH, Fibrinogen, CBC w diff, Urinalysis
CDC Split Type:

Write-up: Pt from home via EMS. Pt reports increased weakness since getting the covid vaccine on the 24th. Pt is normally ambulatory at baseline, but has not been able to get around his house. Pt was found to be 83% on RA and was audibly wheezing per EMS. No history of respiratory issues. Denies fever, but has had a productive cough. A&O x4. Pt received Duoneb treatment in route. Acute respiratory failure with hypoxia , Pneumonia due to COVID-19 virus , Elevated LFTs. Patient admitted to hospital on 2/3 and is still inpatient
VAERS ID: 1006228 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: North Dakota  
Vaccinated: 2021-02-01
Onset: 2021-02-02
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 057G20A / 2 UN / IM

Administered by: Public       Purchased by: ?
Symptoms: Atelectasis, Blood culture, Blood pressure decreased, Chest X-ray abnormal, Death, Dyspnoea, Haematology test, Laboratory test, Lethargy, Oxygen saturation decreased, Pyrexia, Rales, Rhonchi, Urine analysis
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: desmopressin 0.01% nasal spray 1 spray NS BID, dezlansoprazole 60 mg PO Daily, Escitalopram 10mg PO Daily, folic acid 1mg PO daily, furosemide 20mg PO daily, lorazepam 1mg PO TID PRN MDD 3mg in 12H, losartan potassium 100mg PO daily, macula
Current Illness: none known.
Preexisting Conditions: atrial fibrillation, hypertension, high cholesterol, PUD, kidney stones, osteoarthritis, osteoporosis, seizure, anxiety, depression, hypothyroidism, melanoma
Allergies: cephalosporins, codine, diazepam, morphine, penicillins, phenobarbital, sulfailamide, clindamycin
Diagnostic Lab Data: hemetology, chemistry, blood culture, UA, CXR.
CDC Split Type:

Write-up: 2/2/21-1000-patient presented to the local emergency room with complains of fever, shortness of breath and decreased oxygen sats. temp 101.7, pulse 102, respirations 36, BP 141/92, oxygen 94%. Lung sounds crackles bilaterally with rhonchi on the left. patient worked up for sepsis, CXR shows mild atelectasis. blood pressure dropped, and continued to drop through treatment requiring levophed drop to be initiated. Patient POA determined that this would not be her sister''s wishes and made the decision to make patient comfort care status. 2/3/21- patient lethargic throughout night. 0640-patient demise.
VAERS ID: 1006289 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-28
Onset: 2021-02-01
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: none
Preexisting Conditions: HTN: Renal failure with hemodialyis; hypercholesterolemia; reflux; behavioral disorders
Allergies: none
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: death- 2/1/2021
VAERS ID: 1006303 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-28
Onset: 2021-02-01
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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 nursing home record
Current Illness: none
Preexisting Conditions: CVA; HTN; vascular dementia; BPH; neurogenic bladder; COVID positive on 9/12/2020.
Allergies: none
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: death- 2/1/2021
VAERS ID: 1006316 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-28
Onset: 2021-02-02
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: see nursing home record
Current Illness: none
Preexisting Conditions: Trach; tube feeder; ileostomy; HTN; CAD; HLD; hypothyroidism; renal cell carcinoma; prostate cancer; Previously COVID positive but unkown date- it was before entering nursing home.
Allergies: none
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: death- 2/2/2021
VAERS ID: 1006416 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-13
Onset: 2021-01-31
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private       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: 2021-01-31
   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: diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died of a heart attack on 1/31/21, 2.5 weeks after vaccination
VAERS ID: 1006577 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-04
Onset: 2021-01-31
   Days after vaccination: 27
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 073K20A / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Patient passed away within 60 days of receiving a COVID vaccine
VAERS ID: 1006633 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-01-20
Onset: 2021-01-24
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Back pain, Cardiac failure, Cardio-respiratory arrest, Chest pain, Death, Dyspnoea, Pneumonia, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), 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), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: EARLY SUNDAY MORNING THE PATIENT BEGAN VOMITTING AND SHORT OF BREATH AND CHEST AND BACK PAIN. SHE CODED WHEN SHE GOT IN THE ER AND LATER PASSED AWAY THE MONDAY. DIAGNOSIS WAS PNEUMONIA AND HEART FAILURE PER STEP DAUGHTER.
VAERS ID: 1006640 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: New Mexico  
Vaccinated: 2021-02-03
Onset: 2021-02-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 PFIZER / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acidosis, Anaemia, Analgesic drug level decreased, Anxiety, Bacterial test negative, Basophil percentage increased, Bilirubin urine, Blood bicarbonate decreased, Blood gases, Blood magnesium decreased, Blood pH decreased, Blood smear test, Blood urine absent, Bradycardia, Brain oedema, Cardiac arrest, Cardio-respiratory arrest, Chromaturia, Computerised tomogram head abnormal, Crystal urine absent, Culture urine, Death, Drug screen negative, Endotracheal intubation, Eosinophil percentage increased, Fibrin D dimer increased, Gastrointestinal haemorrhage, Glucose urine absent, Haematocrit decreased, Haemoglobin decreased, Head discomfort, Human chorionic gonadotropin negative, Hypoxia, International normalised ratio increased, Lymphocyte percentage decreased, Mean cell haemoglobin decreased, Mean cell volume decreased, Mechanical ventilation, Monocyte percentage decreased, Musculoskeletal stiffness, Neutrophil count normal, Nitrite urine absent, PCO2 normal, PO2 normal, Platelet count decreased, Poisoning, Protein urine absent, Prothrombin time prolonged, Pulse absent, Pulseless electrical activity, Red blood cell count decreased, Red blood cell nucleated morphology, Red blood cells urine positive, Red cell distribution width normal, Resuscitation, SARS-CoV-2 test negative, SARS-CoV-2 test positive, Seizure like phenomena, Specific gravity urine increased, Specific gravity urine normal, Sulphur dioxide test, Syncope, Troponin I increased, Urinary sediment present, Urine abnormality, Urine ketone body absent, Urine leukocyte esterase, Urobilinogen urine decreased, White blood cell count normal, White blood cells urine positive, pH urine normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Liver related investigations, signs and symptoms (broad), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (broad), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Dystonia (broad), Parkinson-like events (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (broad), Ischaemic colitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Arthritis (broad), Tumour lysis syndrome (broad), Proteinuria (broad), Tubulointerstitial diseases (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Naltrexone 25mg PO daily, chlordiazepoxide 25mg was 2/4 at 1:25pm for CIWA 9
Current Illness: Alcohol use disorder, facial laceration, alcohol intoxication, secondary syphillis
Preexisting Conditions: Alcohol use disorder
Allergies: NKDA
Diagnostic Lab Data: UR COLOR Yellow [3873] 02/05/21 01:16 UR CLARITY HAZY [3873] 02/05/21 01:16 UR SPECIFIC GRAVITY 1.010 1.001 - 1.035 [3873] 02/05/21 01:16 URINE PH 7.0 UNITS 5.0 - 9.0 [3873] 02/05/21 01:16 UR PROTEIN 100 mg/dL "Neg " [3873] 02/05/21 01:16 UR GLUCOSE 150 mg/dl "Neg " [3873] 02/05/21 01:16 UR KETONES NEG mg/dL "Neg " [3873] 02/05/21 01:16 UR BILIRUBIN NEG mg/dL "Neg " [3873] 02/05/21 01:16 UR BLOOD MOD mg/dl "Neg " [3873] 02/05/21 01:16 UR NITRITE NEG mg/dL "Neg " [3873] 02/05/21 01:16 UR UROBILINGEN NEG L mg/dL "<2.0" [3873] 02/05/21 01:16 UR L.ESTERASE NEG "NEG" [3873] 02/05/21 01:16 RBC/HPF 262 /HPF [3873] 02/05/21 01:16 WBC/HPF 5 /HPF [3873] 02/05/21 01:16 UR EPITHELIAL CELLS [none] /HPF [3873] 02/05/21 01:16 UR-BACTERIA [none] /HPF [3873] 02/05/21 01:16 WBC CLUMPS [none] /HPF [3873] 02/05/21 01:16 UR-TRIPLE PHOS CRYSTALS [none] [3873] 02/05/21 01:16 UR-CA+OXALATE CRYSTALS [none] [3873] 02/05/21 01:16 UR-URIC ACID CRYSTALS [none] [3873] 02/05/21 01:16 UR-AMORPHOUS SEDIMENT RARE [3873] 02/05/21 01:16 UR-BUDDING YEAST [none] [3873] 02/05/21 01:16 URINE HCG Neg [3873] 02/05/21 01:16 Internal QC Hcg PASS [3873] 02/05/21 01:16 Comment: rare MUCOUS Urine sent for culture. Res Site Test name Result Flg Units Ref. range Code Result Dt/Time Cannabinoids UR NEG "NEG" - [3873] 02/05/21 01:32 "Positive at 50 ng/mL" Methadone, UR NEG "NEG" - [3873] 02/05/21 01:32 "Positive at 200 ng/mL" Cocaine Screen, UR NEG "NEG" - [3873] 02/05/21 01:32 "Positive at 150 ng/mL" Buprenorphine Screen, UR NEG "NEG" - [3873] 02/05/21 01:32 "Positive at 10 ng/mL" Internal QC Ur Tox Screen PASS [3873] 02/05/21 01:32 Amphetamines, UR NEG "NEG" - [3873] 02/05/21 01:32 "Positive at 500 ng/dL" Barbiturates, UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 200 ng/mL" Benzodiazepines, UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 150 ng/mL" Methamphetamine, UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 500 ng/mL" Opiates, UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 100 ng/mL" Oxycodone, UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 100 ng/mL" Phencyclidine Screen, UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 25 ng/mL" Tricyclic Antidepressants,UR NEG "Neg" - [3873] 02/05/21 01:32 "Positive at 300 ng/mL" Propoxyphene, UR NEG "NEG" - [3873] 02/05/21 01:32 "Positive at Res Site Test name Result Flg Units Ref. range Code Result Dt/Time _SARS-CoV-2 NEGATIVE [3873] 02/04/21 23:49 Eval: Positive - The 2019 novel coronavirus (SARS-CoV-2) target nucleic acids are detected. Eval: Eval: Presumptive Positive - The 2019 novel coronavirus (SARS-CoV-2) target nucleic Eval: acids may be present. Sample is retested. For samples Eval: with repeated presumptive positive result, additional Eval: confirmatory testing may be conducted to differentiate Eval: between SARS-CoV-2 and SARS-CoV-1 or other Sarbecovirus Eval: currently unknown to infect humans, for epidemiological Eval: purposes or clinical management. Eval: Eval: Negative - The 2019 novel coronavirus (SARS-CoV-2) target nucleic acids are not detected. Internal QC SARSCOV2 Valid [3873] 02/04/21 23:49 Test name Result Flg Units Ref. range Code Result Dt/Time SO2 88.8 L % 90.0 - 100.0 [3873] 02/04/21 21:58 PH, BLOOD 7.16 L* 7.35 - 7.45 [3873] 02/04/21 21:58 PCO2 34.7 mmHg 30 - 40 [3873] 02/04/21 21:58 PO2 68 mmHg 58 - 70 [3873] 02/04/21 21:58 HCO3 12.6 L mmol/L 18.0 - 24.0 [3873] 02/04/21 21:58 Base Excess -16.8 L mmol/L <3.0 [3873] 02/04/21 21:58 TCO2 34.7 H mmol/L 19.0 - 25.0 [3873] 02/04/21 21:58 SAT 88.8 L % 90 - 99 [3873] 02/04/21 21:58 Oxy Hgb 87.0 % [3873] 02/04/21 21:58 Patient Temperature 92.0 Deg Far [3873] 02/04/21 21:58 COHB% 0.6 % 0.0 - 10.0 [3873] 02/04/21 21:58 METHB 1.5 H % <0.5 [3873] 02/04/21 21:58 Comment: AC RR 28 VT 400 FIO2 100 PEEP +5 Test name Result Flg Units Ref. range Code Result Dt/Time MAGNESIUM-09 0.9 L mg/dL 1.6 - 2.6 [3873] 02/04/21 22:20 Test name Result Flg Units Ref. range Code Result Dt/Time SALICYLATE-09 <1 mg/dL [3873] 02/04/21 22:20 ACETAMINOPHEN-09 <5 L mcg/mL 5 - 200 [3873] 02/04/21 22:20 Res Site Test name Result Flg Units Ref. range Code Result Dt/Time TROPONIN I-09 2.6 H* ng/mL 0.0 - 0.3 [3873] 02/04/21 22:19 Res Site Test name Result Flg Units Ref. range Code Result Dt/Time D-DIMER (TOP) $g5250 H ng/mL 0 - 230 [3873] 02/05/21 00:10 Eval: The HemosIL D Dimer assay is cleared by the FDA for 100% negative predictive value Eval: for results <230 ng/mL DDU, when used in conjunction with clinical pre-test Eval: assessment for the purpose of ruling out Deep Vein Trombosis (DVT) and/or Eval: Pulmonary Embolism (PE). Res Site Test name Result Flg Units Ref. range Code Result Dt/Time _PT (TOP) 29.4 H sec 9.8 - 12.8 [3873] 02/04/21 22:20 _INR (TOP) 2.58 H 0.85 - 1.11 [3873] 02/04/21 22:20 name Result Flg Units Ref. range Code Result Dt/Time WBC-XE 5.70 10*3/uL 4.74 - 10.94 [3873] 02/05/21 00:30 RBC-XE 1.83 L M/uL 4.32 - 5.85 [3873] 02/05/21 00:30 HGB-XE 5.1 L* g/dL 12.6 - 17.3 [3873] 02/05/21 00:30 HCT-XE 18.6 L* % 38.2 - 52.4 [3873] 02/05/21 00:30 MCV-XE 101.6 H fL 81.7 - 96.6 [3873] 02/05/21 00:30 MCH-XE 27.9 pg 26.7 - 32.2 [3873] 02/05/21 00:30 MCHC-XE 27.4 L g/dL 31.4 - 34.7 [3873] 02/05/21 00:30 PLT-XE 37 L 10*3/uL 125 - 400 [3873] 02/05/21 00:30 MPV-XE 10.6 fL 8.7 - 11.8 [3873] 02/05/21 00:30 NEUT% 74.2 % 47.2 - 74.4 [3873] 02/05/21 00:30 LYMPH% 20.0 % 17.9 - 42.6 [3873] 02/05/21 00:30 MONO% 1.2 L % 3.0 - 9.0 [3873] 02/05/21 00:30 EO% 0.7 % 0.0 - 4.6 [3873] 02/05/21 00:30 BASO% 0.2 % 0.0 - 1.1 [3873] 02/05/21 00:30 NRBC 0.5 /100WBC 0.0 - 1.0 [3873] 02/05/21 00:30 IM GRAN% 3.7 H % 0.0 - 1.0 [3873] 02/05/21 00:30 RDW-XE 14.9 % 12.2 - 15.1 [3873] 02/05/21 00:30 NEUT# 4.24 10*3/uL 1.56 - 6.13 [3873] 02/05/21 00:30 LYMPH# 1.14 L 10*3/uL 1.18 - 3.74 [3873] 02/05/21 00:30 MONO# 0.07 L 10*3/uL 0.24 - 0.86 [3873] 02/05/21 00:30 EO# 0.04 10*3/uL 0.04 - 0.36 [3873] 02/05/21 00:30 BASO# 0.01 10*3/uL 0.01 - 0.08 [3873] 02/05/21 00:30 IG# 0.21 10*3/uL [3873] 02/05/21 00:30 NRBC# 0.03 H 10*3/uL 0.00 - 0.01 [3873] 02/05/21 00:30 SEGS 72 % 55 - 75 [3873] 02/05/21 00:30 BANDS 9 H % 0 - 3 [3873] 02/05/21 00:30 LYMPHS 14 L % 20 - 35 [3873] 02/05/21 00:30 MONOS 1 L % 2 - 8 [3873] 02/05/21 00:30 EOS 1.0 % 1.0 - 4.0 [3873] 02/05/21 00:30 META 3.0 H % <0.0 [3873] 02/05/21 00:30 Reactive Lymphs 3 #/100 WBC [3873] 02/05/21 00:30 NUCLEATED RBC/100WBC 1 #/100 WBC [3873] 02/05/21 00:30 MICROCYTOSIS 1+ [3873] 02/05/21 00:30 HYPOCHROMIA 1+ [3873] 02/05/21 00:30 PLT SMEAR EST Reduced [3873] 02/05/21 00:30 RBC COLOR/SIZE ABNORMAL [3873] 02/05/21 00:30 Comment: Notified/Readback Rec''d: PHARM/ED/2.4.21@2159/DD Verified by Repeat Analysis. NO Platelet Clumps Present NO Cells Resembling Immunoblasts Are Present PLATELET ESTIMATE= 36,000 Res Site Test name Result Flg Units Ref. range Code Result Dt/Time _CALCULATED OSMOLALITY 306 H mOsm/kg 275 - 295 [3873] 02/04/21 22:19 Eval: Neonatal: may be as low as 266 Eval: $g60 yrs old: 280 - 301 ALCOHOL-09 <10 L mg/dL "<10" [3873] 02/04/21 22:19 LIPASE-09 26 U/L 13 - 60 [3873] 02/04/21 22:19 T BILI-19 0.3 mg/dL 0.1 - 1.2 [3873] 02/04/21 22:19 Eval: Per manufactures instructions, intereferance substance of IgG $g28 gm/L Eval: may affect Total Bilirubin results. Clincal judgement is recommended. No Eval: significant interference was shown in the bilirubin concentration Eval: ranges $g5.9 mg/dL, medical risk for the newborn population is most Eval: unlikely. GLUCOSE-RANDOM-09 101.0 mg/dL 74.0 - 106.0 [3873] 02/04/21 22:19 Eval: NEONATES: 40 - 60 mg/dL Eval: CHILDREN: 60 - 100 mg/dL BUN-09 3.0 L mg/dl 6.0 - 20.0 [3873] 02/04/21 22:19 Eval: 18 - 60 year old = 6-20 mg/dL Eval: 60 - 90 year old = 8-23 mg/dL CREATININE <0.5 L mg/dL 0.5 - 1.5 [3873] 02/04/21 22:19 SODIUM-09 148.0 H mEQ/L 136.0 - 145.0 [3873] 02/04/21 22:19 POTASSIUM-09 1.5 L* mEQ/L 3.5 - 5.1 [3873] 02/04/21 22:19 Eval: PLASMA reference range: 3.4 - 4.5 mmol/L CHLORIDE-09 134.3 H mEQ/L 98.0 - 107.0 [3873] 02/04/21 22:19 CO2-09 5.0 L* mEQ/L 22.0 - 29.0 [3873] 02/04/21 22:19 ANION GAP-09 9.00 0.00 - 14.00 [3873] 02/04/21 22:19 CALCIUM-09 2.8 L* mg/dL 8.6 - 10.2 [3873] 02/04/21 22:19 T PROTEIN-09 1.5 L gm/dL 6.6 - 8.7 [3873] 02/04/21 22:19 ALBUMIN-09 0.7 L gm/dL 3.5 - 5.2 [3873] 02/04/21 22:19 ALK PHOS-09 43.0 IU/L 37.0 - 108.0 [3873] 02/04/21 22:19 Eval: CHILDREN: Eval: <1 day old: <260 U/L Eval: 6 days-6 months: <467 U/L Eval: 1-3 yrs: <292 U/L Eval: 1-12 years: <312 U/L Eval: 13-17 yrs(f): <195 U/L Eval: 13-17 yrs(m): <406 U/L AST-09 463.0 H IU/L 10.0 - 32.0 [3873] 02/04/21 22:19 ALT-09 89.0 H IU/L 10.0 - 33.0 [3873] 02/04/21 22:19 ESTIMATED GFR N/A mL/min [3873] 02/04/21 22:19 Res Site Test name Result Flg Units Ref. range Code Result Dt/Time LACTATE-09 70.7 H* mg/dL 4.5 - 19.8 [3873] 02/04/21 22:02 Res Site Test name Result Flg Units Ref. range Code Result Dt/Time _ABO Group A [3873] 02/04/21 22:39 _Rh Positive [3873] 02/04/21 22:39 Antibody Screen Negative [3873] 02/04/21 22:39
CDC Split Type:

Write-up: In discussion with Dr., medical director at Detox, she arrived night of 2/3/21 was quite intoxicated so was not going through any withdrawal. She was getting vitals and CIW checked regularly. First dose of chlordiazepoxide 25mg was 2/4 at 1:25pm for CIWA 9. She had repeat vitals at 5:50pm, CIWA 1, vitals: P 67, 118/79, 94% on RA, T 98.3. she had complained of some "pressure in her head" and feeling anxious, but otherwise denied other complaints. she was talking with others in the group, then other patients report she suddenly started having seizure like activity around 6:45pm, med techs came to help and found her stiff, gurgling. they tried to get vitals on her, called 911, noticed that at 6:54pm she had lost a pulse and they started CPR. paramedics arrived at 7:08pm and she was brought to ED. Pt BIBA in cardiac arrest. Pt was at Detox Center when she was reported to have seizure-like activity followed by collapse. She was found to be pulseless and CPR initiated by staff members. EMS arrived and performed approx 15 min of CPR and gave pt epi x 3 and bicarb. No shocks administered but they did not report a rhythm. In the emergency room the patient arrived and was found to be pulseless with PEA arrest, CPR was initiated, patient was intubated. ROSC ultimately achieved, patient remained very acidotic despite ventilator adjustment, head CT revealed cerebral edema. Pt also found to be profoundly anemic with a hemoglobin of 5 and platelets of 37, she was thought to be GI bleeding so medications for this were initiated. Patient then became more hypoxemic with bradycardia, consultation with neurosurgery and critical care medicine at tertiary care center deemed ongoing CPR futile. Patient arrested at 2:30AM on 2/5, pronounced dead at 2:48AM.
VAERS ID: 1006662 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Endotracheal intubation, Haemoptysis, Muscle spasms
SMQs:, Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Dystonia (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had 2nd vaccine, went home and started having "cramping" in all of her muscles. It became bad enough that she was taken to local ED where she then started coughing up blood, required intubation and about 6 hrs later, died.
VAERS ID: 1006994 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: West Virginia  
Vaccinated: 2021-01-22
Onset: 2021-01-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Computerised tomogram, Condition aggravated, Death, Thrombotic thrombocytopenic purpura
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Embolic and thrombotic events, arterial (narrow), Renovascular disorders (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: atorvastatin Excedrin Extra Strength gabapentin lansoprazole Lantus Solostar U-100 Insulin lisinopril Ozempic phenazopyridine Prelief Vitamin B-12 vitamin D3-vitamin K2 (MK4) zolpidem
Current Illness:
Preexisting Conditions: Diabetes Hyperlipidemia
Allergies: penicillin and sulfa
Diagnostic Lab Data: CT scans plus transport to an out of state hospital. No records from that hospital to report.
CDC Split Type:

Write-up: Patient had one occurrence of thrombotic thrombocytopenic purpura in 1996 for which she had plasma exchange therapy in 1996. No other occurrence since 1996 until she received her first dose of the Pfizer covid vaccine.
VAERS ID: 1007033 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-22
Onset: 2021-02-01
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Condition aggravated, Death, Decompressive craniectomy, Fatigue, Glomerular filtration rate, Headache, Platelet count normal, SARS-CoV-2 test negative, Subdural haematoma, Surgery, White blood cell count increased
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), Accidents and injuries (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: ? acetaminophen (TYLENOL) 500 mg tablet, Take 500 mg by mouth once daily as needed for mild pain (level 1-3)., Disp: , Rfl: ? amLODIPine (NORVASC) 10 mg tablet, Take 10 mg by mouth every evening. , Disp: , Rfl: ? ascorbic acid (VITAMI
Current Illness: History of headaches
Preexisting Conditions: Memory impairment, headaches, hypertension, prostate cancer, prior stroke
Allergies: None
Diagnostic Lab Data: 2/1/2021: WBC 11.1, PLT 229, GFR $g60, COVID Rapid PCR test was negative.
CDC Split Type:

Write-up: Patient presented to emergency room on 2/1/2021 with a chief complaint of having a chronic headache and fatigue following receipt of the Moderna vaccine 10 days prior. Following examination by the physician, the patient was diagnosed with an acute subdural hematoma. The patient subsequently underwent decompressive surgery, however demonstrated worsening neurologic status over the next several days and ultimately expired on 2/4/2021.
VAERS ID: 1007310 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dry skin, Dyspnoea, Failure to thrive, Hypopnoea, Lethargy, Mouth breathing, Pain, SARS-CoV-2 test negative, Skin warm, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Neonatal disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Morphine, lorazepam
Current Illness: ALTERED MENTAL STATUS, UNSPECIFIED CARDIAC ARREST, CAUSE UNSPECIFIED UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE ESSENTIAL (PRIMARY) HYPERTENSION HYPERLIPIDEMIA, UNSPECIFIED ANEMIA, UNSPECIFIED PERIPHERAL VASCULAR DISEASE, UNSPECIFIED COVID-19 Resolved 1-1-21 AGE-RELATED COGNITIVE DECLINE CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY UTI
Preexisting Conditions: ALTERED MENTAL STATUS, UNSPECIFIED CARDIAC ARREST, CAUSE UNSPECIFIED UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE ESSENTIAL (PRIMARY) HYPERTENSION HYPERLIPIDEMIA, UNSPECIFIED ANEMIA, UNSPECIFIED PERIPHERAL VASCULAR DISEASE, UNSPECIFIED COVID-19 AGE-RELATED COGNITIVE DECLINE CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY UTI
Allergies: none
Diagnostic Lab Data: Rapid Covid test on 2/3/2021 for discharge- negative
CDC Split Type:

Write-up: view 2/5/2021 09:23 e Progress Note Note Text: Patient passed away in the facility this morning. view 2/5/2021 08:39 Orders - Administration Note Note Text: Resident passed. view 2/5/2021 08:33 Nurses Note Note Text: Body released to funeral home at this time. Personal effects sent with resident include: 1 pair of glasses, 1 yellow wedding band, 1silver spoon ring, 1 ring with black and clear stones. Resident has own teeth view 2/5/2021 08:32 Nurses Note Note Text: cause of death per CRNP failure to thrive. view 2/5/2021 07:44 Orders - Administration Note Note Text: Take and document temp & PO2 every 4 hours for MONITORING Resident passed. view 2/5/2021 06:49 Nurses Note Note Text: Son returned call and was updated of resident''s passing this am view 2/5/2021 06:33 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/air hunger PRN Administration was: Unknown Resident expired @ 0604 [linked] view 2/5/2021 06:06 Nurses Note Note Text: Res found without pulse or respirations. Pronounced at 0604. Updated. N/o''s for RN to pronounce, release body to funeral home, dispose of medications per facility policy. Daughter updated. Funeral Home called to release body. view 2/5/2021 05:26 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/air hunger Pulse ox 60% on O2 @ 5L/min via mask. Resps 44 per minute. view 2/5/2021 01:57 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/air hunger PRN Administration was: Effective Follow-up Pain Scale was: 2 [linked] view 2/5/2021 00:52 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/air hunger Residents resps are 40 per minute, pulse ox 76% on O2 @ 5L/min via mask. Resps are labored, shallow and rapid. view 2/5/2021 00:48 Nurses Note Note Text: Nonresponsive to verbal and tactile stimulation. Appears comfortable. view 2/4/2021 22:01 Nurses Note Note Text: Resident resting comfortably, breathing becoming increasingly shallow, wearing O2 via mask at 5L via mask, no dyspnea noted, feet are mottled, oral and peri care provided Q2H. No s/s of pain or discomfort. view 2/4/2021 21:40 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/air hunger PRN Administration was: Effective [linked] view 2/4/2021 19:32 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/air hunger medicated for air hunger, RR 28 to 32/ min view 2/4/2021 19:22 Nurses Note Note Text: Daughter updated on N/O to increase Morphine Sulfate 20mg/mL 0.25mL to Q2H prn from Q6H prn. view 2/4/2021 18:06 Nurses Note Note Text: POA Daughter and daughter aware of residents current condition. view 2/4/2021 11:58 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 6 hours as needed for pain/SOB PRN Administration was: Effective Follow-up Pain Scale was: 2 [linked] view 2/4/2021 11:13 Nurses Note Note Text: Pt. noted to be lethargic at this time. Does respond to verbal and tactile stimuli by opening her eyes but non verbal currently. Skin warm and dry. No mottling or apnea observed at this time. O2 sat 88% with O2 at 2 LPM via n/c. On increased to 3 LPM via mask as pt. noted to be mouth breathing. Respirations 28. F/U O2 sat 93%. HOB elevated. Pt. medicated with morphine by LPN. Daughter updated on pt.''s condition. Does not want pt. sent out to hospital and would like comfort measures to continue. Daughter also in agreement with delay in d/c d/t pt.''s condition.CRNP updated on pt.''s condition, delay in d/c and daughter''s wishes. No n/o''s at this time. view 2/4/2021 10:56 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 6 hours as needed for pain/SOB Resident showing s/s of discomfort. SOB at this time and high respirations. Repositioned, changed for incontinence care and mouth care provided. view 2/4/2021 10:34 Progress Note Note Text: Spoke with RN regarding change in condition. Updated Sr Living regarding change. Recommendation to cancel d/c/transfer for today, see how resident does through the weekend and re-evaluate on Monday. Daughter updated on cancellation of d/c today. view 2/4/2021 10:04 Nurses Note Note Text: Daughter aware that resident''s O2 sat was 88% on room air on 3-11 shift and that oxygen was applied via nasal cannula. view 2/4/2021 10:03 Nurses Note Note Text: N/O: Discharge 2/4/21 with scripts to Sr. Living. Daughter aware. view 2/4/2021 09:53 Nurses Note Note Text: Pt. to be d/c''d to another facility this am as per MD order. Pt. alert and responsive. Skin assessment done as per facility policy. No pressure areas noted at this time. No s/sx of pain or discomfort observed at this time. V.S. 97.0 67 20 O2 sat 95% with O2 at 2 LPM via n/c. view 2/4/2021 07:45 Nurses Note Note Text: Resident seen by Dr. for discharge. Orders pending at this time. view 2/4/2021 07:36 Nurses Note Note Text: CRNP and Dr. updated on O2 sat 88% on RA with f/u of 93% with O2 on at 2 LPM as well as rest of VS, 3-11 shift 2/3/21. No n/o''s at this time. view 2/3/2021 21:17 Nurses Note Note Text: Resident Sp02 88% on RA. Pulse 124. Respirations 40. PRN morphine given and O2 applied via NC at 2L/min. After recheck pulse ox up to 93%, pulse 100, and respirations 22. Resident appears comfortable at this time. view 2/3/2021 20:05 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 6 hours as needed for pain/SOB PRN Administration was: Effective [linked] view 2/3/2021 19:48 Orders - Administration Note Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 6 hours as needed for pain/SOB PRN given for SOB after elevation of HOB not effective. view 2/3/2021 11:51 Nurses Note Note Text: CRNP updated rapid COVID test done for d/c tomorrow was negative. No n/o''s at this time. view 2/3/2021 11:44 Nurses Note Note Text: Daughter notified of rapid covid swab being negative. view 2/3/2021 09:50 Orders - Administration Note Note Text: Obtain Rapid Covid test on 2/3/2021 for discharge. Please give copy of results to Social Worker every day shift for covid testing for 1 Day Completed and negative. view 2/3/2021 08:45 Skilled Nursing Note Reason for skilled service: Therapy describe skilled service: Nursing, therapy assessment: V.S. 97.8 79 18 138/84 Orientation: Oriented to self only. Oxygen: O2 sat 94% on RA Edema: Trace edema noted BLE. Pedal pulses present. Pain: Denies pain or discomfort at this time. Nursing note: Pt. alert and responsive. Skin warm and dry. Lung sounds diminished. No respiratory distress observed at this time. Abdomen soft. BS+ in all 4 quads. Continent/Incontinent of B&B. 1 assist with ambulation, transfers. 1 assist with ADL''s. Working with therapy on gait training, therapeutic exercise, therapeutic activities & neuromuscular reeducation. view 2/2/2021 14:37 Progress Note Note Text: Per health professional at Sr Living, prepared to accept patient to their Memory Care Unit 2/4. Transportation arranged for 11 AM per family request. Daughter (POA) updated on d/c time on 2/4/21. Facility requesting rapid COVID test completed prior to d/c and results sent to them. All other information sent for continuity of care.
VAERS ID: 1007371 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-19
Onset: 2021-01-29
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Asthenia, Cough, Death, Decreased appetite, Diarrhoea, Dry mouth, Dyspnoea exertional, Gait disturbance, Influenza, Productive cough, SARS-CoV-2 test, Sputum discoloured, Weight decreased
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Parkinson-like events (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No current outpatient medications on file.
Current Illness: None known
Preexisting Conditions: Transplant patient.
Allergies: Not on File
Diagnostic Lab Data: COVID test at PCP 2/3/21
CDC Split Type:

Write-up: Called PCP, from the note: I got my shot on Jan 19. But last Friday I have been down with a horrible flu. I''m wearing diapers because of uncontrollable diarrhea. I can''t leave my sofa to walk over to my desk because I''ll be so out of breath. I have a cough that produces a pink or gold Phelm I have dry mouth. I have no appetite I''m so weak and have lost 15 pounds. Don''t know what to do. My next Covid is shot is feb 11 Called employer on 2/3/21 but hung up. Tried calling multiple times to follow up. In triage she stated she had a COVID test scheduled and had spoken with her PCP. COVID test through PCP: 2/4/21 She passed away the night of 2/4/21
VAERS ID: 1011771 (history)  
Form: Version 1.0  
Age: 84.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-02-03
Onset: 2021-02-03
   Days after vaccination: 0
Submitted: 2021-02-04
   Days after onset: 1
Entered: 2021-02-05
   Days after submission: 1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / UNK LA / -

Administered by: Other       Purchased by: Other
Symptoms: Cerebrovascular accident, Death, Dyspnoea, Hypertensive cerebrovascular disease, Loss of consciousness, Type 2 diabetes mellitus, Unresponsive to stimuli, Vascular dementia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Optic nerve disorders (broad), Cardiomyopathy (broad), Retinal disorders (broad), Central nervous system vascular disorders, not specified as haemorrhagic or ischaemic (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Narrative: Patient with history advanced vascular dementia, hypertensive cerebrovascular disease and stroke, T2DM. Received her second dose of Pfizer COVID-19 vaccine at approximately 14:00 and was reported to have expired at home at 20:55. Dr. (Medical Director) spoke with patient''s son/caregiver 2/4/21. Son reports that patient was in her usual health yesterday morning, deemed well enough by son to travel for vaccination. He reports she had no bothersome symptoms after either first or second vaccinations. Specifically denied rash, wheeze, and difficulty breathing. Son was with patient throughout the day. In the evening, when preparing for bed, he noted she became suddenly unresponsive in a similar fashion as she has done several times in past years. While in all previous such episodes she recovered within minutes, last evening she did not regain consciousness, experiences a brief period of labored breathing, and died. Patient''s son called 911 and the patient''s body was brought to the medical examiners. The medical examiner declined to proceed with autopsy. Patient''s son is not interested in autopsy. Patient''s son reports confidence that his mother''s underlying hypertensive/diabetic cardiovascular disease is the natural cause of her death. Other Relevant Hx: Symptoms: & Death Treatment:
VAERS ID: 1011983 (history)  
Form: Version 1.0  
Age: 77.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-22
Onset: 2021-01-26
   Days after vaccination: 35
Submitted: 2021-01-27
   Days after onset: 1
Entered: 2021-02-05
   Days after submission: 9
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 2 LA / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 3 RA / -

Administered by: Other       Purchased by: Other
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Atrial fibrillation, Bacterial test positive, Bilirubin conjugated, Blood albumin, Blood bilirubin, Blood creatinine increased, Blood culture negative, Blood urea nitrogen/creatinine ratio, Bronchoscopy abnormal, Chest X-ray abnormal, Chest tube insertion, Condition aggravated, Culture urine negative, Cystatin C increased, Death, Dyspnoea, General physical health deterioration, Hepatic enzyme increased, Hypoxia, Intensive care, Ischaemic hepatitis, Klebsiella infection, Lung infiltration, Pneumonia, Protein total, Respiratory failure, SARS-CoV-2 test negative, Serratia infection, Spinal cord injury, Stenotrophomonas infection, Tachycardia, Tracheal aspirate culture
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Hepatitis, non-infectious (narrow), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (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), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Other Medication acetaminophen, albuterol/ipratropium, amlodipine, ascorbic acid, atorvastatin, baclofen, buspirone, calcium carbonate with vitamin D, cholecalciferol, dexmedetomidine, diltiazem, docusate, esomeprazole, famotidine, fentanyl
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Collection DT Spec CoV19BF COVIDIg 01/21/2021 14:10 NASAL Not Detected 01/12/2021 04:00 SERUM 0.03 01/11/2021 12:35 NASAL Not Detected Collection DT Spec WBC BUN Creat Cystn-C 01/25/2021 04:00 BLOOD 15.28 H 01/25/2021 04:00 PLASM 64 H 1.3 2.46 H 01/24/2021 04:00 PLASM 56 H 1.1 01/24/2021 04:00 BLOOD 13.16 H 01/23/2021 04:40 BLOOD 14.02 H 01/23/2021 04:00 PLASM 52 H 0.9 01/23/2021 04:00 BLOOD 7.93 01/22/2021 04:00 BLOOD 10:58 H 01/22/2021 04:00 PLASM 49 H 0.9 01/21/2021 04:00 PLASM 47 H 1.0 01/21/2021 04:00 BLOOD 7.39 01/20/2021 04:00 PLASM 30 H 0.8 01/20/2021 04:00 BLOOD 9.10 01/19/2021 04:00 PLASM 17 0.7 L Collection DT Spec Protein Albumi TotBili DirBili AST AlkPhos 01/25/2021 04:00 PLASM 5.6 L 3.2 L 1.1 1096 H 504 H 51 01/24/2021 04:00 PLASM 6.0 L 3.2 L 0.8 1482 H 699 H 57 01/23/2021 04:00 PLASM 5.5 L 2.9 L 0.6 1778 H 1044 H 53 01/22/2021 04:00 PLASM 5.7 L 2.6 L 0.4 2135 H 1579 H 49 01/21/2021 17:00 PLEUR 1.3 01/14/2021 04:00 PLASM 6.8 3.2 L 0.4 15 21 57 01/13/2021 04:00 PLASM 6.3 L 3.0 L 0.3 14 18 53 01/12/2021 04:00 PLASM 5.8 L 2.7 L 0.3 11 17 55
CDC Split Type:

Write-up: Narrative: See "Other Relevant History" in Section 6 above Other Relevant Hx: 76yo man with a history of for C5 tetraplegia 2/2 cervical stenosis leading to neurogenic bowel/bladder (chronic suprapubic catheter) and chronic respiratory failure with tracheostomy, severe dysphagia s/p G tube placement and multiple aspiration pneumonias, COPD GOLD III, hx MRSA bacteremia (7/2018) and E coli bacteremia (12/2019). Patient transferred from Spinal Cord Injury until to ICU on 1/11/2021 due to worsneing dyspnea, hypoxia (80s) and tachycardia and was found to have acute hypoxic respiratory failure likely 2/2 multifocal pneumonia. CXR findings of "There is interval increase in patchy airspace infiltrates and consolidation in bilateral lungs concerning for pneumonia" Patient was started on vancomycin and pip/tazo on 1/11 and tracheal aspirate cultures were obtained for VAP diagnosis which ultimately grew Serratia liquifaciens and Proteus mirabilis. Infectious Diseases was consulted who recommended a switch to ertapenem therapy for a total 10 day course for VAP. UCx/BCx remained negative. On 1/20, a therapeutic bronchoscopy was completed with cultures growing Stenotrophomonas maltophilia and pan-S Klebsiella pneumoniae. The following day a chest tube was inserted and the course of ertapenem completed but vancomycin was continued. By 1/22, patient developed shock liver with ALT/AST 2135/1579 from normal range the day prior and SCr increased to 1.3 from baseline 0.7/cystatin C of 2.46 up from 1.15. Levofloxacin was added for Stenotrophomonas coverage. By 1/25, patient''s clinical status continued to decline and Cardiology was consulted for new onset Afib with RVR. Discussion was documented with patient''s family who requested DNR. Patient passed away in the early AM on 1/26. Demise does not appear to be related to COVID-19 vaccination but occurred in recent timeframe. Symptoms: ElevatedLiverEnzymes & death, pneumonia, afib
VAERS ID: 1008041 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-01-12
Onset: 2021-01-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Disorientation, Fall, Pruritus, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, bisacodyl supplement, levsin (hyscyamine)
Current Illness: gout
Preexisting Conditions: congestive heart failure diagnosis, alzheimers
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: itchy skin, swelling, disorientation that led to a fall
VAERS ID: 1008758 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Connecticut  
Vaccinated: 2021-01-16
Onset: 2021-01-18
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Diarrhoea, Full blood count, Metabolic function test, Nausea, Pallor, Urine analysis
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Lasix 10mg Aqupril Coumadin
Current Illness:
Preexisting Conditions: Thrombocytopenia, A-fib, CHF, Spinal stenosis, Renal stent
Allergies: Codine
Diagnostic Lab Data: CBC CMP uranalysis
CDC Split Type:

Write-up: Patient began feeling nauseated on 1/18/21 around 6pm, and had uncontrolled diarrhea, reported that she did not feel right. Staff reported to this writer, that her skin tone was gray in tone and she just didn''t look good. She was transferred to the HOSPITAL ER VIA AMBULANCE.
VAERS ID: 1015838 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated: 2021-02-02
Onset: 2021-02-02
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Aspiration, Cardiac arrest, Chills, Cough, Dyspnoea, Endotracheal intubation, Influenza virus test negative, Loss of consciousness, Pulseless electrical activity, Pyrexia, Resuscitation, SARS-CoV-2 test negative, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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 (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was admitted to hospital from home in cardiac arrest. Hx of hypertension, hyperlipidemia, type 2 diabetes (not on insulin) and bilateral carotid artery stenosis. The patient was reportedly at his baseline health on 2/2/21. He received the 2nd dose of COVID vaccine around 1000AM on 2/2/21. Reportedly started running fever of 100.1 and chills the afternoon of 2/2/21. Around 7:00PM he started having dry cough and was complaining of breathing difficulties. He subsequently vomited multiple times (was eating pizza and aspirated) then lost consciousness. His wife called 911, did CPR and EMS reported he in PEA at scene and was intubated. Transported to hospital. SARS CoV-2 and influenza negative.
VAERS ID: 1009266 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-24
Onset: 2021-02-07
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Adult failure to thrive, Decreased appetite, Eating disorder, Failure to thrive, Refusal of treatment by patient
SMQs:, Neonatal disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: atorvastatin 40 mg tablet furosemide 20 mg tablet lamotrigine 200 mg tablet lisinopril 2.5 mg tablet meclizine 12.5 mg tablet metoprolol tartrate 50 mg tablet miconazole nitrate 2 % topical cream nystatin 100,000 unit/gram topical powder Re
Current Illness: Kidney Stones
Preexisting Conditions: CVA, AFib, SSS, Epilepsy, Vascular Dementia
Allergies: Garlic; IV contrast, Iodine containing; mirabegron
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient with failure to thrive symptoms prior to 2nd dose, not eating, not taking medications.
VAERS ID: 1009813 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-01
Onset: 2021-01-25
   Days after vaccination: 24
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Immobile
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient became immobile on 1/25/21 (4 days after receiving Moderna COVID-19 vaccine). He died on 1/27/21
VAERS ID: 1009866 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-29
Onset: 2021-01-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (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: 2021-01-30
   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: unknown
Current Illness: unknown new pt
Preexisting Conditions: unknown
Allergies: penicillins
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: pt was given vaccine on the afternoon of 01-29-2021. Pt was administered the moderna covid-19 shot into the deltoid muscle of this pt. Pt was observed and left pharmacy. on 2-6, pts daughter calls pharmacy, and says the night of 1-29, after recieveing the vaccine, her mother had a hemmorhagic stroke and passed away
VAERS ID: 1009991 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-02-07
Onset: 2021-02-07
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Circulatory collapse, Death, Endotracheal intubation, Mechanical ventilation, Pharyngeal swelling, Pulse absent, Respiration abnormal, Resuscitation, Syncope, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (narrow), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Believed to have chronic atrial fibrillation, believed not to be on anticoagulants
Allergies: No severe allergies reported on questionaire
Diagnostic Lab Data:
CDC Split Type:

Write-up: 73-year-old man s/p first dose of Pfizer at 10:20 AM Ambulated comfortably to exit after 20 minutes in observation but 10:45 collapsed while exiting the building 10:47 CPR initiated 10:49 medical team/EMS found no pulse, agonal respirations, ventricular fibrillation Paramedics and team performed ACLS; of note patient was intubated 7.5 ETT with bilateral breath sounds on ventilation; paramedic reported easy intubation with no apparent throat swelling; 11:02 transported to Emergency Department 11:30 Pronounced dead at Emergency Department
VAERS ID: 1010025 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Guam  
Vaccinated: 2020-12-30
Onset: 2021-01-09
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-10
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Nifediac, Losartan, Atorvastatin, Allopurinol, Glipizide, Pantoprazole, Amoxicillin
Current Illness: NIDDM, CHF, HTN, HLD
Preexisting Conditions: NIDDM, CHF, HTN, HLD
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient Expired
VAERS ID: 1010114 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Guam  
Vaccinated: 2021-01-28
Onset: 2021-02-03
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, SARS-CoV-2 test
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: anemia, NIDDM, ESRD on Hemodialysis, AFib, CAD S/P CABG, COPD , HTN, recently diagnosed with COVID in September, 2020.
Preexisting Conditions:
Allergies: unknown
Diagnostic Lab Data: Presumptive negative for COVID
CDC Split Type:

Write-up: Patient passed away (Dead on Arrival on presentation to ER) on 02/03/2021
VAERS ID: 1020134 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anxiety, Asthenia, Atrial fibrillation, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood culture, Blood lactic acid increased, Blood potassium normal, Blood sodium normal, Blood urea increased, Carbon dioxide normal, Cardiac arrest, Cardiac failure congestive, Cardio-respiratory arrest, Chest pain, Death, Dizziness, Dyspnoea, Fall, Frequent bowel movements, Gaze palsy, Haematocrit decreased, Haemoglobin decreased, Loss of consciousness, Lung disorder, Malaise, Mechanical ventilation, Muscle rigidity, Orthopnoea, Orthostatic hypotension, Platelet count normal, Polyuria, Posturing, Productive cough, Pulmonary oedema, Pulse absent, Respiratory arrest, Restlessness, Resuscitation, Seizure, Sputum discoloured, Tachypnoea, Troponin I increased, Unresponsive to stimuli, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (broad), Lactic acidosis (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (narrow), Akathisia (broad), Dystonia (broad), Parkinson-like events (narrow), Acute central respiratory depression (narrow), Psychosis and psychotic disorders (narrow), 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), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Vestibular disorders (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Chronic kidney disease (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 9
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: 1/29 CBC: WBC 12.8, Hgb 11.7, Hct 35.3, PLT 227 01/29 CMP: Na++ 142, K+ 4.1, CL 106, CO2 29, BUN 45, Creat 2.04, Ca++ 8.7 1/25 Trop-I 0.06
CDC Split Type:

Write-up: anxious, restless, weak, dizzy, felt "horrible". Continued to C/O symptoms,. At 01:15, patient lost consciousness , then stopped breathing and lost pulse. Narrative: Patient was first vaccinated for COVID 19 on 1/8/21. On 1/24/21: 61 year old presents to E.R. with CC of chest pain/sob, with multiple medical conditions including hypertension, atrial fibrillation on apixaban, cardiomyopathy with poor EF, dyslipidemia, COPD, CVA, lung CA s/p radiotherapy, PTSD, depression, Churg Strauss Syndrome, Sjogren''s syndrome presented with chief complaint of chest pain or shortness of breath. He has been having worsening shortness of breath the past few days, also complains of cough productive of yellowish sputum, no hemoptysis. He complains of left upper chest pain with no radiation. There is no diaphoresis, palpitations or lightheadedness. He denies fever or chills. He complains of having fallen a few times recently, thus he passed out. Could not say if there were seizures activity. Admitted to 3D Tele. On 1/27, Pt advises he had episode of substernal CP this am. RN advises pt was in afib w/ RVR at a rate $g140 at time of CP. Pt CP improved w/ prn NTG. Pt HR improved after daily medications. Pt sts his CP has resolved. Pt admits to continued dyspnea. Increased trop, transferred. 1/28, struggling with orthopnea and cough. He has no peripheral edema. He does have intermittent chest pain. Patient having periods of A-Fib RVR with non-sustained rates of 140''s-150''s 1/29 more chest pain at 04:00, relieved with NTG. HR = AF, with RVR 145. At about 08:00, Cardiology sees patient and signs off, "shortness of breath and cough not due to heart failure as evidenced by orthostatic hypotension and no improvement in symptoms with diuresis. Consider underlying lung disease vs acute pulmonary disease." No pulmonary consult noted. 1/29 Patient received 2nd dose COVID19 vaccine at about 3:30-4p. No notes from staff on this event. No notes from MD that this was discussed and still part of the plan. 1/29 nurse''s note: At around 2240 Pt was able to rest briefly but is now restless and anxious again. Tachypneic, stating he feels so weak and dizzy and overall just feel horrible. Continuing to get up frequently to have small soft bowel movements with assistance. Pt also stated ever since he got "that shot" he hasn''t felt well. When asked what shot pt replied "COVID shot." Pt did receive 2nd dose of COVID vaccine 1/29 at 1530. Around 2250 Spoke w MOD to relay above information and overall concern for pt, asked for MOD to come to bedside to evaluate pt. MOD states he''s handing off to oncoming MOD and they will come to bedside to see pt. Around 2300 oncoming MOD called and all above and previous information discussed Around 2310 MOD came to bedside to see pt. Will continue to monitor closely. 01/30/2021 ADDENDUM Around 0115 pt called for help to use bedside commode to urinate and have BM. Assisted x2 to BSC. While sitting on BSC pt''s eyes rolled back and pt made postures consistent with a seizure, body became very rigid. Pt was unresponsive still with pulse. Lifted patient back to bed with 3 staff assist. Pt stopped breathing and lost pulse. Chest compressions started immediately and Code Blue called at 0120. 1/30 Hospitalist note: Called for CODE BLUE AGAIN AT 4:53. While on Vent after s/p Code blue for reasons not clear patient went into Asystole and code called second time. Patient had a prolonged CPR and was actually called off at 5:17 but he started having pulse and agonal resp. he was placed on Levophed and D5NS. He got a total of 9 amps of epi, 3 amps od Bicarb and 1amp of D50. Trope bumped from 0.12 to 0.43 prior to this he already was on ASA, Apixiban for afib. Cards are on board for his CHF for his pulmonary edema Lasix ordered. Hid lactic acid is elevated. Blood cultures pending. Started Zosyn and is on Levophed. Continue to monitor. Updated patients Mom and she requested to do everything at this point. Coded again at 5:40, survived, but AOD writes a death note(?) Coded for the 4th time at 08:18. Family at beside, Mother asks for code to be stopped.
VAERS ID: 1020135 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-30
Onset: 2021-01-24
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-02-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Contusion, Craniocerebral injury, Death, Fall, Femoral neck fracture, Haemoglobin decreased, Head injury, Intensive care, Joint injury, Lower urinary tract symptoms, Lung opacity, Pneumonia, Respiratory failure, SARS-CoV-2 test, Skin laceration, Transfusion, Upper respiratory tract infection, Walking aid user
SMQs:, Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), 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), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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 Narrative: 92 yo male seen in clinic on 12/30/2020 for transfusion, hbg 6.9. PMH includes HLD, CKD, myelodysplastic syndrome, DM, prostate cancer, HTN. Pt also received COVID19 Pfizer vaccine the same day. The patient denied any prior severereaction to this vaccine or its components. Post-transfusion, patient had a mechanical fall (per patient he was seated and used the cane to help him stand. However the cane slipped on the floor causing the patient to fall, patient hit his head and injured his right hip, no loss of consciousness at the time). Rapid response team was called and patient was admitted to the ED. Pt was found to have subcapital right femoral neck fracture, scalp contusion, and TBI (per ED provider''s note). Ortho evaluated and said patient wasn''t a surgical candidate. During his hospitalization, patient tested positive for COVID19 on 1/12/2021, pt was asymptomatic at the time. On 1/13/2021, pt exhibited mild URI symptoms, no respiratory distress. He was started on cetirizine, Montelukast, albuterol, and inhaled steroids to manage his symptoms. Dexamethasone was started on 1/14/2021. Chest Xray was ordered on 1/17/2021, pt''s respiratory was slowly getting worse, resting O2 sats were in the high 80s and low 90s with IS. On 1/18/2021, CXR shows patchy bilateral airspace opacities suspious for pneumonia of bacterial or viral etiology. Pt was started on remdesivir 01/18/2021 (5 doses, from 1/18-1/22/2021). Pt required 5-6 LPM of oxygen at rest. Pt was then transferred to the ICU. His oxygen demand continued to increase and his condition worsened. On 2/14/2021, pt started to desat into the 70s on max high flow. Patient/family agree to comfort care. Medical cause of death was listed as "acute hypoxic respiratory failure due to COVID19." Patient expired 1/24/2021.
VAERS ID: 1010235 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-02-05
Onset: 2021-02-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebral haemorrhage, Cerebrovascular accident, Computerised tomogram
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), 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? Yes
Birth Defect? Yes
Died? Yes
   Date died: 2021-02-15
   Days after onset: 10
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: A fib Type 2 diabetes
Allergies: None
Diagnostic Lab Data: Ct scan
CDC Split Type:

Write-up: Stroke. Massive brain bleed right side
VAERS ID: 1010899 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021102020

Write-up: On the two people who died, one in (State name) and one in (State name); This is a spontaneous report from a contactable other HCP. This other HCP reported similar events for 2 patients. This is 1 of 2 report. An unknown age male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on an unspecific date at single dose for covid-19 immunization. Medical history and concomitant drug were not reported. It was reported that patient was died. Cause of death unknown. Outcome of the event was fatal. Information on the lot/batch number has been requested.; Sender''s Comments: Death with unknown cause is considered related to BNT162B2 for reporting purpose. Information is very limited. Case will be reassessed once receiving additional information, including cause of death. 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.,Linked Report(s) : US-PFIZER INC-2021102049 same reporter/drug/event, different patient; Reported Cause(s) of Death: On the two people who died, one in (State name) and one in (State name)
VAERS ID: 1010900 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021102049

Write-up: patient died; This is a spontaneous report from a contactable Other Healthcare Professional (HCP). This Other HCP reported similar event for 2 patients. This is 2nd of 2 reports. A male patient of an unspecified age received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for covid-19 immunisation. The patient''s medical history and concomitant medications were not reported. It was reported that patient died on an unspecified date. Cause of death unknown. Outcome of the event was fatal. It was unknown if an autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: The causal relationship between BNT162B2 and the event death cannot be excluded as the information available in this report is limited and does not allow a medically meaningful assessment. This case will be reassessed once additional information becomes available. 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.,Linked Report(s) : US-PFIZER INC-2021102020 same reporter/drug/event, different patient; Reported Cause(s) of Death: patient died
VAERS ID: 1010989 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-04
Onset: 2021-01-04
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Anaphylactic reaction, Death, Dyspnoea, Hypertension, Intracranial aneurysm, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Hypoglycaemia (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Arthritis; Hypertension
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Brain aneurysm; Anaphylactic reaction; Collapsed; BP sky rocketed; Shortness of breath; A spontaneous report was received from a consumer concerning a 69-year-old female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and experienced blood pressure skyrocketed, shortness of breath, loss of consciousness, massive anaphylactic reaction, and brain aneurysm. The patient''s medical history, as provided by the reporter, included high blood pressure and arthritis. Products known to have been used by the patient, within two weeks prior to the event, included an antihypertensive. On 04 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. Twenty-two minutes later she had a massive anaphylactic reaction. She experienced shortness of breath, blood pressure skyrocketed, and loss of consciousness. She was taken to the emergency room. The patient had a brain aneurysm and never recovered. No treatment information was provided. The patient died on 04 Jan 2021. The cause of death was reported as brain aneurysm. Plans for an autopsy were not provided.; Reporter''s Comments: This case concerns a 69-year-old, female patient with a medical history of hypertension, who experienced fatal, serious, unexpected events of Anaphylactic reaction, hypertension, dyspnea, loss of consciousness and brain aneurysm. The events occurred 22 minutes after the first dose of mRNA-1273 was administered. No treatment information was provided. The patient never recovered and died. The cause of death was reported as brain aneurysm. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. Additional information has been requested.; Reported Cause(s) of Death: Brain aneurysm
VAERS ID: 1011130 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-17
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood calcium decreased, Blood chloride normal, Blood creatinine normal, Blood potassium normal, Blood sodium normal, Blood urea normal, Body temperature increased, COVID-19, Carbon dioxide normal, Cough, Death, Differential white blood cell count normal, Fibrin D dimer increased, Full blood count, Haematocrit normal, Haemoglobin normal, Platelet count normal, Red blood cell count normal, SARS-CoV-2 test positive, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), 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: 2021-01-29
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aricept Acetaminophen Citalopram Diltiazem Lisinopril Synthroid Vitamin D 3
Current Illness: NONE
Preexisting Conditions: Aricept Acetaminophen Citalopram Diltiazem Lisinopril Synthroid Vitamin D 3
Allergies: NKA
Diagnostic Lab Data: 1/18: CBC: WBC-4.57, RBC-4.50, H/H-13.4/42.2; BUN/CREA-15/0.62; BUN/CREA RATIO-24.19 Platelet- 227,Calcium-8.8, Sodium-136, K+ 4.0, Chloride-104, CO2-28. PCR-+ Covid-19, D-dimer- 1.09 1/21- D-dimer 1.90
CDC Split Type:

Write-up: Temp of 100.1 and unproductive cough on 1/17; temp of 100.4 1/28; O2 desaturation 88% on RA 1/28; Diagnosed with Covid-19 on 1/18/2021 Patient passed away on 1/29/2021
VAERS ID: 1011149 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-22
Onset: 2021-02-04
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8261 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia, Death
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 325 mg tablet Take 2 tablet by mouth every four hours as needed for pain. aripiprazole 15 mg tablet TAKE 1 TABLET BY MOUTH EVERY EVENING. Aspirin Low Dose 81 mg tablet,delayed release Take 1 tablet by mouth once a day. atorvas
Current Illness: paronychia of right index finger
Preexisting Conditions: Borderline Intellectual Functioning.*Paranoid Schizophrenia.*Depression.*Anxiety.*Diabetes Type II.*Esophageal Reflux.*Hiatal Hernia.*Diverticulosis.*CAD.*COPD.*NSTEMI.*Constipation.*BPH.*Urethral Stricture.*Hearing Deficit.*Sleep Apnea- uses C-PAP.*Hypercholesteremia.*HX Pancytopenia.*CHF.*Right Eye Floaters.*Hyponatremia.*Vit D Deficiency.*Dysphagia-moderate.*Hypertension.*
Allergies: PCN, ACE inhibitors, erythromycin, Tamsulosin, ranexa, sulfasalazine, lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed heart arrhythmia and was unable to be revived.
VAERS ID: 1011222 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-05
Onset: 2021-01-17
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Asthenia, Death, Diet refusal, Fatigue, Feeding disorder, General physical health deterioration, Moaning, Somnolence, Weight decreased
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Medicine to keep blood pressure from dropping and medicine for AFIB (irregular heart)
Current Illness: Dementia. Physical health was good. Hospice was thinking of releasing her because she was doing so well.
Preexisting Conditions: Dementia. I am told that 20 other residents passed in January after the vaccine was administered. A monthly death count very high for the care home.
Allergies: Allergies to grass and environment and a touch of asthma
Diagnostic Lab Data:
CDC Split Type:

Write-up: My mom received the Covid 19 vaccine on Jan 5, 2021 and became very about a week later. I was informed that she tested positive for Covid 19 on January 14th. One January 17th she became very tired and weak and would not eat. Hospice called me and told me that she was in a decline state. I saw her on January 25 and 26 and she was just sleeping and could not open her eyes. Her vitals were good and she seemed to understand when I talked to her - she would squeeze my hand and moan but she could not talk or open her eyes. My mom passed away on January 27, 2021 just 22 days after receiving the Covid 19 vaccine. She was very think to begin with and being to weak and tired to eat resulted in her losing even more weight. Some of the other residents were given fluids to help and they recovered. My mom was not given fluids. I believe there were 20 deaths in her care home for the month of January when they vaccinated. This was an alarming number of deaths for the home. The facility had very few Covid deaths in 2019 and 2020. I asked every week if they had any Covid and or Covid deaths and this amount was shocking to me and the workers there.
VAERS ID: 1011362 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-28
Onset: 2021-01-28
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA MOD/013L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: COPD Diabetes
Allergies:
Diagnostic Lab Data: An autopsy is being performed
CDC Split Type:

Write-up: Patient''s son came to the vaccine clinic today 2/8/2021, stated that his father 2/24/1948 passed away the same day as the vaccine.
VAERS ID: 1011440 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-26
Onset: 2021-01-30
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: unanticipated death
VAERS ID: 1011487 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-02-06
Onset: 2021-02-06
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Life support, Resuscitation, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Tylenol, albuterol, Norvasc, Eliquis, Voltaren, Neurontin, lidocaine, Cozaar, Mevacor, Lopressor, Prilosec, Miralax, Senna, Renvela, Kayexolate, Incruse Ellipta, Vit. B complex, Coumadin
Current Illness:
Preexisting Conditions: ESRD (dialysis fistula), peripheral vascular disease (R mid-foot amputation), cardiac disease (pace-maker), malnutrition (cachexic), possible liver disease (distended abdomen)
Allergies: Protein Supplement
Diagnostic Lab Data: CPR/ ACLS initiated on 2/6/2021
CDC Split Type:

Write-up: Received Covid vaccine in am. Last seen by family at 17:30 pm and observed to be well. About an hour later he collapsed, unresponsive. A 911 call was initiated at 18:29. Paramedics arrived to find the patient in cardiac arrest. CPR/ACLS was initiated, but resuscitation was unsuccessful. Pt. was transported to MC where he was pronounced dead at 19:32. There was no sing of an injection site reaction, nor of allergic reaction..
VAERS ID: 1011492 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-27
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood calcium normal, Blood chloride increased, Blood creatinine normal, Blood potassium normal, Blood sodium normal, Blood urea increased, COVID-19, Death, Dysphagia, Full blood count, Haematocrit normal, Haemoglobin decreased, Lethargy, Metabolic function test, Oxygen saturation decreased, Platelet count normal, Polymerase chain reaction positive, Red blood cell count decreased, SARS-CoV-2 test positive, White blood cell count normal
SMQs:, Acute renal failure (broad), Haematopoietic erythropenia (narrow), Haemorrhage laboratory terms (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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: Escitalopram Miralax Isosorbide Mononitrate Lactulose Melatonin Milk of Magnesium, Protnix, Acetaminophen, Senna-S, Zyprexa, Aspercreme lot
Current Illness: NONE
Preexisting Conditions: CAD, Bradycardia, HTN, Hyperlipidemia, Protein Calorie Malnutrition, GERD, STEMI, Vitamin D deficiency
Allergies: Macrobid
Diagnostic Lab Data: CBC and BMP 12/2/2021-not Covid-19 related: WBC 6.17 RBC 3.80 HGB 11.2 HCT 36.6 Platelet Count 234 BUN/CREA 22/0.64 Creatinine 0.64 Calcium 9.0 Sodium 144 Potassium 3.9 Chloride 111 1/18/2021- PCR positive.
CDC Split Type:

Write-up: 1/18/2021- Tested positive for Covid-19. 1/20 Patient lethargic, unable to swallow. 1/24 Although 90% O2 sat on RA, it has decreased from her baseline ranging at high 90''s. 1/27/2021 Patient passed.
VAERS ID: 1011577 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-02-04
Onset: 2021-02-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Death, Increased bronchial secretion, Productive cough, Rhinorrhoea, Secretion discharge, Swelling face
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: albuterol sulfate nebulization hyoscyamine sulfate atropine sulfate lorazepam concentrate morhpine sulfate metolazone lasix benadryl robitussin levothyroxine fluocinonide cream nystatin cream remeron spironolactone tylenol extra strength tr
Current Illness: Was started on hospice between first dose of vaccine (1/7/21) and second dose (2/4/21), primarily for inability to control fluid balance due to heart failure and kidney failure. Started to have increased edema and respiratory symptoms (nasal drainage, raspy voice but denied sore throat) and tested negative for COVID twice starting 1/5/21 and 1/7/21 (day of first vaccine), and once again after the vaccine, increased confusion at that time and continued between vaccination. Later the nasal drainage was attributed to fluid overload. UTI on 1/11/21. Hospice referral by MD on 1/15/21.
Preexisting Conditions: History of type 2 diabetes, benign prostatic hyperplasia, heart failure, hypertension, constipation, vitamin D deficiency, hypothyroidism, chronic kidney disease stage 3, insomnia, tinea corporis, macular degeneration, polyosteoarthritis, UTIs. Short term memory difficulties. Resided in LTCF for 3 years prior to death.
Allergies: no known allergies
Diagnostic Lab Data: None performed due to hospice status.
CDC Split Type:

Write-up: Resident expired on 2/5/21 at 03:35pm, about 25 hours after second dose of vaccine. At breakfast, resident was spitting a lot of secretions, coughing up liquids from nose and phlegm, facial swelling, which were all symptoms that he was struggling with prior to both doses of COVID vaccine, but had increased more than prior incidences on 2/5/21. Gurgling noted in upper airways, hyscolamine given, bath given to loosen secretions, morphine given. Family notified and came into facility for compassionate care visit around 1300. 1400 HR was 3 and RR was 2, but increased back to 60 and 12 within 20 minutes. Then resident expired at 1535.
VAERS ID: 1011595 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-28
Onset: 2021-02-03
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Azotaemia, Blood creatinine increased, Blood urea increased, Brain natriuretic peptide, Cardiac arrest, Death, Full blood count, Metabolic function test, Renal failure, Ventricular fibrillation, Vital signs measurement
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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 (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Glimepiride Tablet 1 MG,hydrALAZINE HCl Tablet 10 MG,Pantoprazole Sodium Tablet Delayed Release 40 MG,Meclizine HCl Tablet,Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG,Senna Tablet 8.6 MG (Sennosides),Furosemide Tablet 20
Current Illness: ACUTE RESPIRATORY FAILURE WITH HYPOXIA, COPD, CHF, HTN, ANEMIA IN CHRONIC KIDNEY DISEASE, TYPE 2 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY, GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS, HYPERLIPIDEMIA, UNSPECIFIED, DEMENTIA, AFIB, CKD STAGE 4, BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS, UNSPECIFIED ASTHMA, UNCOMPLICATED, HYPERPARATHYROIDISM, UNSPECIFIED
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: BNP, CBC, CMP
CDC Split Type:

Write-up: On 2/5/2021 resident noted to be azotemic. Creatinine up to 3.8 and BUN in 80''s. He was started on NS hydration. On 2/7/2021 he was noted without VS, per MD notes, possible VF arrest, renal failure; death unclear exact cause.
VAERS ID: 1011677 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-11
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood albumin decreased, Blood creatinine increased, Blood thyroid stimulating hormone normal, Blood urea increased, COVID-19, Decreased appetite, Food refusal, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin increased, Lethargy, Platelet count normal, Red blood cell count decreased, Refusal of treatment by patient, SARS-CoV-2 test positive, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic erythropenia (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen Tablet Exelon Patch Lisinopril Tablet Metoprolol Tartrate Tablet Protonix
Current Illness: 01/16/2021 Pt had bried unresponsive episode
Preexisting Conditions: Alzheimer''s disease, Hx of TIA, Vitamin D deficiency, HTN, Syncope and collapse, Hyperlipidemia.
Allergies: NKA
Diagnostic Lab Data: 1/07/2021 CBC/BMP: WBC-10.86 RBC- 3.76 HGB-106 HCT- 34.6 Platelet count-282 BUN/CREA-33/1.49 ALBUMIN-2.5 GFR-32 12/29- TSH -1.930
CDC Split Type:

Write-up: Lethargic, refusing medications and meals. 1/11/2021- Covid+, poor appetite.
VAERS ID: 1011732 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-30
Onset: 2021-02-03
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: patient passed away with in 60 days of receiving COVID vaccine series
VAERS ID: 1011774 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-02-03
Onset: 2021-02-06
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / SC

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Resuscitation, Syncope
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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: ASPRIN CLOPIDOGREL LISINOPRIL NITROQUICK FINASTERIDE AMLODPINIE PRAVASTATIN TAMSULOSIN
Current Illness: CAROTID ARTERY STENOSIS CORONARY ARTERY DISEASE PACEMAKER CABG, 4-VESSEL BPH
Preexisting Conditions: SAME AS ABOVE
Allergies: NONE KNOWN
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Cardiac arrest resulting in death on the third day post vaccine administration, 0224. Reported syncopal event post toileting. Rescue measures attempted but not successful. Time of death 0358, 02/06/2021.
VAERS ID: 1011834 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-27
Onset: 2021-02-06
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: patient passed away within 60 days of receiving COVID vaccine series
VAERS ID: 1011894 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2020-12-29
Onset: 2021-02-04
   Days after vaccination: 37
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: patient passed away within 60 days of receiving COVID vaccine
VAERS ID: 1011905 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-08
Onset: 2021-01-20
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, General physical health deterioration, Lethargy, SARS-CoV-2 test positive
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Refused medications on day of vaccine. Aspirin Tablet 81 MG(Last dose 1/6 8am), Docusate Sodium Tablet 100 MG(Last dose 1/6 8am), FLUoxetine HCl Capsule 20 MG(Last dose 8am), Lisinopril Tablet 10 MG(Last dose 1/6 8am), Melatonin Tablet 3 MG
Current Illness: Recent overall decline with generalized weakness, refusal of meals and medications, weight loss, and frequent falls. 1/5 Overall decline reviewed with APRN and ADPOA updated. 1/6-CBC WNL, BUN/Cr 55/1.93, GFR 24. Admitted to Hospice Services on 1/6. Covid Antigen Test negative on Jan 4th, 5th, 6th, 7th, 8th, & 9th. Covid positive on 1/10.
Preexisting Conditions: Dementia , Expressive aphasia, right-sided neglect and right sided weakness, high fall risk. S/P CEREBRAL INFARCTION DUE TO THROMBOSIS CORONARY ARTERY ANEURYSM ESSENTIAL (PRIMARY) HYPERTENSION PAROXYSMAL ATRIAL FIBRILLATION ABNORMAL RESULTS OF KIDNEY FUNCTION STUDIES CEREBRAL ANEURYSM, NONRUPTURED
Allergies: NKA
Diagnostic Lab Data: Covid positive on 1/10 without respiratory signs or symptoms. Considered recovered on 1/22 from acute illness.
CDC Split Type:

Write-up: Ongoing decline overall. Remained on Hospice with increased lethargy documented on 1/20/21 and progressively worsening thereafter.
VAERS ID: 1011929 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-21
Onset: 2021-01-27
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / UNK AR / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Death, Dyspnoea, Dyspnoea exertional, Fatigue, Lethargy
SMQs:, Anaphylactic reaction (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), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 8
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: hypercholesterolemia
Allergies: none
Diagnostic Lab Data: The coroners office has not confirmed with us a cause of death yet and continues to investigate her death. They have not shared with the family any results from medical or laboratory tests related to their post-mortem analysis.
CDC Split Type:

Write-up: Within a few days, my mother started reporting profound fatigue and shortness of breath while conducting routine household activities. She no longer had to energy for her daily exercise walks and became increasingly lethargic. She died in her sleep while taking an afternoon nap on Thursday, February 4th. I am highly concerned this could be a vaccine related.
VAERS ID: 1011935 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-02-06
Onset: 2021-02-06
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cough, Death, Dyspnoea, Fatigue, Malaise, Oxygen saturation decreased, Resuscitation
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: Unknown
Preexisting Conditions: Unknown
Allergies: No known drug/food allergies
Diagnostic Lab Data: Pulse Ox #1 (home) - 92% (2/8 PM) Pulse Ox #2 (home) - 90% (2/8 PM) Pulse Ox #3 (emergency department) - 60% (2/8 PM) *All results were patient reported
CDC Split Type:

Write-up: Patient received his second dose of Moderna COVID vaccine on 2/6 at 12:40PM. Patient was observed for 15 minutes post-vaccination with no adverse events. On the evening of 2/6 (time unknown) the patient began to develop dry cough and fatigue. He was checked by a physician at that time (who was a family member). Patient continued to feel unwell into Sunday. His lungs were clear when checked Sunday afternoon (time unknown). At approximately 5:30pm on 2/7 the patient began experiencing sudden onset shortness of breath. A pulse ox was conducted at that time and it was 92%, and again shortly thereafter and it was 90% (as reported by family member). 9-1-1 was contacted at this time. CPR was initiated when he arrived at the emergency department, pulse ox was 60% (as reported by family member). The patient passed away shortly thereafter on 2/8/2021.
VAERS ID: 1012021 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-19
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Hypoglycaemia, Respiratory tract congestion, SARS-CoV-2 test positive, Tremor
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Hypoglycaemia (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tenormin Tylenol Extra Strength
Current Illness: None
Preexisting Conditions: CAD, Anemia, CKD Stage 3, Type 2 DM, HTN, Hyperlipidemia
Allergies: Codeine
Diagnostic Lab Data: 1/19/2021 Binax Card now antigen test+ positive for Covid-19, she became symptomatic the day of testing positive.
CDC Split Type:

Write-up: Resident on Hospice. 1/18 Hand Shaky. 1/19- Covid +19. 1/20 Desat 85% on RA, provided 2L O2 supplement= 97% 1/20 congestive cough, 1/28- RR-28;1/29- Hypoglycemia 1/30-NPO. 1/30-resident passed away.
VAERS ID: 1012047 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-02-01
Onset: 2021-02-06
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acidosis, Cardiac arrest, Encephalopathy, Endotracheal intubation, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Amlodipine Besylate; Antacid Suspension; Atorvastatin Calcium; Atropine Sulfate; Clozaril; Cyanocobalamin; metformin HCl; Metoprolol Tartrate; Tylenol
Current Illness: DMII
Preexisting Conditions: Tobacco use, Schizophrenia, DMII, Bipolar, HTN, COVID 19 hx,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sudden death 2/7/21 @ 0309 Started acute encephalopathy & required intubation Soon after intubation went into cardiac arrest Likely severe acidosis.
VAERS ID: 1012604 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-11
Onset: 2021-02-05
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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
VAERS ID: 1012612 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-21
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Death, Dyspnoea
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 33
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol apixiban diclofenac exenatide finasteride furosemide lantus novolog liptor lotrel metoprolol succinate pantoprazole levothyroxine tasulosin tiotropium-olodaterol
Current Illness: COPD exacerbation 2 weeks prior
Preexisting Conditions: Atrial fibrillation on anticoagulation benign prostatic hyperplasia CKD stage 3 Chronic obstructive pulmonary disease - on baseline 2L NC supplemental O2 Gastro-esophageal reflux disease Hyperlipidemia Hypertension Hypothyroidism Obstructive sleep apnea Type 2 diabetes mellitus asbestosis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was hospitalized on 31 Jan for COVID pneumonia after 3 days of increasing baseline supplemental O2 requirements and dyspnea and ultimately died on comfort care on 3 Feb 2021.
VAERS ID: 1012703 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New Hampshire  
Vaccinated: 2021-01-07
Onset: 2021-01-14
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3248 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium normal, Blood sodium normal, Blood urea increased, COVID-19, Carbon dioxide normal, Confusional state, Cough, Differential white blood cell count normal, Ear haemorrhage, Fibrin D dimer increased, Full blood count, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin normal, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume normal, Metabolic function test, Nucleated red cells, Platelet count normal, Rales, Red blood cell count decreased, Red cell distribution width normal, SARS-CoV-2 test positive, Thrombosis, Vomiting, White blood cell count normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic erythropenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Thrombophlebitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG clonazePAM Tablet 0.5 MG Colace Capsule 100 MG DULoxetine HCL Furosemide Tablet 20 MG Norvasc Tablet 10 MG Potassium Chloride ER CapsulE QUEtiapine Fumarate Tablet Galantamine Hydrobromide Tablet
Current Illness: Intermittent delusional periods-followed by Generations Mental Health.1/6 Increased BLE edema, BP trending up. Acute visit with APRN, N.O. started Lasix & KCL. CBC and BMP ordered for 1/8 with elevation in BMP/Creatinine. Lasix and KCL placed on hold. On palliative services presently.
Preexisting Conditions: Alzheimer?s Disease/Depression; HTN; CAD, CKD, AAA w/o Rupture, no surgical intervention per ADPOA, Dyslipidemia, GERD.
Allergies: HEPARIN LATEX BLEACHED SHEETS
Diagnostic Lab Data: 1/14-Covid Antigen test positive 1/14-11:49 am D-DIMER-32.33 WBC 8.71 RBC 4.55 HGB 12.9 HCT 41.4 MCV 91.0 MCH 28.4 MCHC 31.2 RDW-CV 12.6 MPV 10.1 Platelet Count 225 NRBC Automated 0.0 RDW-SD 41.7 Glucose 125 BUN 29 Creatinine 2.34 Calcium 9.4 Sodium 140 Potassium 4.2 Chloride 107 CO2 24 BUN/Creatinine Ratio 12.39 GFR 27
CDC Split Type:

Write-up: 1/14/2021-0545, blood noted left and right ear. 0715, vomited x 1. Covid Antigen positive. Acute MD visit-basilar crackles right and coughing. Increased confusion.
VAERS ID: 1012717 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-02-01
Onset: 2021-02-02
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: unknown
Preexisting Conditions: unknown
Allergies: No per screening form completed
Diagnostic Lab Data: unknow
CDC Split Type:

Write-up: Patient that received his first dose of Pfizer vaccine on 2/1/2021 passed away on 2/2/2021. No further information is available at this time.
VAERS ID: 1012795 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Connecticut  
Vaccinated: 2021-02-05
Onset: 2021-02-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH UNKNOWN / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Hypertension, Coronary Artery Disease, Previous Myocardial Infarction, Atrial Fibrillation, Hyperlipidemia, Arthritis
Allergies: Adhesive Tape, Niacin, Banana, Bandaids, Benzodiazepines, Calcium Channel Blockers, Digoxin, Hydralazine, Levaquin, Minoxidil, Tomatoes, Oranges
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was administered second dose of Pfizer vaccine in Nursing Home on 2/5/2021 around noon and was found unresponsive at 5:03AM the following day 2/6/2021. Patient arrived to Hospital in cardiopulmonary arrest and was pronounced dead.
VAERS ID: 1012894 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-22
Onset: 2021-02-05
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fatigue, Headache, Nausea, Pain
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Acetaminophen Amiodarone 100mg Diclofenac 1% gel Furosemide 40mg tablet Hydralazine 50mg tablet Metoprolol 100mg tablet Potassium Chloride 10meqER tablet Warfarin 2.5mg tablet
Current Illness: Anxiety A. Fib Cardiac Pacemaker Cerebral Infaction CHF Urinary Incontinence
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 1-2 days after vaccine, pt developed weakness, fatigue, body aches, nausea, headache and poor appetite. Pt was admitted to the hospital on 2/5/21 and death occured on 2/6/21
VAERS ID: 1012926 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: New Hampshire  
Vaccinated: 2020-12-31
Onset: 2021-01-31
   Days after vaccination: 31
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest X-ray, Decreased appetite, Fatigue, Hypotension, Pneumonia, Rales
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED ATRIAL FIBRILLATION, ESSENTIAL (PRIMARY) HYPERTENSION ATRIOVENTRICULAR BLOCK, COMPLETE, NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED, PERSONAL HISTORY OF PULMONARY EMBOLISM,
Allergies: NKA
Diagnostic Lab Data: Chest x-ray in the ED
CDC Split Type:

Write-up: Early in the shift on January 31 resident was noticed to be more tired than usual and was not eating well. Lung sounds were crackly and resident was found to be hypotensive. He was evaluated in emergency department. He was diagnosed with pneumonia. Received a loading dose of antibiotic and returned to facility.
VAERS ID: 1013006 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: herbal medicines such as ginger, garlic, beetroot and a herbal reboot, No perceptions or over the counter drugs
Current Illness: no illness
Preexisting Conditions: High cholesterol
Allergies: No allergies
Diagnostic Lab Data: Awaiting coroner report and lab results
CDC Split Type:

Write-up: Patient complained of soreness in muscles morning after receiving the shot. She went about her day had a smoothie, spoke to people and also went for a walk came home and went into her jacuzzi tub and consequently passed away while in the tub. She was found by her husband at around 545pm, time of death is unknown and cause of death is currently pending.
VAERS ID: 1013041 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-15
Onset: 2021-01-31
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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-Patient doesn''t not regularly use our pharmacy
Current Illness: None
Preexisting Conditions: Heart failure
Allergies: Penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccine was administered on 1/15/2021 and death occurred on 1/31/2021.
VAERS ID: 1013051 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-24
Onset: 2021-02-06
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Facial paralysis, Hemiparesis, Ischaemic stroke
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hearing impairment (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 7
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81mg, Citalopram 10mg, Furosemide 40mg, Insulin glargine, Losartan 50mg, Metoprolol 25mg, Vitamin B-12 1000mcg
Current Illness:
Preexisting Conditions: Dementia, Congestive Heart Failure, Diabetes, Osteoarthritis
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 2/6/21 at 6:00PM, resident experienced sudden left facial droop, left arm and left leg weakness. She was sent to hospital and they confirmed she had an acute ischemic stroke.
VAERS ID: 1013087 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-23
Onset: 2021-01-30
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: Unknown-Patient does not regularly use our pharmacy
Current Illness: None
Preexisting Conditions: Heart problems
Allergies: Penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient received vaccine on 1/23/2021 and death occurred on 1/30/2021.
VAERS ID: 1013095 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Hawaii  
Vaccinated: 2021-02-03
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: See list below. Flomax 0.4 mg 1 Cap P.O. QD Tylenol 500mg 2 tabs PO PRN Carbidopa/levodopa 25-100mg PO 3 tab PO TID CoQ10 1 cap PO QD B12 1 tab PO QD Omega-3 Fatty Acids-Vitamin E 1,000mg 1 Cap PO QD Timolol 0.25% 1 gtt OU BID Finasterid
Current Illness: Unknown.
Preexisting Conditions: See list below. Glaucoma, Hyperlipidemia, Inguinal Hernia, Hx-Gi bleed, Mandibular salivary gland removal- 2012, Hx-TIA, Hypertension, Lumbar disc disease, Parkinsonism, Pancreatitis history
Allergies: No known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was technically a resident of retirement community, however, he chose to live independently at home at his current home. Only his spouse actually resides at retirement community. Patient received the second dose of the Moderna vaccine via pharmacy vaccination clinic at retirement community on 2/3/2021. He was found deceased in his home by a certified nursing assistant on 2/4/2021 at approximately 10:00am.
VAERS ID: 1013145 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-02-05
Onset: 2021-02-08
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Fatigue, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient texted a friend on 2/7/2021 c/o arm pain and feeling tired. I don''t know if he was taken to a hospital. Autopsy today.
VAERS ID: 1013297 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated: 2021-02-02
Onset: 2021-02-02
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anal incontinence, Chest pain, Death, Fatigue, Malaise, Urinary incontinence
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Noninfectious diarrhoea (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: Lovaza, Ibersantan, Flomax, Amaryl, Prednisolone, B-12 sublingual, Horse Chestnut Extract, Iron, Crestor, Xarelto, Triplix, Klonopin, Elavil, Folic Acid, Lantus, Tri Sleep, Elavil
Current Illness: NONE
Preexisting Conditions: DIABETES TYPE 2 POLIMIALGYA HIGH BLOOD PRESSURE HIGH CHOLESTEROL STENT PACE-MAKER
Allergies: NONE
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Patient was vaccinated at 11:30am. By 7pm he started presenting symptoms of fatigue, chest pain. Patient urinated and defecated in himself. Was not feeling well. Patient died at 10:30pm.
VAERS ID: 1014559 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-02-04
Onset: 2021-02-04
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cerebral haemorrhage, Death
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhagic central nervous system vascular conditions (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Atenolol Plavix HCTZ MYAMBUTOL Omeprazole RAnexa Sertraline Simvastatin Rifampin ASA Nitroglycerin Latanoprost Imodium Fish oil MVI Combigan Vitamin D Butalbital
Current Illness:
Preexisting Conditions: CAD Migraine Hyperlipidemia
Allergies: Codeine Hydrocodone Hydroxyzine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Unsure if related to vaccine, but wanted to report event of death due to brain bleed on evening of administration of the vaccination.
VAERS ID: 1014628 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-02-03
Onset: 2021-02-03
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20R / 1 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: a long list
Current Illness: none
Preexisting Conditions: melanoma, skin cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death within 8 hours.
VAERS ID: 1014659 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-14
Onset: 2021-01-18
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pneumonia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 8
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:
Current Illness:
Preexisting Conditions: hypothyroidism
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Four days after being vaccinated, she developed pneumonia and died 8 days later.
VAERS ID: 1014740 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-04
Onset: 2021-02-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Agonal rhythm, Cardiac arrest, Death, Fall, Heart rate irregular, Loss of consciousness, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopri, Sertraline, pravastatin, alendronate, Cetirizine, Vitamin D3,
Current Illness: no acute illnesses
Preexisting Conditions: HTN, Cavernous hemangioma of liver, RBBB, hx of bilateral carotid bruits, hx of squamous cell carcinoma of right hand, arthralgia of both knees, spondylolisthesis at L3-L4, DDD thoracic, ovarian cyst, hx of pneumonia, cholelithiasis w/o obstruction, liver lesion, depression, hyperlipidemia, hypercalcemia, vitamin d deficiency, osteoporosis, former smoker, depression
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient found down at home with agonal respirations and per EMS asystole, received 2 rounds of epi at her house with return of spontaneous pulses, lost pulse again in route to ER and another round of epi was given, CPR in progress when arrived at hospital. Prior to this patient''s husband states he heard her fall in the bathroom but did not immediately check on her as he states that this has happened before. He checked on her 10 min later and that''s when he found her unconscious. Daughter called 911 and she began CPR. No previous complaints of headache, chest pain, back pain, fever or chills. Husband states patient was drinking that evening which is not unusual for her. Patient died at hospital.
VAERS ID: 1014774 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Washington  
Vaccinated: 2021-01-13
Onset: 2021-01-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

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: Unknown
Current Illness: Unknown
Preexisting Conditions: None Reported
Allergies: None Reported
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: We were informed the patient passed away 2 days after receiving the vaccine. We do not have any details about what happened, we were informed by one of his employees. We have no knowledge that this had anything to do with the vaccination in any way.
VAERS ID: 1014865 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-23
Onset: 2021-02-02
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Malaise, Pneumonia, Renal failure, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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 (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: n/a
Current Illness: Tested positive for Covid in November
Preexisting Conditions: Muscular dystrophy
Allergies: n/a
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: He had not been feeling well after his second Covid vaccination (on 01/23/2021) and was found unresponsive in his room at the nursing home (late evening on 02/02/2021). He was taken to a hospital where they did tests and he had pneumonia and kidney failure, but he was being transferred to a larger hospital when he arrested and died (02/03/2021)
VAERS ID: 1015465 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-21
Onset: 2021-02-07
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA ELO140 / 1 UN / SYR
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EL1283 / 2 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Heart rate abnormal, Pulse absent, Respiratory arrest, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: acetaminophen [OTC] tablet; 500 mg; amt: 500 MG; oral Special Instructions: 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED As Needed PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6, PRN 7, PRN 8, PRN 9, PRN 10 03/14/2020- Open Ended Prescription Artifi
Current Illness: U07.1 2019-nCoV acute respiratory disease (Primary) N39.0 Urinary tract infection, site not specified (Admission) K21.9 Gastro-esophageal reflux disease without esophagitis G89.4 Chronic pain syndrome E66.01 Morbid (severe) obesity due to excess calories M54.2 Cervicalgia F41.9 Anxiety disorder, unspecified (History of) G47.00 Insomnia, unspecified E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E03.9 Hypothyroidism, unspecified F06.30 Mood disorder due to known physiological condition, unspecified I50.22 Chronic systolic (congestive) heart failure I10 Essential (primary) hypertension M81.0 Age-related osteoporosis without current pathological fracture Z95.0 Presence of cardiac pacemaker F39 Unspecified mood [affective] disorder C85.84 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb C82.94 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb F31.62 Bipolar disorder, current episode mixed, moderate K59.09 Other constipation Z45.2 Encounter for adjustment and management of vascular access device D64.9 Anemia, unspecified Z79.01 Long term (current) use of anticoagulants Z51.81 Encounter for therapeutic drug level monitoring M17.9 Osteoarthritis of knee, unspecified M15.0 Primary generalized (osteo)arthritis I87.2 Venous insufficiency (chronic) (peripheral) F31.9 Bipolar disorder, unspecified C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites I73.9 Peripheral vascular disease, unspecified F32.9 Major depressive disorder, single episode, unspecified I89.0 Lymphedema, not elsewhere classified Q24.5 Malformation of coronary vessels I42.8 Other cardiomyopathies E03.9 Hypothyroidism, unspecified J30.9 Allergic rhinitis, unspecified Z86.718 Personal history of other venous thrombosis and embolism R33.9 Retention of urine, unspecified K42.9 Umbilical hernia without obstruction or gangrene Z90.89 Acquired absence of other organs R20.8 Other disturbances of skin sensation L03.111 Cellulitis of right axilla I87.2 Venous insufficiency (chronic) (peripheral) Z87.81 Personal history of (healed) traumatic fracture H04.121 Dry eye syndrome of right lacrimal gland R42 Dizziness and giddiness R53.81 Other malaise F48.2 Pseudobulbar affect R06.02 Shortness of breath H26.9 Unspecified cataract C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site H53.2 Diplopia E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene G89.4 Chronic pain syndrome E78.5 Hyperlipidemia, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G60.8 Other hereditary and idiopathic neuropathies K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding I48.91 Unspecified atrial fibrillation J02.9 Acute pharyngitis, unspecified (Preliminary) F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features Z46.89 Encounter for fitting and adjustment of other specified devices R09.81 Nasal congestion Z46.89 Encounter for fitting and adjustment of other specified devices M25.562 Pain in left knee L53.9 Erythematous condition, unspecified R29.3 Abnormal posture F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified T81.30XA Disruption of wound, unspecified, initial encounter R05 Cough (Preliminary) F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features S28.222A Partial traumatic amputation of left breast, initial encounter Z48.3 Aftercare following surgery for neoplasm F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features R41.841 Cognitive communication deficit N63.0 Unspecified lump in unspecified breast H25.012 Cortical age-related cataract, left eye (Preliminary) H25.011 Cortical age-related cataract, right eye (History of) H25.091 Other age-related incipient cataract, right eye Z23 Encounter for immunization Z74.1 Need for assistance with personal care M62.81 Muscle weakness (generalized) K59.00 Constipation, unspecified I49.9 Cardiac arrhythmia, unspecified E55.9 Vitamin D deficiency, unspecified (History of) L23.9 Allergic contact dermatitis, unspecified cause (History of) F33.8 Other recurrent depressive disorders (History of) Z11.1 Encounter for screening for respiratory tuberculosis D51.9 Vitamin B12 deficiency anemia, unspecified (History of) R13.11 Dysphagia, oral phase N18.31 Chronic kidney disease, stage 3a G44.021 Chronic cluster headache, intractable (Preliminary) C50.912 Malignant neoplasm of unspecified site of left female breast
Preexisting Conditions: U07.1 2019-nCoV acute respiratory disease (Primary) N39.0 Urinary tract infection, site not specified (Admission) K21.9 Gastro-esophageal reflux disease without esophagitis G89.4 Chronic pain syndrome E66.01 Morbid (severe) obesity due to excess calories M54.2 Cervicalgia F41.9 Anxiety disorder, unspecified (History of) G47.00 Insomnia, unspecified E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E03.9 Hypothyroidism, unspecified F06.30 Mood disorder due to known physiological condition, unspecified I50.22 Chronic systolic (congestive) heart failure I10 Essential (primary) hypertension M81.0 Age-related osteoporosis without current pathological fracture Z95.0 Presence of cardiac pacemaker F39 Unspecified mood [affective] disorder C85.84 Other specified types of non-Hodgkin lymphoma, lymph nodes of axilla and upper limb C82.94 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb F31.62 Bipolar disorder, current episode mixed, moderate K59.09 Other constipation Z45.2 Encounter for adjustment and management of vascular access device D64.9 Anemia, unspecified Z79.01 Long term (current) use of anticoagulants Z51.81 Encounter for therapeutic drug level monitoring M17.9 Osteoarthritis of knee, unspecified M15.0 Primary generalized (osteo)arthritis I87.2 Venous insufficiency (chronic) (peripheral) F31.9 Bipolar disorder, unspecified C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites I73.9 Peripheral vascular disease, unspecified F32.9 Major depressive disorder, single episode, unspecified I89.0 Lymphedema, not elsewhere classified Q24.5 Malformation of coronary vessels I42.8 Other cardiomyopathies E03.9 Hypothyroidism, unspecified J30.9 Allergic rhinitis, unspecified Z86.718 Personal history of other venous thrombosis and embolism R33.9 Retention of urine, unspecified K42.9 Umbilical hernia without obstruction or gangrene Z90.89 Acquired absence of other organs R20.8 Other disturbances of skin sensation L03.111 Cellulitis of right axilla I87.2 Venous insufficiency (chronic) (peripheral) Z87.81 Personal history of (healed) traumatic fracture H04.121 Dry eye syndrome of right lacrimal gland R42 Dizziness and giddiness R53.81 Other malaise F48.2 Pseudobulbar affect R06.02 Shortness of breath H26.9 Unspecified cataract C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site H53.2 Diplopia E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene G89.4 Chronic pain syndrome E78.5 Hyperlipidemia, unspecified G47.33 Obstructive sleep apnea (adult) (pediatric) G60.8 Other hereditary and idiopathic neuropathies K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding I48.91 Unspecified atrial fibrillation J02.9 Acute pharyngitis, unspecified (Preliminary) F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features Z46.89 Encounter for fitting and adjustment of other specified devices R09.81 Nasal congestion Z46.89 Encounter for fitting and adjustment of other specified devices M25.562 Pain in left knee L53.9 Erythematous condition, unspecified R29.3 Abnormal posture F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified T81.30XA Disruption of wound, unspecified, initial encounter R05 Cough (Preliminary) F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features S28.222A Partial traumatic amputation of left breast, initial encounter Z48.3 Aftercare following surgery for neoplasm F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features R41.841 Cognitive communication deficit N63.0 Unspecified lump in unspecified breast H25.012 Cortical age-related cataract, left eye (Preliminary) H25.011 Cortical age-related cataract, right eye (History of) H25.091 Other age-related incipient cataract, right eye Z23 Encounter for immunization Z74.1 Need for assistance with personal care M62.81 Muscle weakness (generalized) K59.00 Constipation, unspecified I49.9 Cardiac arrhythmia, unspecified E55.9 Vitamin D deficiency, unspecified (History of) L23.9 Allergic contact dermatitis, unspecified cause (History of) F33.8 Other recurrent depressive disorders (History of) Z11.1 Encounter for screening for respiratory tuberculosis D51.9 Vitamin B12 deficiency anemia, unspecified (History of) R13.11 Dysphagia, oral phase N18.31 Chronic kidney disease, stage 3a G44.021 Chronic cluster headache, intractable (Preliminary) C50.912 Malignant neoplasm of unspecified site of left female breast
Allergies: Iodinated Contrast- Oral and IV Dye, Penicillins (PCN)
Diagnostic Lab Data:
CDC Split Type:

Write-up: DISCOVERED UNRESPONSIVE WITHOUT PULSE, RESPIRATIONS, HEART BEAT ON 2/7/21 AT 0435 A.M. RESIDENT WAS DNR STATUS.
VAERS ID: 1015630 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: 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: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died of a heart attack; A spontaneous report was received from a consumer concerning a 56-year-old male patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and died due to a heart attack. The patient''s medical history was not provided. Products known to have been used by the patient, within two weeks prior to the event, included additional medications. On an unknown date, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. - On an unknown date, the reporter stated the patient received Moderna''s COVID-19 vaccine and sometime after he was found dead by his bedside around 02:30 am. The patient died on an unknown date. The cause of death was due to a heart attack. Plans for autopsy were not provided.; Reporter''s Comments: This case concerns a 56 year old, male patient, who experienced fatal unexpected event of myocardial infarction. The event occurred on an unspecified date after mRNA-1273 (Lot# Unknown). Treatment details not provided. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Additional information has been requested.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1015670 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-29
Onset: 2021-01-02
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Death, SARS-CoV-2 test positive, 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), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 16
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: Dementia
Allergies:
Diagnostic Lab Data: Test Date: 20210102; Test Name: Covid test; Result Unstructured Data: Test Result:Positive; Test Date: 20210115; Test Name: Xrays; Result Unstructured Data: Test Result:covid Poss pockets all in her lungs
CDC Split Type: USPFIZER INC2021104685

Write-up: Xrays showed covid Poss pockets all in her lungs on 15Jan; Xrays showed covid Poss pockets all in her lungs on 15Jan; This is a spontaneous report from a contactable consumer. An 85-years-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 29Dec2020 at single dose for covid-19 immunisation. Medical history included dementia. Concomitant medications were not reported. Patient popped hot 02Jan2021 along with 4 others on the hall she lived. Within 9 days 50+ patients were positive. All had the vaccine the same day. Patient was test positive on 02Jan2021. She was on day 12 of her quarantine when she started to get worse. She was unresponsive by 16Jan2021 and passed 18Jan2021. We were with her from 14Jan2021 to 18Jan2021. But had not been allowed to visit with her since Mar2020. And what post treatment pairs well with it? Publicly we hear Remdesivir and Bamlanivimab but these patients only received a general antibiotic and some vitamins. Death cause was Xrays showed covid Poss pockets all in her lungs on 15Jan2021. No autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: Based on the information available, a possible contributory role of the suspect products cannot be excluded for the reported event of positive for corona virus infection for the lack of efficacy of the vaccine. However, based on the mechanism of action of the vaccine, it is unlikely the patient would have fully developed immunity for the vaccine to be effective, due to the number of days passed since the vaccine is given. Case will be reevaluated based on follow-up information; Reported Cause(s) of Death: Xrays showed covid Poss pockets all in her lungs on 15Jan
VAERS ID: 1015671 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-13
Onset: 2021-01-18
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Abdominal pain upper, Apparent life threatening event, Computerised tomogram abnormal, Computerised tomogram intestine, Death, Intestinal perforation
SMQs:, Acute pancreatitis (broad), Gastrointestinal perforation (narrow), Acute central respiratory depression (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (broad), Neonatal disorders (broad), Respiratory failure (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: MEMANTINE; DICLOFENAC; CARBIDOPA/LEVODOPA; QUETIAPINE; LEXAPRO; TYLENOL; GLUCOSAMINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Arthritis; Dementia
Allergies:
Diagnostic Lab Data: Test Date: 202101; Test Name: CT; Result Unstructured Data: Test Result:bowel perforation; Comments: CT showed a bowel perforation in the small bowel
CDC Split Type: USPFIZER INC2021107105

Write-up: bowel perforation; pain in her upper abdomen; This is a spontaneous report from a contactable consumer. An 86-year-old female patient received the 2nd dose of bnt162b2 (BNT162B2) at single dose on 13Jan2021 for Covid-19 immunisation, administerd at nursing home/senior living facility Medical history included dementia, arthritis. No known allergies. Patient was not pregnant. Patient had not COVID prior vaccination. Concomitant medication in 2 weeks included: memantine (manufacturer unknown) 10 mg BID, diclofenac (manufacturer unknown) BID, carbidopa, levodopa (manufacturer unknown) 25-100 mg TID, quetiapine (manufacturer unknown) 12.5 mg q HS, escitalopram oxalate (LEXAPRO) 10 mg q HS, paracetamol (TYLENOL) 650 mg BID, glucosamine (manufacturer unknown) drink. The patient received the 1st dose of bnt162b2 (BNT162B2) at single dose on 24Dec2020 for Covid-19 immunisation. No other vaccine received in 4 weeks. The patient experienced bowel perforation and pain in her upper abdomen on 18Jan2021 07:30. The events resulted in Emergency room/department or urgent care, Life threatening illness (immediate risk of death from the event), and death. On 18Jan2021 07:30 AM, less than a week after the second shot, she had pain in her upper abdomen and was taken to the ER on 18Jan2021. CT showed a bowel perforation in the small bowel. She had never had bowel surgery or diverticulitis. She had been healthy other than her dementia and arthritis. Patient received treatment for the events: hospice and pain management. COVID-19 was not tested post vaccination. The cause of death was bowel perforation. An autopsy was not performed. Information about lot/batch number has been requested.; Reported Cause(s) of Death: bowel perforation
VAERS ID: 1015687 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-02-08
Onset: 2021-02-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, Cardiac arrest, Cough, Death, Dyspnoea, Headache, Intraosseous access placement, Laryngeal mask airway insertion, Oxygen saturation decreased, Pulse absent, Pulseless electrical activity, Pyrexia, Respiratory arrest, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: lipitor, pepcid, uloric, prozac, synthroid, lisinopril, troprol xl, multivitamin, niacin, nifedical xl, ranexa, demadex, xarelto
Current Illness: none
Preexisting Conditions: a fib, HTN, CAD, PTSD, CHF, anxiety, gout, reflux, high cholesterol, obese, hypothyroidism.
Allergies: nknda or food allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Almost immediate headache per wife. Developed fever around 4 pm. Headache all day. Took Tylenol at 4 and 10 pm. Gradual development of SOB and cough. Temp of 101.4 at 10 pm. pulse ox 92% at 10 pm. Went to sleep, woke up at 0050 with increasing SOB. Pulse ox 82%. Used albuterol inhaler, wife called emergency services at 0113. EMS arrived around 0130 to patient''s home. pulse ox 86%, coughing, sob, hard time breathing. Walked to stretcher. Became unresponsive. Found to have no pulse, stopped breathing. CPR initiated at about 0140. King airway placed in field, I/O in left tibia. Patient from PEA to asystole, to vfib, to asystole. ACLS followed. Unrecoverable asystole and patient time of death 0213.
VAERS ID: 1015773 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-02-01
Onset: 2021-02-02
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: aspirin 81 mg,
Current Illness: skin rash
Preexisting Conditions: Demenita, GERD, Heart failure, Kidney disease, stage 3,
Allergies: Lisinipril, Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away in her sleep. No s/s of adverse events leading up to the residents death. Resident was previously declining- MD stated the vaccine had nothing to do with the death.
VAERS ID: 1015996 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-14
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 30
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: Family reported patient expired 1/31/2021.
VAERS ID: 1016067 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-02-04
Onset: 2021-02-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Fatigue, Pyrexia, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Metolazone, potassium CL, Torsemide, Acetaminophen, Loperamide, melatonin, tramadol, certirzine, Eliquis,
Current Illness: nasal congestion
Preexisting Conditions: diabetes, heart failure, Afib, HTN
Allergies: Procaine, epinephrine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident was weak, fatigued and had a fever of 101. F the following morning after receiving the 2nd dose of vaccine. Later in the day she was feeling better and vital signs were WNL. The next morning, she was found unresponsive and pronounced dead by paramedics.
VAERS ID: 1016097 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-20
Onset: 2021-02-08
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: Amlodipine, carvedilol, clopidrogrel, cyclobenzaprine, docusate sodium, ferrous sulfate, guaifenesin, norco, insulin nph, levothyroxine, magnesium, metformin, nitrostat, rosuvastatin, spironolactone, tramadol, warfarin
Current Illness:
Preexisting Conditions: CABG-2014, CAD, HTN, hyperlipidemia, systolic murmur, type 2 diabetes, diabetic neuropathy, cervical dystonia, benign essential tremor, degenerative disc disease, intermittent claudication, PVD, former smoker-greater than 30 pack year, cervical spinal stenosis, long-term use of anticoagulant
Allergies: Hydrochlorothiazide, ACE inhibitors, Lisinopril, Valsartan, Angiotensin Receptor blockers
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died 02/08/21
VAERS ID: 1016111 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-01-24
Onset: 2021-02-06
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Death, Pain in extremity
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), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: lipatore high blood pressure meds a-fib medications
Current Illness: no
Preexisting Conditions: High Blood Pressure High Cholesterol A-Fib
Allergies: Penicillin Amoxicillin Sulfa Drugs
Diagnostic Lab Data: yes but unsure of what labs and tests she had. We don''t have her death certificate yet.
CDC Split Type:

Write-up: her arm was sore but no other adverse reactions until Saturday, Feburary 6th 2021 she had stroke between 4 and 6pm. She died within 6 to 7 hours later.
VAERS ID: 1016155 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Kansas  
Vaccinated: 2021-02-04
Onset: 2021-02-04
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bundle branch block left, Death, Pulse absent, Respiratory arrest
SMQs:, Anaphylactic reaction (broad), Conduction defects (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Align Capsule 1 capsule QD Aspirin 81 mg QD Cholecalciferol 125 mcg QD Donepezil HCl 10 mg QHS Ensure Max Protein BID Furosemide 20 mg QD Potassium Chloride ER 10 MEQ BID Proventil HFA TID
Current Illness: Acute Exacerbation CHF Cellulitis of intergluteal fold due to decubitus ulcer
Preexisting Conditions: Unspecified Dementia without Behavioral Disturbance Edema Hypokalemia Chronic Bronchitis Heart Failure Vitamin D Deficiency Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris History of Aortic Stenosis LBBB
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 2/7/2021 at 0630, resident found in recliner without pulse or respirations. Resident had not been found to have any adverse reactions to the vaccine between the time of the vaccine on 2/4 until found deceased on 2/7.
VAERS ID: 1016222 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-21
Onset: 2021-01-25
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Angina pectoris, Blood test abnormal, Death, Dyspnoea, Electrocardiogram, Injection site pain, Resuscitation, Syncope, Transfusion
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: Coreg, Ranexa, Bayer low dose Aspirin, Brilinta, Tums, Pantoprazole, Nitro 0.4mg sq prn, Imdur, Rosuvastatin, Glimiperide, Sucralfate
Current Illness: 3 weeks prior to immunzation hospitalized for one day due to symptomatic anemia and got a blood transfusion
Preexisting Conditions: Hypertension, CAD s/p cabg 1996 s/p multiple stents last 2013, history of stroke 1996, high cholesterol, diabetes type 2, iron deficiency anemia
Allergies: Contrast dye, lisinopril
Diagnostic Lab Data: No labs or tests were done, she was transported to hospital for further resuscitation measures but not successful.
CDC Split Type:

Write-up: My mom only had site soreness after her covid vaccine on 1/21 which resolved within a couple days. However, she died in the early morning hours of 1/25, she was fine the day before, no sign of injury. We found her collapsed on the ground and although we tried cpr she was already dead. She had gone to the hospital on 12/28 for shortness of breath, angina and symptomatic anemia, her ekg was unchanged and blood work normal except for anemia. The cardiologist did not think a cardiac cath was needed. Her shortness of breath improved with a blood transfusion and a dose of lasix (no heart failure).
VAERS ID: 1016605 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Sepsis; A spontaneous report was received from a consumer post , concerning an approximately 55-year-old, male physician who received Moderna''s COVID-19 vaccine (mRNA-1273) and developed sepsis, resulting in death. There was no medical history provided. There were no concomitant medications provided. On an unknown date (Thursday), the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. According to the post, two days after vaccine administration, the patient died of sepsis on Saturday. Action taken with mRNA-1273 in response to the event was not applicable. The event, sepsis, was considered fatal. The patient''s date of death was not provided. The cause of death was reported as sepsis.; Reporter''s Comments: This case concerns a 55-year-old, male subject, who experienced a serious unexpected event of Sepsis. Sepsis occurred after first dose of mRNA-1273 vaccine administration. On an unknown date, two days after vaccine administration, the patient died of sepsis. Treatment for the event was not provided. The patient''s medical history was not provided. The patient is a physician. Concomitant product use was not reported. Very limited information regarding this event has been provided at this time and no definite diagnosis or autopsy report have been provided. Based on the current available information and temporal association between the use of the product and the start date of the event of Sepsis, a causal relationship cannot be excluded.; Reported Cause(s) of Death: Sepsis
VAERS ID: 1016709 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-02-08
Onset: 2021-02-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Dyspnoea at rest, Hypopnoea, Oral pain, Respiratory failure
SMQs:, Anaphylactic reaction (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), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: OXYCONE, LASIX, FLOMAS, CEPHALEXIN,EFFEXOR, EXELON, SEROQUEL, OMEPRAZOLE
Current Illness: ACUTE RESPIRATORY FAILURE, PALLATIVE CARE
Preexisting Conditions: ATRIAL FIBRILLATION, ALZHEIMERS, CHARLES BONNET SYNDROME, NON RHEUMATIC MITRAL VALVE DISORDER
Allergies: PENICILLIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: ON 02/08/2021 AROUND 0600 RESIDENTCOMPLAINED OF MOUTH PAIN AND RECEIVED OXYCODONE. DURING THE COURSE OF THE MORNING, RESIDENT EXHIBITED A FEW EPISODES OF LABORED/SHALLOW BREATHING AND SOB AT RESTING. 0XYGEN SATURATION RATE WAS 93-98% ON ROOM AIR, LUNG SOUNDS CLEAR IN ALL LOBES AND PULSE AND TEMPERATURE WITHIN NORMAL RANGE. AS THE DAY PROGRESSED, VITAL SIGNS REMAINED STABLE BUT RESIDENT CONTINUED TO HAVE PERIODS OF SOB/LABORED BREATHING.FAMILY AND NURSE PRACTIONER UPDATED AND THE ORDER WAS RECEIVED TO SEND PATIENT TO MEDICAL CENTER ER FOR EVALUATION PER AMBULANCE. RESIDENT TRANSPORTED AT 1425. RESIDENT RETURNED FROM THE ER AT 1830 ON HOSPICE CARE WITH THE DIAGNOSIS OF: ACURE RESPIRATORY FAILURE WITH HYPOXIA AND END OF LIFE DECISION MAKING. RESIDENT WAS MADE COMFORTABLE AND MONITORED DURING THE NIGHT AND EXPIRED AT 0630 ON 02/09/2021.
VAERS ID: 1016770 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-02-02
Onset: 2021-02-06
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN531881 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Dilantin 300mg Aspirin 81mg Atorvastatin 40mg Levothyroxine 100mcg Ferrous Sulfate 325mg Symbicort 160/4.5mcg inhaler Ventolin 90mcg inhaler Calcium 600mg Latanoprost eye drops
Current Illness: None
Preexisting Conditions: Fahr syndrome, Dementia, hypercholesteremia, metabolic encephalopathy, syncope, hypothyroidism, seizures, Coronary Artery Disease, iron deficiency anemia, asthma, ataxia.
Allergies: No known allergies
Diagnostic Lab Data: NA, client death.
CDC Split Type:

Write-up: Patient received 2nd dose of Pfizer vaccine on 2/2/21 and on 2/6/21 he died in his sleep in the a.m. No other signs or symptoms were observed prior to death.
VAERS ID: 1016907 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-21
Onset: 2021-01-30
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 2 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cough, Death
SMQs:, Anaphylactic reaction (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen, aspirian, bisacodyl, buspirone, celebrex, cetaphil, levothyroxine, isoartan, MOM, miralax, mult vit, namenda, nizoral, remeron, senna plus.
Current Illness:
Preexisting Conditions: acute respiratory disease, unspecified dementia, weakness, hx of falling, ostearthritis, hypothyroidism, unsteady on feet, cognitive communication deficit, expressive long. disorder, anxiety, hypertension.
Allergies: KNA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident coughing in dining room, staff suctioned, physician stated to transfer via 911 to hospital, 6:33 PM. Hospital notified Nursing Home staff resident passed away at 8:25 PM. No adverse reaction noted to the Covid vaccine 24 hours after each dose at Nursing Home. There was no airway obstruction, cardiorespiratory arrest, death was natural at hospital.
VAERS ID: 1017011 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-01-22
Onset: 2021-01-26
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   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: Dialysis
Preexisting Conditions: Chronic Kidney Failure Respiratory Failure
Allergies: NKA
Diagnostic Lab Data: Asymptomatic prior to expiration.
CDC Split Type:

Write-up: Resident expired 01/26/21 at 5:25am.
VAERS ID: 1017051 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-03
Onset: 2021-02-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Acute myocardial infarction, Anaemia, Cardiac failure congestive, Cardio-respiratory arrest, Chest pain, Death, Dyspnoea, Intensive care, Pulseless electrical activity, Transfusion, Vasopressive therapy
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Haematopoietic erythropenia (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 3
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:
Preexisting Conditions: coronary artery disease with prior two-vessel CABG in 2006, Ischemic cardiomyopathy, hypertension, hyperlipidemia, bilateral carotid artery disease, paroxysmal atrial fibrillation, systolic heart failure, pulmonary hypertension, and moderate -severe aortic stenosis, ulcerative
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt received vaccine on 2/3. early on 2/4 developed chest pain, dyspnea, and was seen in ED and diagnosed with acute exacerbation of CHF and NSTEMI type 2, and anemia. on 2/5 transfusion was started and pt developed worsening dyspnea and then PEA arrest. Pt achieved ROSC and was transferred to the cardiac intensive care unit where he required vasopressor support. he subsequently declined and died on 2/7
VAERS ID: 1017128 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021130110

Write-up: Passed away; This is a spontaneous report from a Pfizer-sponsored program Corporate (Pfizer) Social Media Platforms. This is a spontaneous report from a contactable consumer reporting for friend''s mother. A 50-years-old female patient received the second dose of bnt162b2 (BNT162B2) vaccine , via an unspecified route of administration on an unspecified date at single dose for Covid-19 immunisation . The patient medical history and concomitant medications were not reported. The patient received the first dose of BNT162B2 vaccine on an unknown date. The patient passed away on an unspecified date. The patient was a healthy woman, who just got her 2nd dose of the vaccine a couple of days before. The patient died in her sleep. Doctor labeled her death as ''natural causes''. It was not reported if an autopsy was performed. No follow-up attempts are Possible. Information on lot/batch cannot be obtained.; Reported Cause(s) of Death: Passed away
VAERS ID: 1017129 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Nevada  
Vaccinated: 2020-12-17
Onset: 2020-12-28
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Autopsy, Coronary artery thrombosis, Sudden cardiac death
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-28
   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: Losartan, aspirin.
Current Illness:
Preexisting Conditions: Hypertension. Diet & exercise-controlled diabetes. History of DVT 4 yrs prior to event. After completing a course of Xarelto has been on aspirin ever since.
Allergies: None known
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Sudden cardiac death. Autopsy report: right coronary artery thrombosis.
VAERS ID: 1017176 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2020-12-30
Onset: 2021-01-05
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute kidney injury, Atrial fibrillation, Blood pressure decreased, Cardiac failure congestive, Cardiomyopathy, Death, Laboratory test abnormal, Multiple organ dysfunction syndrome, Oedema peripheral, Oxygen saturation decreased, Urinary incontinence
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Supraventricular tachyarrhythmias (narrow), 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 (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Apixaban, Aspirin, Atorvastatin, Budesonide, Carvedilol, Docusate, Ferrous Gluconate, Furosemide, Lisinopril, Omperazole, Tiotropium Bromide inhaler, Amlodipine, Tylenol, Albuterol, Naproxen
Current Illness: Hypertension, Chronic ischemic heart disease, COPD, Atrial Fibrillation, Cardiomyopathy, Edema, Dementia, Anemia, Hyperlipidemia
Preexisting Conditions: COPD, Chronic ischemic heart disease, A fib, Hypertension
Allergies: NKA, NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had Covid-19 in October of 2020. He recovered. He received the vaccination on 12/30/2020 with no complaints. On 01-05-2021 it was noted to he was incontinent of urine and bilateral lower extremity edema. Lab work was completed showed acute kidney injury. He had decreased blood pressure and oxygen saturations on 01-06-2021 He was admitted to the hospital with rapid progression of symptoms and suggested multi-system failure. He had a long cardiac history. On 01-14-2021 he passed away with a diagnosis of Cardiomyopathic CHF, A.Fib contributory.
VAERS ID: 1017212 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-06
Onset: 2021-02-07
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SC

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac 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), Cardiomyopathy (broad), Respiratory failure (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? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CHF Diabetes
Allergies: Erythromycin, Nabumetone, Zocor, Sulfa drugs
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient suffered a cardiac arrest and remains in the hospital at this time.
VAERS ID: 1017339 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-30
Onset: 2021-02-05
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute kidney injury, Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, SARS-CoV-2 test negative, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Myocardial infarction (narrow), 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), Guillain-Barre syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives
Diagnostic Lab Data:
CDC Split Type:

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.
VAERS ID: 1017367 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-01-05
Onset: 2021-01-14
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration, 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: 2021-01-17
   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: Individual was healthy prior to vaccination.
Preexisting Conditions: Individual had Alzheimer''s disease.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Individual collapsed 9 days post-vaccination with no known reason. Despite being healthy prior to vaccination, individual''s condition deteriorated rapidly. Individual passed away on 1-17-2021.
VAERS ID: 1017381 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-06
Onset: 2021-02-08
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased
SMQs:, Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident passed away 2 days after receiving the vaccine. oxygen level has decreased shortly 1 day after receiving the vaccine.
VAERS ID: 1017393 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-26
Onset: 2021-02-01
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Patient received the vaccine on 1/26/2021 and per employee at facility patient passed away on 2/01/2021.
VAERS ID: 1017509 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-02-04
Onset: 2021-02-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain, Blood culture positive, Death, Endotracheal intubation, Escherichia bacteraemia, Magnetic resonance imaging abnormal, Ovarian cancer
SMQs:, Acute pancreatitis (broad), Angioedema (broad), Retroperitoneal fibrosis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ovarian malignant tumours (narrow), Respiratory failure (broad), Non-haematological malignant tumours (narrow), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine vitamin c calcium vitamin D cetirizine questran vit b12 estradiol gabapentin MOM Magnesium oxide potassium chloride Avastin, Carboplatin, Gemcitabine
Current Illness: Advanced Ovarian Cancer
Preexisting Conditions: spinal stenosis
Allergies: penicillins
Diagnostic Lab Data: As noted above.
CDC Split Type:

Write-up: Day after receiving the vaccine, the patient complained of abdominal pain which worsened over the day. She went to the ED and was hospitalized. Abdominal pain complaints increased and continued, she decompensated rapidly, was intubated and subsequently died 3 days later. Imaging results showed, progressive ovarian cancer in the bowels. Blood culture revealed that she had E.Coli in her blood. It is thought that this is NOT related to the vaccine.
VAERS ID: 1017549 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-02-04
Onset: 2021-02-09
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Medications amlodipine atorvastatin budesonide cephalexin ciclopirox desloratadine epinephrine flaxseed oil fluticasone propionate glucosamine HCl hydrocodone-acetaminophen ipratropium bromide Keflex lisinopril-hydrochlorothiazide olopatadi
Current Illness:
Preexisting Conditions: Problem List: abscess of sublingual space abscess of submandibular region chronic ethmoidal sinusitis chronic maxillary sinusitis disorder of salivary gland essential hypertension history of asthma hyperglycemia hyperlipidemia leukocytosis localized enlarged lymph nodes mass of hand seasonal allergic rhinitis
Allergies: Penicillins, Levofloxacin, sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dr. received an urgent request to call a local Justice of the peace regarding one of her patients who was found dead in her home today. At this time no foul play is suspected. Dr. said the patient was relatively healthy with no major issues other than some hypertension
VAERS ID: 1017563 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-09
Onset: 2021-01-09
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Pyrexia, SARS-CoV-2 test negative
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   Days after onset: 21
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: gabbapentin, morphine
Current Illness: arthritis, heart issues
Preexisting Conditions: neuropathy pain
Allergies: none that we know of
Diagnostic Lab Data: He tested negative for Covid. They thought it was heart related. They kept him in the hospital. Then they sent him to Nursing Home where they believe he contracted COVID. He went back to the hospital and passed away.
CDC Split Type:

Write-up: Patient got the injection and quickly developed a fever and felt weak. Family was contacted and he was sent to Hospital.
VAERS ID: 1017660 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-10
Onset: 2021-01-26
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, COVID-19 pneumonia, Death, Respiratory failure
SMQs:, Anaphylactic reaction (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), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient contracted COVID and was hospitalized. He later died- respiratory failure secondary to COVID-19 pneumonia. This was not related to a vaccine adverse event, but reporting based on requirements.
VAERS ID: 1017675 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-03
Onset: 2021-01-10
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ELI1284 / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, General physical health deterioration
SMQs:

Life Threatening? No
Birth Defect? No
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: capsacin pad, Ativan liquidMorphine Sulfate 20mg/ml
Current Illness: COPD, Diabetes Mellitus type 2
Preexisting Conditions: Nalignant neoplasm of cecum, COVID positive 10/2020, cerebral infarction,athersclerotic heart disease, heart failure, AV block
Allergies: sulfa antibiotics
Diagnostic Lab Data:
CDC Split Type:

Write-up: This 96 year old resident was diagnosed with COVID on 10/28/2020. She has a significant, complicated medical history and did not return to her pre-infection level of health. She began declining in early January and was made care and comfort measures only on 1/2/2021. Most of her medications were d/c''d except for those that provided comfort. No obvious reaction to the vaccine was seen and we do not suspect that her death was vaccine related, however we were directed by Dept of Epidemiology to report her death as it was within one week of receiving the vaccine.
VAERS ID: 1017744 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-26
Onset: 2021-01-27
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Unknown
VAERS ID: 1017960 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-06
Onset: 2021-02-03
   Days after vaccination: 28
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy.
VAERS ID: 1017971 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-06
Onset: 2021-02-02
   Days after vaccination: 27
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt was deceased when we came for second dose. COD unknown to pharmacy
VAERS ID: 1017974 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-06
Onset: 2021-02-01
   Days after vaccination: 26
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Pt was deceased when we came for second dose. COD unknown to pharmacy
VAERS ID: 1017978 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-06
Onset: 2021-02-01
   Days after vaccination: 26
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J202A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Pt was deceased when we came for second dose. COD unknown to pharmacy
VAERS ID: 1018126 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-02-04
Onset: 2021-02-08
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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:
Current Illness: chronic conditions listed below
Preexisting Conditions: per wife-diabetes, hypertension, hypercholesterolemia, depression, cvd, previous stroke
Allergies: na
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccination on 2/4. Patient''s wife reported that he felt a slight soreness in his arm the day following the shot, but had no other symptoms. On 2/8 he passed away. Wife reports that it was related to his heart and they never made it to a hospital. The wife also reported that the patient had been in poor health prior to the vaccination
VAERS ID: 1018146 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-28
Onset: 2021-02-01
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Intracranial aneurysm
SMQs:, Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, carpidopa-levodopa, colchicine, januvia, sertraline HCL, finasteride, valsartan, febuxostat, daily vitamin centrum, vitamin d
Current Illness: None
Preexisting Conditions: Type 2 diabetes, BPH, gout, high blood pressure
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Four days later, my father had a severe brain aneurysm.
VAERS ID: 1018278 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-01-27
Onset: 2021-02-09
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Lisinopril, Flonase, famotidine
Current Illness:
Preexisting Conditions: Hypertension, breast cancer
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: death- unexplained cause
VAERS ID: 1018448 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Hawaii  
Vaccinated: 2021-02-01
Onset: 2021-02-06
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cerebrovascular accident, Condition aggravated, 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: 2021-02-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: aspirin 81 mg qd. vitamin D. duloxetine, cymbalta 20 mg qd. Jalyn one daily. ferrous sulfate. namenda. spiriva inhaler. zinc 50 mg qd
Current Illness: none
Preexisting Conditions: dementia. hx stroke. carotid disease. emphysema. hyperlipidemia. BPH
Allergies: oxycodone. penicillin. simvastatin
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/6/2021 stroke. 2/8/2021 he died
VAERS ID: 1019548 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-27
Onset: 2021-01-30
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9265 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute hepatic failure, Asthenia, Bacteraemia, Chills, Death, Disseminated intravascular coagulation, Fatigue, Loss of personal independence in daily activities, Malaise, Metabolic disorder, Nausea, Pneumonia, Sepsis
SMQs:, Hepatic failure, fibrosis and cirrhosis and other liver damage-related conditions (narrow), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: CVA, hypertension, pulmonary hypertension, GERD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received her first covid vaccine on 1/27/21. on 1/30/21 she presented to the emergency department complaining of nausea, she had a negative work up, felt better and was sent home. on 2/5/21 she returned to the emergency department more ill-appearing and complaining of "feeling sick". she had fatigue, chills, decrease in activity level. her work up at this visit revealed multiple metabolic abnormalities, sepsis and bacteremia. She ultimately passed away at this visit with at cause of death listed as acute liver failure, pneumonia, and DIC$g
VAERS ID: 1019573 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: South Dakota  
Vaccinated: 2021-01-18
Onset: 2021-01-19
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute kidney injury, Blood disorder, Cardiac disorder, Hypoxia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Asthma/bronchospasm (broad), Haematopoietic cytopenias affecting more than one type of blood cell (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 (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Blood Disorder (diagnosed by MD)-Severe, Systemic: Cardiac Disorder (diagnosed by MD)-Severe, Systemic: Other- Acute Kidney Injury, Hypoxia; lasted 10 days
VAERS ID: 1019661 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-06
Onset: 2021-02-07
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cerebrovascular accident, Ischaemic stroke
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 6
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: lipitor 20mg daily, zetia 10mg daily, HCTZ 12.5mg daily prn, lisinopril 20mg daily, vitamin d daily, motrin prn, magnesium oxide 400mg daily, MVI daily, fish oil daily, asa 81mg daily, eye drops (latanoprost, cosopt, prednisolone)
Current Illness: hip replacement, HLD, HTN, atherosclerotic heart disease, cataract surgery
Preexisting Conditions: hip replacement, HLD, HTN, atherosclerotic heart disease, cataract surgery
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient admitted to hospital evening of 2/7/21 with acute ischemic stroke and received tenectaplase. Diagnosis Left MCA stroke. Reporting event given was just over 24 hours after first COVID vaccine dose.
VAERS ID: 1019669 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Connecticut  
Vaccinated: 2021-02-08
Onset: 2021-02-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / UNK LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: heart failure with EF of 20-30%, coronary artery disease, type two diabetes, obstructive sleep apnea, diabetic nephropathy
Allergies: sulfonamides
Diagnostic Lab Data:
CDC Split Type:

Write-up: the following morning the patient became unresponsive while taking a shower, became asystolic and died despite about an hour of ACLS and 8 rounds of epi
VAERS ID: 1019670 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Washington  
Vaccinated: 2021-01-27
Onset: 2021-02-02
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3302 / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Anion gap, Aspartate aminotransferase increased, Asthenia, Bacterial test positive, Base excess, Basophil count increased, Bilirubin urine, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bicarbonate increased, Blood bilirubin normal, Blood calcium decreased, Blood chloride decreased, Blood creatine phosphokinase MB decreased, Blood creatine phosphokinase normal, Blood creatinine increased, Blood glucose increased, Blood lactic acid normal, Blood pH decreased, Blood potassium normal, Blood sodium decreased, Blood sodium normal, Blood urea increased, Blood urea nitrogen/creatinine ratio increased, C-reactive protein normal, Carbon dioxide decreased, Cardiac arrest, Chest X-ray abnormal, Chromaturia, Creatine urine increased, Crystal urine present, Death, Differential white blood cell count normal, Dysuria, Endotracheal intubation, Eosinophil count decreased, Erythema, Fluid overload, Full blood count normal, Globulins decreased, Glomerular filtration rate decreased, Glucose urine absent, Haematocrit normal, Haemoglobin decreased, Hypoperfusion, Hypotension, Immature granulocyte count increased, Influenza virus test negative, Intestinal ischaemia, Lipase, Lung opacity, Lymphocyte count normal, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin normal, Mean cell volume increased, Mean platelet volume normal, Metabolic function test, Metamyelocyte percentage, Monocyte count decreased, Monocyte count normal, Neutrophil count, Neutrophil count normal, Nitrite urine absent, Opiates negative, Oxygen saturation decreased, PCO2 increased, PO2 normal, Platelet count normal, Pleural effusion, Pneumonia aspiration, Pneumonitis, Procalcitonin decreased, Protein total decreased, Protein urine present, Pulse absent, Pyrexia, Red blood cell count decreased, Red blood cell sedimentation rate normal, Red blood cells urine, Red cell distribution width increased, Resuscitation, Rib fracture, SARS-CoV-2 test negative, Small intestinal obstruction, Specific gravity urine normal, Toxicologic test normal, Troponin I normal, Urinary casts, Urinary lipids present, Urinary occult blood positive, Urine analysis, Urine analysis abnormal, Urine analysis normal, Urine ketone body present, Urine leukocyte esterase, Urobilinogen urine, Vomiting, White blood cell count normal, White blood cells urine positive, pH urine normal
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Lactic acidosis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Hyperglycaemia/new onset diabetes mellitus (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Gastrointestinal obstruction (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Ischaemic colitis (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (narrow), Osteoporosis/osteopenia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Cerebral Palsy, Anxiety, Crohns, Bipolar, GERD, Nutrition deficiency, Iron deficiency
Allergies: lactose
Diagnostic Lab Data: 2/2/2021- CDC, CMP, Lipase, UA, CXR. COVID negative, Influenza Negative. WBC 8.2, HCT 48.2, HGB 16.3, CRP 4.9, NA 135, K+ 4.0, CHL 94, Bicarb 33, BUN 29, Creatinine 0.8, Glucose 145, Alkaline Phosphatase 106, Lipase 24. UA negative. 2/4/2021- 02/04 02/04 02/04 2145 2039 2039 Blood Gas VBG pH (7.31 - 7.41) 6.99 VBG pCO2 (40 - 50 mmHg) 73 VBG pO2 (40 - 50 mmHg) 81 VBG HCO3 (22.0 - 26.00 mmol/L) 17.7 VBG O2 Sat (Meas) (%) 85.8 VBG Base Excess (-2 TO 3 mmol/L) -14.9 VBG Lactic Acid (0.5 - 2.2 mmol/L) 10.1 Chemistry Sodium (135 - 148 mmol/L) 133 Potassium (3.6 - 5.2 mmol/L) 4.2 Chloride (98 - 107 mmol/L) 101 Carbon Dioxide (21 - 32 mmol/L) 18 Anion Gap (mmol/L) 14 BUN (7 - 25 mg/dL) 40 Creatinine (0.7 - 1.5 mg/dL) 1.4 Estimated GFR ($g60) 56 BUN/Creatinine Ratio 28.6 Glucose (70 - 110 mg/dL) 212 Calcium (8.4 - 10.2 mg/dL) 7.4 Total Bilirubin (0.1 - 1.5 mg/dL) 0.4 AST (5 - 40 U/L) 41 ALT (7 - 52 U/L) 40 Alkaline Phosphatase (34 - 104 U/L) 112 Creatine Kinase (35 - 232 U/L) 95 CK-MB (CK-2) (0.6 - 6.3 ng/mL) 2.8 Troponin I (<=0.03 ng/mL) 0.05 C-Reactive Prot, Quant (0.1 - 0.3 mg/dL) 5.7 Serum Total Protein (6.0 - 8.3 g/dL) 4.3 Albumin (3.5 - 5.0 g/dL) 2.6 Globulin (g/dL) 1.7 Albumin/Globulin Ratio 1.5 Procalcitonin (< 0.1 ng/mL) 0.7 Hematology WBC (4.0 - 11.0 K/uL) 6.9 RBC (4.30 - 5.70 M/uL) 4.39 Hgb (13.0 - 17.4 g/dL) 13.4 Hct (39.0 - 52.2 %) 42.8 MCV (80 - 100 fL) 98 MCH (25.0 - 35.0 pg) 31 MCHC (31 - 36 g/dL) 31 RDW Coeff of Var (11.0 - 16.0 %) 14.6 Plt Count (150 - 450 K/uL) 239 MPV (9.4 - 12.4 fL) 9.5 Immature Gran % (Auto) (0.1 - 0.3 %) 13.8 Neut % (Auto) (37.0 - 80.0 %) 56.2 Lymph % (Auto) (10.0 - 50.0 %) 21.8 Mono % (Auto) (0.0 - 12.0 %) 4.9 Eos % (Auto) (0.0 - 5.0 %) 0.6 Baso % (Auto) (0.0 - 3.0 %) 2.7 Immature Gran # (Auto) (0.01 - 0.03 K/uL) 0.96 Absolute Neuts (auto) (2.00 - 8.00 K/uL) 3.90 Absolute Lymphs (auto) (1.00 - 5.00 K/uL) 1.51 Absolute Monos (auto) (0.00 - 1.20 K/uL) 0.34 Absolute Eos (auto) (0.00 - 0.50 K/uL) 0.04 Absolute Basos (auto) (0.00 - 0.30 K/uL) 0.19 Total Counted (CELLS) 100 Neutrophils % (Manual) (37 - 80 %) 41 Band Neutrophils % (< 6 %) 12 Lymphocytes % (Manual) (10 - 50 %) 37 Monocytes % (Manual) (0 - 12 %) 8 Eosinophils % (Manual) (1 - 7 %) 0 Basophils % (Manual) (<4 %) 0 Metamyelocytes % (%) 2 Nucl RBC Rel Cnt (Man) (/100 WBC) 2 ESR (0 - 20 mm/hr) 4 Toxicology Urine Opiates Screen (NEG) NEG Ur Oxycodone Screen (NEG) NEG Urine Methadone Screen (NEG) NEG Ur Propoxyphene Screen (NEG) NEG Ur Barbiturates Screen (NEG) NEG U Tricyclic Antidepress (NEG) NEG Ur Phencyclidine Scrn (NEG) NEG Ur Amphetamines Screen (NEG) NEG U Methamphetamines Scrn (NEG) NEG U Benzodiazepines Scrn (NEG) NEG Urine Cocaine Screen (NEG) NEG U Marijuana (THC) Screen (NEG) NEG Urines Urine Source URINE - FOLEY CATH Urine Color YELLOW Urine Appearance (CLEAR/HAZY) TURBID Urine pH (5 - 9) 5.5 Ur Specific Gravity (1.005 - 1.030) $g=1.030 Urine Protein (NEG/TRACE mg/dL) $g=300 Urine Glucose (UA) (NEG mg/dL) NEGATIVE Urine Ketones (NEG mg/dL) 15 Urine Occult Blood (NEG) LARGE Urine Nitrite (NEG) NEGATIVE Urine Bilirubin (NEG) MODERATE Urine Urobilinogen (0.2 - 1.0 E.U./dL) 0.2 Ur Leukocyte Esterase (NEG) NEGATIVE Urine RBC (<3 /HPF) 11-20 Urine WBC (<6 /HPF) $g100 Ur Squamous Epith Cells (/HPF) RARE Amorphous Crystals (/HPF) MOD Urine Bacteria (/HPF) FEW Hyaline Casts (NONE SEEN /LPF) FEW Fine Granular Casts (NONE SEEN /LPF) FEW Urine Mucus (/LPH) FEW Ur Oval Fat Bodies (NONE SEEN /HPF) FEW Vol Urine Centrifuged (mL) 5 U Random Total Protein (mg/dL) 446 U Rand Prot/Creat Ratio (LT 0.2 RATIO) ND Urine Creatinine (mg/dL) 94
CDC Split Type:

Write-up: 2/2/2021- seen in Ed with c/o intermittent fever following 2nd dose. Redness to bilateral upper extremities, c/o some pain with urination, weak. V/S stable, afebrile in ED. Assess for infection. No significant abnormal labs (see below), hydrated and discharged. 2/4/2021- arrived in ED with c/o vomiting, seen earlier by PCP that day labs drawn. Shortly after arriving in the ED copious amouts of emesis noted, the patient went into full cardiac arrest and CPR was started. -Please see HPI above, in addition after intubation the patient coded again. More epinephrine and lidocaine were given. CPR was resumed. We did obtain ROSC and targeted temperature management was pursued. He is placed on a lidocaine drip and a right femoral central line was placed by myself. At this time, norepinephrine drip was initiated given his continued hypotension. Post intubation chest x-ray suggests possible abdominal pathology and once the patient was stabilized further, he was sent to the CT scanner where CT head without IV contrast and CT chest, abdomen and pelvis with IV contrast was obtained. He did lose pulses once in the radiology suite. This was brief. IV fluids were initiated and he received over 2 L of crystalloid therapy. He continued to be hypotensive in the emergency department and vasopressin was added. He also had a single dose of Neo-Synephrine and IV push fashion to help bring his blood pressure up. CT scan reveals probable bilateral aspiration pneumonia/pneumonitis and dilated loops of small bowel without a transition point and pneumatosis involving loops in the left upper quadrant. I did try to initiate consult with critical care and possible transfer, however he continued to be unstable and coded requiring CPR multiple times. He was given IV bicarbonate given his prolonged CPR state and pH. Ultimately, the family decided to make the patient comfort measures only given his critical illness. Shortly after making this decision he did pass away in the emergency department. RADIOLOGY DIAGNOSTIC - CHEST PORTABLE 02/04 2051 *** Report Impression - Status: SIGNED Entered: 02/04/2021 2059 IMPRESSION: 1. Findings highly suspicious for portal venous gas which can be seen in the setting of bowel ischemia. Consider CT for further evaluation and/or surgical consultation. 2. Endotracheal tube 3.7 cm above the carina. 3. Low lung volumes with mild patchy perihilar opacities. Final Report Signed by: M.D., Sign Date/Time: 02/04/2021 8:55 PM Impression By: MD CT SCAN - CT HEAD WO 02/04 2140 *** Report Impression - Status: SIGNED Entered: 02/04/2021 2200 IMPRESSION: Negative for acute intracranial process. No evidence of mass effect, acute hemorrhage or definite acute cortical infarct. Final Report Signed by: M.D., Sign Date/Time: 02/04/2021 9:57 PM Impression By: - MD CT SCAN - CT CHEST/ABD/PELVIS W 02/04 2140 *** Report Impression - Status: SIGNED Entered: 02/04/2021 2214 IMPRESSION: 1. Ill-defined patchy opacities within the bilateral upper lobes, right middle lobe, in consolidative opacities within bilateral lower lobes which could represent aspiration, and/or multifocal pneumonia. 2. Small right trace left pleural effusions. 3. Diffusely dilated small bowel without a transition point and mucosal hyperenhancement involving the colon with areas of pneumatosis involving loops of small bowel within the left upper quadrant and portal venous air consistent with hypoperfusion complex. There is a small caliber appearance of the aorta and a flattened appearance of the IVC is well. 4. Intravascular air within the IVC and bilateral iliac veins could be secondary to right femoral central lying injection. 5. Somewhat abnormal enhancement pattern of the kidneys with hypoenhancement of the medullary pyramids which may suggest hypoperfusion injury as well. 6. Probable nondisplaced rib fractures on the right at ribs 2 through
VAERS ID: 1019850 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2020-12-30
Onset: 2021-02-10
   Days after vaccination: 42
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood sodium decreased, Cardiac arrest, Endotracheal intubation, Pulse absent, Pulseless electrical activity, Resuscitation, 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), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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:
Current Illness:
Preexisting Conditions:
Allergies: sulfa
Diagnostic Lab Data: Ordered BAG/MASK OXYGEN 1 Time ONE TIME 02/10/21 0727 EPINEPHrine PF 0.1 mg/mL (1:10,000) injection ONCE PRN 02/10/21 0657 sodium bicarbonate 8.4 % injection ONCE PRN 02/10/21 0657 EPINEPHrine PF (ADRENALIN) 1 mg/mL (1:1,000) injection ONCE PRN 02/10/21 0656 atropine syringe ONCE PRN 02/10/21 0655
CDC Split Type:

Write-up: HPI Patient is a 77 y.o. male who presents with in full cardiac arrest. Patient is resident of local nursing home. According to nursing home staff, a tech was in his room talking with him as patient was laying in bed. Tech began walking out of patient''s room and turned around to tell him one last thing when the tech noticed patient had gone unresponsive. Patient had no spontaneous respirations or pulse, subsequently CPR was started immediately. 911 was called. This occurred around 5:30 a.m.. Upon EMS arrival on scene, they found a male unresponsive with CPR being performed. There was no spontaneous respirations or circulation. Thus, ET tube was placed and ACLS guidelines initiated. Patient was found to be in PEA, and according to EMS, patient was given a total of 6, 1 mg epinephrine IV push and 1, 1 Amp sodium bicarb. Patient was worked on at the scene for approximately 40 min before being transferred to ER. Upon arrival to ER trauma room 1 patient is still in full arrest. ET tube in place with good ventilation. Patient remains in PEA. Chest compressions and ACLS guidelines initiated. In reviewing patient''s chart and nursing home notes, patient is a full code. Patient has a significant cardiac history including known coronary artery disease with 4 vessel CABG. Patient also has history of 3rd degree heart block and pacemaker placement. Patient has history of ischemic cardiomyopathy but last echo performed in 2020 shows ejection fraction of 45%.
VAERS ID: 1019911 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-25
Onset: 2021-02-09
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Mechanical ventilation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Tested positive for COVID-19 on 01/26/2021 (Antigen positive) - presented to ED due to shortness of breath and fatigue
Preexisting Conditions: Active Problems Noted Date Hypokalemia 1/28/21 Pneumonia due to COVID-19 virus 1/28/21 Acute hypoxemic respiratory failure 1/28/21 Stone of salivary gland or duct 1/8/21 Recurrent major depressive disorder, in partial remission 1/7/21 Secondary hyperparathyroidism of renal origin 1/7/21 Abnormal blood smear 7/22/20 Alkaline reflux gastritis 1/2/20 Severe obesity (BMI 35.0-39.9) with comorbidity 12/20/18 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin 12/20/18 Morbid obesity due to excess calories 6/18/18 Psoriasis 12/13/17 Proteinuria 10/20/17 Bilateral leg edema 12/5/16 Hypertriglyceridemia 6/27/16 Essential hypertension with goal blood pressure less than 130/85 6/27/16 Anxiety, generalized 6/27/16 Hypothyroid 11/24/14 Aortic valve replaced 7/7/14 Pulmonary emphysema 1/22/09 Obstructive sleep apnea syndrome 8/4/1943 Resolved Problems Noted Date Resolved Date Other chest pain 10/29/19 10/30/19 Chest pain 10/29/19 10/30/19 Type 2 diabetes mellitus without complication, without long-term current use of insulin 6/24/19 7/6/20 Sialadenitis 1/4/19 1/2/20 Obesity (BMI 35.0-39.9 without comorbidity) 12/20/18 1/29/21 Abdominal pain 11/21/18 1/2/20 Type 1 diabetes mellitus with stage 3 chronic kidney disease 6/18/18 6/18/18 CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min 10/20/17 1/2/20 Sarcoidosis of lung 6/27/16 6/26/20 Uncontrolled type 2 diabetes mellitus with stage 3 chronic kidney disease, without long-term current use of insulin 6/27/16 12/13/17 Overview: Recent onset HbA1C 4/21/16 11.9. Last FBS-110 5/17/16 Diabetic eye exam 9/23/16 no diabetic retinopathy. fup one year. Hypothyroidism (acquired) 6/27/16 12/13/17 Exertional dyspnea 6/27/16 6/26/20 Tobacco abuse 11/19/08 9/23/11 documented as of this encounter (statuses as of 01/29/2021) Patient Active Problem List Diagnosis ? Obstructive sleep apnea syndrome ? Pulmonary emphysema (*) ? Aortic valve replaced ? Hypothyroid ? Hypertriglyceridemia ? Essential hypertension with goal blood pressure less than 130/85 ? Anxiety, generalized ? Bilateral leg edema ? Proteinuria ? Psoriasis ? Morbid obesity due to excess calories (*) ? Obesity (BMI 35.0-39.9 without comorbidity) ? Severe obesity (BMI 35.0-39.9) with comorbidity (*) ? Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin (*) ? Alkaline reflux gastritis ? Abnormal blood smear ? Recurrent major depressive disorder, in partial remission (*) ? Secondary hyperparathyroidism of renal origin (*) ? Stone of salivary gland or duct ? Hypokalemia ? COVID-19 virus infection ? Acute hypoxemic respiratory failure (*) Past Medical History: Diagnosis Date ? Anxiety ? Arthritis ? Asthma ? Back pain ? Chronic kidney disease, stage II (mild) 10/20/2017 ? Dependent edema ? DJD (degenerative joint disease) ? Gastritis ? Glucose intolerance (impaired glucose tolerance) ? History of pulmonary function tests 10/20/2010 showing decreased lung flow consistent with normal variant versus mild obstruction and emphysema ? History of stress test 12/2009 Normal ? Hyperlipidemia ? Hypothyroid Previously had hyperthyroidism ? Kidney stone 05/1999 Right ? Proteinuria 10/20/2017 ? Psoriasis ? Sarcoidosis ? Sleep apnea Past Surgical History: Procedure Laterality Date ? AORTIC VALVE REPLACEMENT 05/2001 #25 St. Jude''s aortic valve replacement ? APPENDECTOMY 1960''s ? CHOLECYSTECTOMY 1994 ? COLONOSCOPY 2010 ? COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD N/A 11/21/2018 COLONOSCOPY with hot polypectomy snare ? OTHER SURGICAL HISTORY 09/2018 spot removed from left arm ? TOTAL KNEE ARTHROPLASTY Right 11/19/2012 ? UPPER GI ENDOSCOPY,DIAGNOSIS N/A 11/21/2018 EGD with cold biopsies performed ? WISDOM TOOTH EXTRACTION
Allergies: Review of patient''s allergies indicates: Allergies Allergen Reactions ? Other [Uncoded Nonscreenable Allergen] Rash Neoprene
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client was administered the vaccine while symptomatic (01/25/21) although client did not know he was symptomatic for COVID-19. He had been exposed to a family member who had tested positive and should have been in quarantine but wasn''t either because it was not felt he was considered a close contact by his family opinion or his family member never notified public health of this close contact...?. Clinet had presented to the ED following day after vaccination for shortness of breath and fatigue and an antigen test showed he was positive for COVID-19. He was sent home that same day 01/26/21. He was back in ED on 01/28/21 for worsening symptoms and admitted to hospital and later placed on ventilator. He passed away on 02/09/2021 (date of death was per his wife).
VAERS ID: 1019964 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Louisiana  
Vaccinated: 2021-02-07
Onset: 2021-02-07
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Ferrous sulfate, Proteinex, Tylenol, Eliquis, Aspirin, Lipitor, Vitamin D3, Cholestyramine, finasteride, flavoxate, lactobacillus, loratadine, magnesium oxide, metoprolol, protonix, miralax, potassium cl, Tamsulosin, acetic acid (for foley)
Current Illness: Peg tube placement Malignant neoplasm of esophagus
Preexisting Conditions: Attention and concentration deficit, Hyperlipidemia, Acute embolism thrombosis of Deep veins or upper extremity, cognitive communication deficit, cerebral infarction, Dysphagia, Thrombocytopenia, Obstructive and reflux uropathy, Hypomagnesemia, Allergic rhinitis, GERD, Hydronephrosis with renal and ureteral calculous obstruction, Benign prostatic hyperplasia with lower urinary tract symptoms, anemia, ulcerative pancolitis, cerebral cysts, chronic obstructive pyelonephritis, hypo-osmolality and hyponatremia, HTN, Vascular dementia with behavioral disturbances, DM II, Moderate protein-calorie malnutrition, Vitamin D deficiency, Folliculitis, Hypokalemia, Aphasia following cerebral infarction, metabolic syndrome
Allergies: None
Diagnostic Lab Data: none
CDC Split Type:

Write-up: The resident received his COVID-19 Moderna vaccination on 2/6/2021 2:11 pm and expired on 2/7/2021 at 6:04 am. There were no signs or symptoms of vaccination reaction leading up to death.
VAERS ID: 1019979 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, Death, General physical health deterioration, Hypoxia, Mechanical ventilation, Oxygen saturation abnormal, Respiratory distress, Tachycardia
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Interstitial lung disease (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ALBUTEROL HFA (8.5GM) 90 MCG INHA Exp: 05/06/2021 SIG: 90mcg Inhalation every four (4) to six (6) hours as needed x 180 day(s) -- Limited to two (2) canisters every six (6) months Artificial Tears Ophthalmic Solution 1.4 % Exp: 02/23/2021 S
Current Illness: Vitamin Deficiency
Preexisting Conditions: GERD, COPD, HTN, Hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: Patient was assessed at hospital and transferred to another facility on 2/3/21. At this time, the COVID protocol was followed. His condition deteriorated and he was placed on a vent 2/9/21. He was pronounced deceased 2/10/21 at 0610.
CDC Split Type:

Write-up: Patient received the Moderna COVID vaccine 1/28/21. He was tested for COVID 19 on 1/29/31. Results were received 1/30/21, at which time he was evaluated and found to be hypoxic with tachycardia. He was sent to the local ER and returned this same day. On 2/2/21, he was evaluated by the provider, who sent him to the emergency room with acute respiratory distress and poor O2 sats
VAERS ID: 1020002 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-19
Onset: 2021-02-05
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Respiratory arrest, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Albuterol, Bumetanide, Metolazone, Candesartan, Carvedilol, Gabapentin, Insulin Pantoprazole, Tamsulosin, Warfarin
Current Illness: CHF
Preexisting Conditions: CHF, DM, CAD, CKD, Sleep apnea, COPD
Allergies: cyclobenzaprine
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Given First Moderna covid vacc 1/19/2021. Doing well on multiple contacts from health care providers, then 2/5/2021 was driving, pulled over to the side of the road into a yard, got out of the car and told an observer that he could not breathe, collapsed face down in the snow, EMS called, unable to revive him.
VAERS ID: 1020018 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-02-08
Onset: 2021-02-09
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 2 AR / IM

Administered by: Public       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: 2021-02-09
   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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient reported to be unresponsive on the morning after receiving his second dose of Moderna COVID-19 vaccine. Patient had expired during the night.
VAERS ID: 1020079 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-14
Onset: 2021-01-31
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Dyspnoea, General physical health deterioration, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Symbicort, sotalol, mexilitine, tiotropium, carbidopa/levodopa, aripiprazole, allopurinol, citalopram, insulin, pantoprazole, pravastatin, tamsulosin, tioptropium, warfarin, bumetanide, bupropion
Current Illness:
Preexisting Conditions: Ischemic Cardiomyopathy, Coronary Artery Disease (MI x2 1989 and 1995), VT (ablation 2009) with Boston Scientific ICD Sick Sinus Syndrome (PPM), Type 2 Diabetes, Chronic Kidney Disease, Hypertension, Hyperlipidemia Peripheral Vascular Disease, Parkinson''s Disease Antiphospholipid Antibody Syndrome Heparin Induced Thrombocytopenia
Allergies: Heparin Atorvastatin
Diagnostic Lab Data: Related to hospital stay. Unavailable currently.
CDC Split Type:

Write-up: Received Moderna covid vaccination 1/14/2021. 1/16/2021 received report of cough and difficulty breathing. Proceeded to hospital and was diagnosed Covid+ on testing. Continued to decline, died 1/31/2021.
VAERS ID: 1020119 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-18
Onset: 2021-02-03
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 7+ UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Internal haemorrhage, Shock, Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypovolaemic shock conditions (narrow), Toxic-septic shock conditions (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypoglycaemic and neurogenic shock conditions (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Unknown
Current Illness: Unknown
Preexisting Conditions: Chronic lukemia
Allergies: None
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: My mother died suddenly on February 3rd. She went into shock/cardiac arrest and appeared to have internal bleeding. No autopsy has been performed. Unsure if it was related to the COVID vaccine.
VAERS ID: 1020183 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-02-02
Onset: 2021-02-07
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: School       Purchased by: ?
Symptoms: Death, Headache
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Angina
Allergies: Unknown
Diagnostic Lab Data: Death Certificate.
CDC Split Type:

Write-up: Death. I actually not sure which Covid Vaccine she took. I just know the date and time she took it at her local school where she worked. Died in her sleep after complaining of a headache. I talked to her around 5pm on sunday through a videochat and she seemed happy and well. But a local friend commented that she had complained of a headache late in the afternoon.
VAERS ID: 1020195 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-12
Onset: 2021-01-15
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, COVID-19, Colonoscopy normal, Condition aggravated, Death, Dyspnoea, Occult blood negative, Oesophagogastroduodenoscopy normal
SMQs:, Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol, amlodipine, Atorvastatin, carvedilol, ipratropium, asa
Current Illness: None
Preexisting Conditions: HTN, Osteoarthritis, brain aneurysm
Allergies: None
Diagnostic Lab Data: Per hospital record which is currently unavailable
CDC Split Type:

Write-up: Received Moderna #1 on 1/12/2021. 1/15/2021 developed worsening shortness of breath. Went to hospital and diagnosed with anemia, 4 negative fecal tests, neg EGD and colonoscopy. Discharged and readmitted (circumstances unknown for this episode) then readmitted a third time 1/20/2021 for shortness of breath. Diagnosed covid + at third hospitalization and continued to get worse. He died 1/23/2021.
VAERS ID: 1020227 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: New Mexico  
Vaccinated: 2021-02-05
Onset: 2021-02-07
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Illness, Patient isolation, 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: 2021-02-07
   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: ALENDRONATE SODIUM 70MG TABLET (4''S) TAKE ONE (1) TABLET ACTIVE BY MOUTH ONE TIME EACH WEEK WITH WATER 30 MINUTES BEFORE EATING OR TAKING OTHER MEDICATIONS CALCIUM W/ VITAMIN D 600/500 SLOW RELEASE TAKE 2 TABLETS ACTIVE BY MOUT
Current Illness: Pt had COVID with symptom onset 1/27/21, pos test 1/28/21 admitted to Hosptial and was treated w/ remdesivir at , discharged 1/30 on Dexamethasone 6mg daily, no need for O2 supplement. First moderna COVID vaccine was 1/5/21.
Preexisting Conditions: 1)*AU SEVERE LOSS 2)Anemia - 3)Tubular adenoma of colon - 4)*SCLERAL PLAQUE EXCISION OS - STILL PO 2+ MONTH 5)Osteoarthritis - bilateral knees...worse in right knee -QUALIFIERS: Severity Moderate to severe 6)Chronic obstructive lung disease - 7)Onychomycosis - x10 -QUALIFIERS: Severity Mild to moderate Clinical course Chronic 8)Artificial lens present - OU 9)Hypermetropia - OD 10)Presbyopia - OU 11)Regular astigmatism - OD 12)Arcus of cornea - OU 13)Scarred macula - OS 14)Osteoporosis - 15)Osteoarthritis of knee - 16)Hypothyroidism - 17)Benign prostatic hyperplasia - 18)Hip pain, Right - Had right hip fracture pinning and has post traumatic DJD 19)Chronic pain - 20)Dry eyes - 21)Sensorineural hearing loss, Bilateral - 22)Nonexudative age-related macular degeneration, Bilateral -
Allergies: Allergies: CODEINE
Diagnostic Lab Data: None
CDC Split Type:

Write-up: This is the patient who passed away 2d after his second COVID vaccine. Of note, the 2/8 telephone note makes it sound like he was hospitalized at time of death - that is incorrect. His daugther listed as EM contact works in the eye clinic here. He had mild illness, completed 10d isolation but missed his scheduled booster dose on 2/2 due to isolation. He was called on 2/5 when there was a booster visit cancellation and received his booster dose on that day. His daugther reported that he was doing fine and looking well on 2/7 AM, ate breakfast, shortly after stood up and just collapsed.
VAERS ID: 1020443 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-30
Onset: 2021-02-03
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acidosis, Apnoea, Cardiac arrest, Chest pain, Dyspnoea, Endotracheal intubation, Hypoxia, Malaise, Resuscitation, Ultrasound abdomen, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (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 (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Unknown
Current Illness: Unknown, per patient''s daughter patient had unevaluated chest pain for 2 days prior to presentation
Preexisting Conditions: Unknown
Allergies: No known drug allergies
Diagnostic Lab Data: No tests were performed.
CDC Split Type:

Write-up: For the two days prior to presentation the patient had been complaining of chest pain, his breathing seemed to be labored Monday. He and the family thought the pain was due to shingles as he carried this diagnosis from a month ago. Patient had also received the COVID vaccine 2 days prior to presentation and assumed he was feeling unwell due to the vaccine. Family wanted to take him to the hospital yesterday and earlier today but he refused. She left him in his home earlier this afternoon prior to presentation and returned to check on him finding him unresponsive and apneic at which time EMS was activated. #cardiac arrest -- suspect primary cardiac given collateral from family at home, consider hypoxemia which was corrected with advanced airway and 100% FiO2, patient clinically euvolemic and with soft brown stool in diaper not suggestive of GI hemorrhage, attempt to address acidosis with CPR and bicarbonate, not hypoglycemia, on bedside ultrasound FAST neg and no pericardial effusion suggestive of tamponade and +lung sliding bil not spontaneous pneumothorax Assessment/Diagnosis: -cardiac arrest, cause unspecified
VAERS ID: 1020654 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Maine  
Vaccinated: 2021-02-04
Onset: 2021-02-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Pulse absent, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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: 2021-02-05
   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: Xarelto, Verapamil ER, Amlodipine, Durezol, Trelegy Ellipta, Gabapentin, Oxycodone, Sertraline, Carafate, Trazadone, Atorvastatin, Calcium and Vit. D, Vit. D 25mcg, Vit. B-12, Famotadine, Ferrous Sulfate, Metoprolol Succinate XR, Pantoprazo
Current Illness: Acute Onchronic Respiratory Failure, Aspiration Pneumonia, and NSTEMI, Diarrhea, Hypertrophic cardiomyopathy, Gram positive bacteremia, Acute kidney injury, Afib,
Preexisting Conditions: COPD, Non-small cell lung cancer, CAD, Rheumatoid Arthritis, Chronic Normocytic Anemia, GERD, HTN, Hypokalmia, Aneurysm of the thoracic aorta,
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient found unresponsive in room with no pulse or respirations. She was pronounced dead by paramedics at 06:25am on 2/5/2021.
VAERS ID: 1020684 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-13
Onset: 2021-01-16
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Anticonvulsant drug level decreased, Blood pressure abnormal, Death, Heart rate abnormal, Pneumonia, Seizure
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (broad), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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:
Current Illness:
Preexisting Conditions: history of seizure disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine at Public Health Clinic. Patient ended up having a seizure 3 days later and ended up in the hospital. Found to have right lobe pneumonia and low depakote level. Patient noted to have multiple seizures at hospital, issues with stabilizing HR and BP, and passed away on 1/20/21.
VAERS ID: 1020702 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Virginia  
Vaccinated: 2021-01-20
Onset: 2021-02-09
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Hydrochlorothiazide, Hydroxyzine, Mirena, Ocrevus, Prednisone, triamcinolone acetonide, valacyclovir, vitamin D 3
Current Illness:
Preexisting Conditions: calcaneal spur displacement of intervertebral disc without myelopathy female stress incontinence foot pain hand joint pain herpes simplex low back pain menorrhagia multiple sclerosis neck pain numbness of lower limb peripheral edema polyneuropathy
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Passed away the morning of 2/9/21.
VAERS ID: 1020724 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Alabama  
Vaccinated: 2021-01-21
Onset: 2021-02-02
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: COVID19,
Preexisting Conditions: hypertension and Coronary Artery Disease
Allergies: codeine, penicillin
Diagnostic Lab Data: COVID19 Roche LIAT PCR test - Detected
CDC Split Type:

Write-up: Patient sent to the ED or sudden onset of shortness of breath on 02/02/2021. Per documentation by the MD, the patient had COVID19 "several weeks ago" and the nursing facility felt like he had recovered. A rapid test done in the ED was negative. When the patient worsened and seemed to be following the same path as other COVID patients, a send out PCR test was done, which was positive. The patient worsened and passed away that same day (02/05/2021) I was not made aware that the patient had the vaccine on 01/21/2021 until Monday 02/08/2021.
VAERS ID: 1020749 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Mississippi  
Vaccinated: 2021-01-13
Onset: 2021-01-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cyanosis, Death, Myocardial infarction
SMQs:, Anaphylactic reaction (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Hypotonic-hyporesponsive episode (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: Unknown
Current Illness: Unknown
Preexisting Conditions: HTN, Diabetes, High Cholesterol
Allergies: Unknown
Diagnostic Lab Data: No test, lab, nor autopsy.
CDC Split Type: MS0032021

Write-up: Patient had no reaction at the clinic. Patient is a medical doctor whose partner called in this death. States patient had no complaint on 1/13 nor 1/14 while at work. States patient died at home on 1/15 a.m. Physician who stated she was called to the patient''s home @ 0157 1/15/2021 and found cyanotic from head to toe. State girlfriend found him sitting in the chair a few minutes before they called her. The Coroner did not order autopsy. Did not sent patient to the hospital. Sent him directly Funeral Home. Death Certificate Number 123-2021-002593 list cause of death as pending. I spoke with the patient''s primary doctor who gave me the history of HTN, Diabetes, & High Cholesterol. States he had not seen this patient since April 2020. They were also friends and he was not aware of any medical problems. The Coroner state she thinks patient has a heart attack. Neither the Coroner nor PMD think death was related to COVID Vaccine. Informed both that MSDH would have to complete VAERS. Both voiced understanding.
VAERS ID: 1020816 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-19
Onset: 2021-01-25
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / UNK AR / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal wall haematoma, Acute respiratory failure, COVID-19 pneumonia, Death, Endotracheal intubation, Haemodynamic instability, Hypotension, Intensive care, Oxygen saturation abnormal
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (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), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt with acute resp failure, COVID PNA, that developed symptoms 9 days prior to admit and ultimately received first vaccine 6 days prior toa admit, then shortly after progressed with other covid symptoms and was admitted. She decompensated while intp and was transferred to ICU for rising O2 needs, ultimately had to be intubated. Became hypotensive due to massive hamatoma 2'' bleeding into abd rectus muscle. Sx and IR consulted and did beside exploration of hematoma. Initially blood pressure responded but overnight continued with refractory hypotension. Maxed out vasopressin and levophed, hemodynamics deteriorated. Pt passed soon after(2/2).
VAERS ID: 1020830 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-01-21
Onset: 2021-01-30
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Aortic aneurysm rupture, Death
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-30
   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: UTO
Current Illness: Leaking Aortic Aneurysm -
Preexisting Conditions: Aortic Aneurysm
Allergies: None
Diagnostic Lab Data: Hospitalization with testing - UTO
CDC Split Type:

Write-up: This resident of the assisted living facility received his Covid-19 Moderna (1st) vaccination and he has a leaking Aortic Aneurysm which resulted in hospitalization and he entered into Hospice care on 1.30.2021 and passed away on 1.30.2021.
VAERS ID: 1021038 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 31
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: Patient had passed since the first dose was given.
VAERS ID: 1021040 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2021-01-06
Onset: 2021-01-17
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / UN

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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 - LTCF will also be reporting
Current Illness: Unknown - LTCF will also be reporting
Preexisting Conditions: Obesity, others unknown
Allergies: Unknown - LTCF will also be reporting
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Pfizer-BioNTech COVID-19 Vaccine Hospital Emergency Room Provider reported cause of death as COVID vaccine administered 11 days prior to death. Additional information being reported from LTCF.
VAERS ID: 1021045 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-02-01
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Patient had passed since the first dose was given.
VAERS ID: 1021052 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-02-01
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 9
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: Patient had passed since the first dose was given.
VAERS ID: 1021058 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-02-01
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 9
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: Patient had passed since the first dose was given.
VAERS ID: 1021171 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-03
Onset: 2021-02-04
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / 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: 2021-02-04
   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: Albuterol, ASA, Zyrtec, D3, CPAP, Zetia, FeSO4, Flonase, Lantus, Atrovent solution, Losartan, Melatonin, Reglan, Metoprolol Succinate, Pantoprazole, Paroxetine, Polyethylene Glycol, Sucralfate, Tamsulosin, Stiolto Respimat
Current Illness: Hypertension, chest pain x 1 month, nausea (1/18/21 primary care visit); memory loss, small left cerebellar infarct (neurology 2/1/21)
Preexisting Conditions: HTN, CAD, cerebellar dysfunction, claudication, old myocardial infarction, COPD/dyspnea/sleep apnea, hx thoracic aortic aneurysm, CHF, DM II (insulin dependent), CKD stage 3, anemia, irregular heartbeat, PVC, hx of smoking, atelectasis, BPH, vascular dementia, angina of effort, GERD/abnormal barium swallow/DM gastroparesis, dyslipidemia, depression
Allergies: Statin intolerance (muscle tightening)
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient received first dose of Moderna COVID-19 vaccine on 2/3/21. Primary Care physician received call from coroner''s office 2/8/21 asking for information contributing to cause of death. Per Primary Care Physician notes, wife states she and patient took turns shoveling snow on 2/4/21. On one trip back into the house she found him unresponsive on the floor and called 911. Paramedics were unable to revive patient and he passed away (2/4/21).
VAERS ID: 1022902 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-19
Onset: 2021-01-29
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / UNK RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Ammonia increased, Blood lactic acid, Cholangiocarcinoma, Computerised tomogram abnormal, Death, Endoscopy upper gastrointestinal tract normal, Gastrointestinal haemorrhage, Gastrointestinal tube insertion, Haematemesis, Paracentesis, Small intestinal obstruction
SMQs:, Liver related investigations, signs and symptoms (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal obstruction (narrow), Gastrointestinal haemorrhage (narrow), Ischaemic colitis (broad), Biliary malignant tumours (narrow), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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 Narrative: 71 yo male who passed away on 1/29/2021, medical cause of death "cholangiocarcinoma, interval between onset and death 14 months. Since patient passed away within 42 days of the covid19 vaccine administration, we are required to complete a report to VAERS. Vaccine (Pfizer) was administered without complications. The patient denied any prior severe reaction to this vaccine or its components or a severe allergic reaction such as anaphylaxis to any vaccine or to any injectable therapy. Synopsis- 1/23 71 yo male presented to ED with upper GI bleed. PMH: DM, HTN, cholangiocarcinoma of biliary tract requiring recurrent paracentesis, COPD, perigastric and lower esophageal varices (not on beta blockers due to bradycardia). Pt has had 2 episodes of coffee ground emesis. Lactic 2.6, ammonia 52. Rec''d protonix, octreotide, and ceftriaxone in ED. Family has been previously encouraged to speak to palliative care but has never been willing to. GI consulted. 1/24 EGD completed. No signs of active bleed. MDs recommending hospice. CT + for small bowel ileus. 1/26 Requires placement of NG tube to suction. Palliative care consulted. 1/27 Paracentesis completed. 4100mls removed. 1/28 Pt changed to palliative status. 1/29 Pt passed away.
VAERS ID: 1021919 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-06
Onset: 2021-01-17
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Dyspnoea, Oxygen therapy, Renal failure, Urinary retention
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (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 (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   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: Heart disease, unspecified; Renal disease
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; kidney failure (unable to urinate); shortness of breath; required oxygen; A spontaneous report was received from consumer concerning an 87-year-old, female patient, who received Moderna''s COVID-19 vaccine (mRNA-1273) and experienced shortness of breath, kidney failure and death. The patient''s medical history included advanced kidney and heart disease. No relevant concomitant medications were reported. On 06 Jan 2021, the patient received their first of two planned doses of mRNA-1273 (Lot: unknown) intramuscularly for prophylaxis of COVID-19 infection. On 17 Jan 2021, the husband reported that the patient experienced adverse events. Symptoms included shortness of breath and kidney failure (unable to urinate). The patient was admitted to the hospital and discharged to hospice. Oxygen was administrated for shortness of breath. Action taken with mRNA-1273 in response to the events was not applicable. On 20 Jan 2021, the patient died. The cause of death was unknown. Autopsy details were unknown.; Reporter''s Comments: This case concerns a 87-year-old, female patient with the medical history of advanced kidney and heart disease, who experienced fatal unexpected event of dyspnea, renal failure and death. The events of dyspnea and renal failure occurred 12 days and the event of death occurred 15 days after the first dose of mRNA-1273 (Lot: unknown). The patient was admitted to the hospital and discharged to hospice. Oxygen was administrated for shortness of breath. The cause of death was unknown. Autopsy details were unknown. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. However, the history of advanced kidney and heart disease may remain as confounder. Additional information has been requested.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1021926 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-05
Onset: 2021-01-08
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

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: 2021-01-18
   Days after onset: 10
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: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data: Test Date: 20210108; Test Name: Covid-19 test; Test Result: Positive ; Result Unstructured Data: Positive
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; Positive result; A spontaneous report was received from a consumer concerning a female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed COVID-19 and passed away. The patient''s medical history was not provided. Concomitant product use was not reported. On 05 Jan 2021, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 08 Jan 2021, the patient had a positive COVID-19 test. On 18 Jan 2021, the patient passed away. No treatment information was provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on 18 Jan 2021. The cause of death was not reported.; Reporter''s Comments: This spontaneous report concerns a female patient who experienced COVID-19 and passed away. The event of COVID-19 occurred 4 days after the first and only dose of the mRNA-1273 vaccine administered and death occurred 14 days after administration of the mRNA-1273 vaccine. Based on the information provided and the known etiology of COVID-19, it is unlikely to be associated with mRNA-1273 vaccine administration. With no definite information on the clinical details of the death, it is difficult to adequately assess a causal association with mRNA vaccine. Main field defaults to ?possibly related''; Reported Cause(s) of Death: unknown cause of death
VAERS ID: 1022127 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2021-01-12
Onset: 2021-01-19
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / -

Administered by: Private       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: 2021-01-19
   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: Heart disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021117157

Write-up: One week to the day after patient''s first vaccine he died of a heart attack; This is a spontaneous report from a contactable consumer and from a contactable physician. A 71-year-old male patient (husband) received first dose bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 12Jan2021 at single dose on the right arm for COVID-19 immunization. The patient medical history included past heart conditions. No known allergies. Patient took other medications in two weeks. Facility type vaccine was doctor''s office/urgent care. No other vaccine received in four weeks. One week to the day after patient''s first vaccine he died of a heart attack on 19Jan2021 18:30. Cause of death was heart attack. No COVID prior vaccination. No COVID tested post vaccination. It was unknown if an autopsy was performed. The physician reported that the patient arrived DOA. Physician signed the death certificate based on the patient''s prior diagnosis. Physician would not provide additional cause of death medical background without consent. He was not aware of any adverse events experienced from the time of vaccination to the date of death. Follow-up (05Feb2021): This is a follow up spontaneous report from a contactable physician. This physician reported in response to HCP telephonic follow up activity which the following: patient death and cause of death were confirmed. Follow-up attempts are completed. No further information is expected. Information about Lot number is not available.; Sender''s Comments: Based on the temporal relationship, the association between the event fatal heart attack with BNT162b2 can not be fully excluded. 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: One week to the day after patient''s first vaccine he died of a heart attack
VAERS ID: 1022160 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-02-05
Onset: 2021-02-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Chills, Death, Listless, Pyrexia, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: aspirin, b-12 shot, Bumex, Calcitrail, Colace, Eztimibe,Imdure, Lantus, Novolog, Lorazepam, Metrprol Suc, Nexium, Plavics, Rena, Sertaline, Synthyroid, VIT D
Current Illness: Kidney failure required dialysis 5x weekly
Preexisting Conditions: Cardiac, Diabetes, Kidney failure Kidney transplant with kidney failure
Allergies: no
Diagnostic Lab Data: none
CDC Split Type:

Write-up: 24 hours after shot had high fever 101, chills, weakness, became listless, family called 911, client became unresponsive and died in the Emergency room.
VAERS ID: 1022397 (history)  
Form: Version 2.0  
Age: 98.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-16
Onset: 2021-02-09
   Days after vaccination: 24
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9289DEATH / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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:
Current Illness: Resident was end of life/comfort measures which started 7/2/2020. diagnosed with covid 1/20/21. received first vaccination 1/16/21 and second dose 2/6/21. expired 2/9/21.
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death 2/9/21
VAERS ID: 1022440 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-23
Onset: 2021-02-01
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Acute myocardial infarction, Chest pain, Death, Dyspnoea, Pericarditis
SMQs:, Anaphylactic reaction (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Chronic kidney disease (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 8
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: HTN, hyperlipidemia, pericarditis (diagnosed in 2014)
Allergies: None
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: The decedent experienced severe chest pain and dyspnea approximately nine days following the first series of the vaccine. He reported to family members that he was having a "severe reaction" to the vaccine and believed it was acute pericarditis due to the same symptoms he experienced prior. He reported that on 2/1/21 around 0300 hours, the symptoms were the most severe and he was going to seek medical attention, but did not. He waited till the convenient store opened and purchased OTC Tylenol for relief of symptoms. He continued to have dyspnea and chest pain up until 2/9/21, when he called 911 complaining of chest pain and was found to have a STEMI; subsequently died at Hospital in the ER.
VAERS ID: 1022529 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-01-27
Onset: 2021-02-09
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Respiratory arrest, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Venlafaxine Hcl ER 150 daily, Multi vitamin, Aspirin 81mg, Nitro 0.4 prn, Vitamin E 200 daily, Ipratropium-Albuterol 0.5-2.5 inhalation q 6 hrs, omeprazole 20mg daily, isorbide monintrate ER 60mg daily, spironolactone 50mg , mens multi vita
Current Illness: pt was seen 1/8/21 for a Scatica flare Pt had a follow up colonscopy performed 1/21/21 where a couple polyps were found and diverticulosis
Preexisting Conditions: pt has COPD and used Oxygen at night, Coronary atherosclerosis, Diabetes Type 2, hypertriglyceridemia, OSA, hyperlipidemia, hypertension, IBS, pulmonary emphysema, acute or chronic heart failure, morbid obesity, atrial fibrillation, depression, hypercholesteremia, stage 3 kidney disease
Allergies: Amoxicillin(rash), Lisinopril (cough)
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pt suffered Cardiac Arrest and respiratory arrest on 2/9/21 and passed away at a local hospital. He had multiple health conditions likely contributing to this. he arrested at home and CPR was attempted and unsuccessful. Pt received his Covid vaccine #1 on 1/27/21. No issues were noted after vaccine and was due for his 2nd dose next week. However, we were notified he passed away on 2/9/21. Very likely death not at all related to vaccine but wanted to document as patient was in the middle of the covid vaccine series.
VAERS ID: 1022552 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-14
Onset: 2021-01-21
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L204 / 1 RA / IM

Administered by: Private       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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amiodarone (PACERONE) 200 mg tablet aspirin 81 mg chewable tablet(Expired) atorvastatin (Lipitor) 40 mg tablet cholecalciferol, vitamin D3, (VITAMIN D3) 1,000 unit capsule furosemide (LASIX) 40 mg tablet LORazepam (Ativan) 0.5 mg tablet met
Current Illness: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Preexisting Conditions: Nervous Coronary artery disease of native artery of native heart with stable angina pectoris (CMS/HCC) Acute chest pain Unstable angina (CMS/HCC) Circulatory VT (ventricular tachycardia) (CMS/HCC) Occlusion and stenosis of unspecified carotid artery PVD (peripheral vascular disease) (CMS/HCC) Non-rheumatic mitral regurgitation Hypertensive heart disease with chronic systolic congestive heart failure (CMS/HCC) Chronic systolic congestive heart failure (CMS/HCC) Idiopathic hypotension Endocrine/Metabolic Mixed hyperlipidemia Hyperkalemia Other ICD (implantable cardioverter-defibrillator) in place Increased BMI
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died of cardiac arrest on 01/21/2021
VAERS ID: 1022685 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-02-09
Onset: 2021-02-09
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 9581 / 2 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Colitis ischaemic, Diarrhoea, Fatigue, Intestinal ischaemia, Megacolon, Nausea, Surgery, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ischaemic colitis (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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:
Current Illness:
Preexisting Conditions: Parkinson''s disease, Diabetes, Leukemia
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received Pfizer Covid Vaccine in the AM on 2/9/21. Arrived to emergency department later the same day complaining of nausea, weakness, fatigue, Vomiting, Diarrhea. Post operative diagnosis, Ischemic colon/toxic megacolon.
VAERS ID: 1022918 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-02-05
Onset: 2021-02-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatine abnormal, Blood urea abnormal, Cardiac failure congestive, Cardiomegaly, Chest X-ray abnormal, Death, Feeling hot, Hiatus hernia, Hypoxia, Leukocytosis, Pleural effusion, Pulmonary oedema, Pulmonary vascular disorder, Renal failure, Spinal fracture, Urinary tract infection, Vomiting, White blood cell disorder
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (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 (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Osteoporosis/osteopenia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (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: 2021-02-06
   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: Alprazolam, Furosemide, Keflex, Losartan, Metoprolol, Protonix
Current Illness: Urinary Tract Infection
Preexisting Conditions: Atrial fibrillation, heart failure, Gerd, Dysphagia, PVD, dementia, anxiety disorder, osteoarthritis
Allergies: Ciprofloxacin, Shellfish
Diagnostic Lab Data: Labs and radiology examinations with abnormal results
CDC Split Type:

Write-up: Resident complained of feeling "hot" at supper time. Had emesis an hour or so later. Became hypoxic and was transferred to the hospital emergency room. Her evaluation in the ED revealed continued presence of UTI, leukocytosis (19.8), and renal insufficiency (BUN 22 Cr. 1.3) BP 99/63; P 74; Temp 98.1; RR 16; and O2 sat of 95% with 2 LPNC (she is typically on RA). CXR reported changes most consistent with CHF with cardiomegaly and bilateral pulmonary vascular prominence. Bibasilar pleural effusions greater on the right than left with pulmonary edema. Large hiatal hernia and likely old chronic wedge defromities involving the mid thoracic vertebral body. She was admitted for IV antibiotics. She expired 2/6/2021
VAERS ID: 1023061 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-30
Onset: 2021-02-08
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Axillary pain, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: Levothyroxine 100 mcg tab once a day
Current Illness: pt had teeth pulled for possible dental implants , non ulcer dyspepsia, treated for diverticulitis 1/6/21
Preexisting Conditions: COPD; hypothyroidism; cricopharyngeal achalasia post surgical treatment, aortic atherosclerosis, hx of perforated ulcer from aspirin use
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received the vaccine on 1/30/21 Pt reported symptoms of left armpit pain to wife on 2/7/21, went to work 4 am 2/8/21 and found face down, dead at work later that morning. Pt worked at a pet store, per wife he did complete his tasks and generally comes home by 7:30 am. Wife called when pt did not come back home and he was found dead.
VAERS ID: 1023673 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2021-01-14
Onset: 2021-01-22
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Acute respiratory distress syndrome, COVID-19 pneumonia, Death, Endotracheal intubation, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Interstitial lung disease (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), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 19
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: HTN, HLD, diabetes type II, iron deficiency anemia, GERD, BPH, COPD
Allergies: unknown
Diagnostic Lab Data: Patient tested positive by rapid PCR on 1/22/2021 through in-house hospital lab for COVID-19.
CDC Split Type: KYIR ID 5405946

Write-up: Patient was vaccinated on 1/14/2021. On 1/22/2021, patient tested positive for COVID-19 and admitted to the hospital for acute hypoxemic respiratory failure, COVID-19 pneumonia, and severe ARDS. Patient was intubated on 1/23/2021 and later died on 2/10/2021 after being extubated and placed on comfort measures.
VAERS ID: 1023791 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-27
Onset: 2021-02-01
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: Escitalopram Oxalate,amlodipine,aspirin,cyanocobalamin,docusate sodium,ergocalciferol,evothyroxine,Melatin,multivitamin,pravastatin,loratadine,senna,Protonix,carvedilol,Lokelma,lidocaine adhesive patch,buprenorphine ,hydralazine,Miralax,hy
Current Illness: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Preexisting Conditions: : G93.40 Encephalopathy, unspecified(Primary, Admission), R56.9 Unspecified convulsions, S06.5X9D Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, M62.81 Muscle weakness (generalized), R26.89 Other abnormalities of gait and mobility, Z48.811 Encounter for surgical aftercare following surgery on the nervous system, W19.XXXD Unspecified fall, subsequent encounter, R47.01 Aphasia, N17.9 Acute kidney failure, unspecified, N18.30 Chronic kidney disease, stage 3 unspecified, D64.9 Anemia, unspecified, N28.1 Cyst of kidney, acquired, E11.9 Type 2 diabetes mellitus without complications, E03.9 Hypothyroidism, unspecified, I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris, I50.22 Chronic systolic (congestive) heart failure, I21.4 Non-ST elevation (NSTEMI) myocardial infarction, N28.9 Disorder of kidney and ureter, unspecified, F33.9 Major depressive disorder,
Allergies: methadone, morphine, nortriptyline
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DIED WITHIN 5 DAYS OF RECEIEVING THE 2ND DOSE, EXPERIENCED GENERALIZED WEAKNESS.
VAERS ID: 1023803 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-01-04
Onset: 2021-01-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E51686 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration, Death, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 10
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: Was contacted by the person''s daughter on 2/5/21. Patient started vomiting 2 days after vaccination. She aspirated and passed away 1/16/21. Patient had history of stroke and swallowing problems.
VAERS ID: 1023840 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-04
Onset: 2021-02-08
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Ziprasidone, divalproex, haloperidol, allopurinol, Lisinopril, atorvastatin, aspirin, carvedilol
Current Illness: Hypertension, Morbid Obesity, DMII, Neuropathy, Cardiomyopathy, Hyperurecemia, Glaucoma, Polyp, Foliculitis, Bi-Polar disorder.
Preexisting Conditions: Same as above.
Allergies: NKDA, NKA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was administered Moderna Covid-19 Vaccine on 2/4/2021. Pt exhbited no symptoms of an adverse reaction of any sort. Pt was ambulating alert and attentive. Pt was observed for the alloted 15 mins by pharmacist and case worker who had escorted pt to vaccination clinic. It was reported that Either on sunday 2/7/2021 or monday 2/8/2021 pt had passed away. Circumstances revolving patient death is still unknown.
VAERS ID: 1023948 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-02-06
Onset: 2021-02-08
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal distension, Alanine aminotransferase increased, Aspartate aminotransferase increased, Bacterial test positive, Blood sodium decreased, Blood urine present, Cardio-respiratory arrest, Death, Decreased appetite, Fatigue, Feeling abnormal, Lymphocyte count increased, Neutrophil count increased, Prothrombin time prolonged, Resuscitation, Troponin increased, Urine abnormality, Urine analysis abnormal, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hyponatraemia/SIADH (narrow), Chronic kidney disease (broad), Proteinuria (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Vitamin C 500 mg daily Bisacodyl 10 mg daily Calcium Carbonate/Vitamin D 500/200 twice daily Clomipramine 100 mg twice daily Divalproex DR 1000 mg twice daily Levothyroxine 50 mcg daily Lisinopril 10 mg twice daily Metoprolol Succinate ER 5
Current Illness: No
Preexisting Conditions: Intellectual Disability Disorder Behavior Disorder (OCD/IED) Hypertension Hyperlipidemia Hypothyroidism Constipation Osteopenia
Allergies: Carbamazepine Loxapine Sulfa Antibiotics Tetracyclines Penicillins
Diagnostic Lab Data: 02/09/21: Urinalysis showed trace blood, cloudy and 2+ bacteria Na= 125 WBC = 13.6 Lymphocytes 6.7 ANC = 10.7 Labs from hospital showed elevated troponin = 155; PT = 22.6; ALT = 405, AST = 205
CDC Split Type:

Write-up: 02/08/21--2 days after vaccine--Resident stated that she "didn''t feel good" (She is developmentally delayed and less able to communicate how she feels than those in the community) and stopped eating most foods; also had fatigue. Vitals, coloring, & behavior were normal. 02/09/21--Belly was firm and mildly distended (although she stated it didn''t hurt); she coded this evening and CPR was performed before EMT could transport her to the hospital. 02/10/21--Resident passed.
VAERS ID: 1023979 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-02-01
Onset: 2021-02-10
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: Medications Azopt 1% ophthalmic suspension, 1 drops, Eye-Both, BID bacitracin/neomycin/polymyxin B topical, 1 appl, Topical, BID, PRN Briviact, 50 mg, 5 mL, Oral, BID calcium carbonate 600 mg (elemental Ca 240 mg) oral tablet, 600 mg,
Current Illness: Dehydration Leukocytosis Dysphagia UTI - Sepsis-resolved Hypernatremia Paroxysmal atrial fibrillation with sick sinus syndrome; S/P pacemaker placement 12/29/20 Acute kidney injury secondary to hypovolemia Macrocytic anemia
Preexisting Conditions: Active Problems Coloboma of iris Atrial fibrillation Mild to moderate hearing loss Dysphagia Peripheral vascular disease Dementia with behavioral disturbance Seborrhea Lagophthalmos Benign prostatic hyperplasia Chronic constipation Gastroesophageal reflux disease Osteopenia Epilepsy Profound ID (IQ <20) ASCVD risk Age-related nuclear cataract, left eye Cardiomegaly Chronic Ileus and megacolon Chronic conjunctivitis Chronic diastolic (congestive) heart failure Chronic obstructive pulmonary disease, unspecified Colostomy and ileostomy status Cyst of right kidney, acquired Dementia with behavioral disturbance Dry eye syndrome of bilateral lacrimal glands Hypocalcemia Hypothyroidism Hypovitaminosis D Iron deficiency anemia Mild hearing loss Mood disorder Nonexudative age-related macular degeneration, left eye, intermediate dry stage Obstructive sleep apnea (adult) (pediatric) Ogilvie''s syndrome Other seasonal allergic rhinitis Presence of cardiac pacemaker 12/29/2020 Primary open-angle glaucoma, bilateral, moderate stage Proteinuria Recent weight gain Recurrent UTI - urinary tract infection Recurrent hypernatremia and dehydration Sick sinus syndrome Sick sinus syndrome s/p pacemaker 12/29/20
Allergies: NKDA
Diagnostic Lab Data: autopsy results are pending
CDC Split Type:

Write-up: Moderna administered 02/01/21. Patient expired 02/10/2020 unexpectedly
VAERS ID: 1024067 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-15
Onset: 2021-01-31
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Chills, Death, Oropharyngeal pain, Productive cough, Pyrexia, SARS-CoV-2 test positive, Sputum discoloured
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (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: 2021-01-31
   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: Hydrocodone/Chlorphen ER Suspension Tylenol Mucinex
Current Illness: N/A
Preexisting Conditions: None
Allergies: No
Diagnostic Lab Data: 1/23: COVID test administered 1/25: Reported positive for COVID 1/26: Patient was informed of positive result
CDC Split Type:

Write-up: 1/15: Pfizer vaccine dose 1 administered 1/16: Fever, chills 1/22: Sore throat, coughing w/white phlegm, taking Tylenol and Mucinex. Fever and chills from 1/16 subsided. Had telehealth consultation with PA. Per her notes, patient said he gets these symptoms annually, requested for an antibiotic. PA referred him for a COVID test. Ordered hydrocodone/chlorphen ER suspension for his cough and an antibiotic. Antibiotic was recommended if symptoms do not subside. 1/23: COVID test administered 1/25: Reported positive for COVID 1/26: Telehealth session w/PA: she informed patient of his positive test, advised to quarantine and seek medical help at hospital if symptoms worsen. Patient reported that his sore throat mostly subsided but is still coughing at night. Said that the pharmacy didn''t receive the prescription order for the antibiotic, so this was re-ordered. 1/31: Partner found him dead at 8:18AM on his bed. Death certificate issued by state says cause of death: COVID. Autopsy was not performed. Buried on 2/9/21.
VAERS ID: 1024157 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Texas  
Vaccinated: 2021-01-11
Onset: 2021-01-20
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Decreased appetite, Diarrhoea, Oxygen saturation decreased, Pain, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Pseudomembranous colitis (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   Days after onset: 9
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Simvastatin, HCTZ, Sertraline, Donepezil, Fenofibrate, Vitamin D3, Vitamin B12, Zyrtec, 81mg Aspirin, Colace
Current Illness: Alzheimer''s, Type II Diabetes
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: 7 days after receiving the vaccine, patient suffered excessive diarrhea and slight coughing. 9 days after vaccine, patient was tested for Covid 19, and received positive results. Patient was transported to hospital via ambulance but hospital returned her to the nursing home since chest was clear, no respiratory issues, and no fever. 10 days after receiving the vaccine, patient was turned over to hospice care but still in the nursing home. Hospice was called in to provide better physician advice and access 24/7. 14 days after receiving vaccine, patient began experiencing excruciating body aches, coughing, low oxygen levels, and no appetite. 18 days after vaccine, patient died.
VAERS ID: 1024226 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-01-06
Onset: 2021-01-14
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dizziness, Haematemesis, Hypotension, Tachycardia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Respiratory failure (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-14
   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: CAD, Atrial Fibrillation, dementia, stroke, htn, ckd, AAA
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: New onset dizziness with hypotension, tachycardia, and vomiting blood. Sent to ER - told he went into cardiac arrest and died.
VAERS ID: 1024325 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-02-03
Onset: 2021-02-05
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: N/A
Current Illness: SHINGLES ABOUT A MONTH AGO
Preexisting Conditions: AFIB, HIGH BLOOD PRESSURE, HIGH CHOLESTEROL
Allergies: LATEX
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed away on February 5, 2021. There was no reaction after the shot was given, the patient''s son said the death was not related to the vaccine. The patient had a bad case of shingles about a month prior to receiving the vaccine which the son said had been hard on the patient, the patient was also 90 years old. Per the son, the patient''s doctor had wanted the patient to get the vaccine. Due to the close proximity of the date the vaccine was given and the date Patient passed away we wanted to complete the VAERS form.
VAERS ID: 1024343 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Hawaii  
Vaccinated: 2021-02-05
Onset: 2021-02-09
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 6201 / 2 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL 8982 / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac 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), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
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: HYDROXYCHLOROQUINE MONTELUKAST METOPROLOL XL PANTOPRAZOLE
Current Illness:
Preexisting Conditions: LUPUS
Allergies: ERYTHROMYCIN
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT ARRIVED TO ED ON 2/9 IN FULL CARDIAC ARREST
VAERS ID: 1024420 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-21
Onset: 2021-01-24
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cardiac arrest, Chills, Death, Decreased appetite, Headache, Nausea, Pain in extremity, Psychomotor hyperactivity, Pyrexia, Unresponsive to stimuli
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), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Akathisia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Heart Disease
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had the first Moderna Covid vaccine on Thursday 1/21/2021. She had a bit of sore arm on that day and the day after. On Saturday 1/23/2021, she had a fever of 100.5 F (11AM), nausea, light headache and chills. The temperature went down after she took ibuprofen. Patient''s husband enrolled her to V-Safe to report all the adverse effects she experienced. On Sunday 1/24/2021, her temperature was 98.3F. She still had nausea and no appetite. She and her husband watched a football game in their bedroom upstairs. Husband noticed that his wife was pacing around the room many times. At 7Pm, Husband went downstairs for dinner but she refused to come down to eat. He went upstairs around 8pm, TV was still on. He turned off TV and went down stairs again thinking his wife felt as sleep while watching TV. He went back upstairs for bed around 10:30 PM. Husband said his wife had a deviated septum so she would snore very loudly when asleep. He didn?t hear her snoring so he went to check on her and found her not responsive. Husband called emergency services. Paramedic came at 10:45 and said patient was passed. Husband sent many texts to V-safe after that to report the incident. No response was received from V-safe. Patient?s doctor told her husband that she died due to cardiac arrest.
VAERS ID: 1024539 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Arizona  
Vaccinated: 2021-01-15
Onset: 2021-01-28
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, COVID-19, Dyspnoea, Nausea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinol, citalopram, sodium bicarb., furosemide, ascorbic acid, folic acid, pravastatin, vitamin D2, levothyroxine, potassium chloride, calcium carbonate, b complex, omega 3s, prednisone, levocetirizine, tumeric, krill oil, metoprolol
Current Illness: shoulder pain, dermatitis, chronic kidney disease, edema, gerd, venous insufficiency, hypertension, RA, hypothyroidism, osteoporosis, depression, radiculopathy, rosacea.
Preexisting Conditions:
Allergies: alupent, coumadin, cephalexin, saccharin, gabapentin, codeine sulfate, sulpher, onion, perfumes and fragrances, adhesive.
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient tested positive for covid on 1/29/21. was hospitalized on 2/8/21 for shortness of breath, generalized weakness, nausea.
VAERS ID: 1024592 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-02
Onset: 2021-02-11
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / UNK LA / IM
UNK: VACCINE NOT SPECIFIED (NO BRAND NAME) / UNKNOWN MANUFACTURER DF1306 / UNK RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cerebral arteriosclerosis, Respiratory distress
SMQs:, Anaphylactic reaction (broad), Ischaemic central nervous system vascular conditions (narrow), Acute central respiratory depression (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: 2021-02-11
   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: Allopurinol, Ativan, Vit B12, Colace, Ferrous Sulfate, Gabapen Gabapentin, Lansoprazole, LEvsin, Miralax, Mirtazapine, Morphine Sulfate, Multivitamin with minerals, Omeprazole, Senna, Trazadone, Valproic Acid, Vitamin C
Current Illness: acute pyelonephritis, acute respiratory failure
Preexisting Conditions: Metabolic Encephalopathy, Sepsis, anemia, neuropathy, chronic kidney disease, aspergers syndrome, hydronephrosis with uretral calculous obstruction, uterovaginal prolapse, obstructive and reflux uropathy, protein-calorie malnutrition, anxiety, major depressive disorder, gastro-esophageal reflux disese, diabetes mellitus 2.
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reactions noted. Resident is on hospice for end of life care for terminal diagnosis cerebral atherosclerosis. Experiencing respiratory distress 2/10/2021 r/t to hospice prognosis.
VAERS ID: 1024626 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated: 2021-02-01
Onset: 2021-02-06
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 42L20A / 7+ LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: amlodipine,aspirin,losartan,metformin,pravastatin,polyethylene glyco,Colace,cholecalciferol
Current Illness: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Preexisting Conditions: N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms(Primary, Admission), Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system, M62.81 Muscle weakness (generalized), R26.2 Difficulty in walking, not elsewhere classified, R13.12 Dysphagia, oropharyngeal phase, R48.8 Other symbolic dysfunctions, I66.3 Occlusion and stenosis of cerebellar arteries, G95.20 Unspecified cord compression, I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, M47.12 Other spondylosis with myelopathy, cervical region, I10 Essential (primary) hypertension, E78.5 Hyperlipidemia, unspecified, E55.9 Vitamin D deficiency, unspecified, E11.9 Type 2 diabetes mellitus without complications, I63.9 Cerebral infarction, unspecified, R33.9 Retention of urine, unspecified, D64.9 Anemia, unspecified, N18.9 Chronic kidney disease
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: DEATH ON 5TH DAY OF 2ND DOSE.
VAERS ID: 1024627 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Louisiana  
Vaccinated: 2021-02-02
Onset: 2021-02-05
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Atrial fibrillation, COVID-19, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia
SMQs:, Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Supraventricular tachyarrhythmias (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Hypertension (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda
Diagnostic Lab Data:
CDC Split Type:

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died
VAERS ID: 1024743 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-01
Onset: 2021-02-08
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Decreased appetite, Diet refusal, Lethargy
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: xalatan drops, cosopt drop, alphgan drops, Norco, Seroquel, dulcolax supp, Senna, depakote sprinkles, trazodone,
Current Illness: none
Preexisting Conditions: vascular dementia, glaucoma, osteoporosis
Allergies: none known
Diagnostic Lab Data: none
CDC Split Type:

Write-up: pt became lethargic, stopped eating. No fever; no nausea
VAERS ID: 1024788 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-01-25
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.
VAERS ID: 1024790 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-01-25
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.
VAERS ID: 1024795 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-13
Onset: 2021-01-25
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt had passed away before second dose given.
VAERS ID: 1024817 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Guam  
Vaccinated: 2021-02-11
Onset: 2021-02-12
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Aspiration, Blood pressure systolic decreased, Cardio-respiratory arrest, Death, Dialysis, Endotracheal intubation, Gastrointestinal haemorrhage, Mechanical ventilation, Pulse absent, Pulseless electrical activity, Respiratory arrest, Resuscitation, Seizure like phenomena, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Acute renal failure (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Meds Prior to hospitalization: Propanolol, cilostazol, duloxetine HCL DR 30
Current Illness: NIDDM, HTN, CAD s/p CABG x4v, liver cirrhosis, ESRD on HD, cataracts, dysarthria, PAD s/p angioplasty 2020 bilateral lower extremity
Preexisting Conditions: social history of alcohol abuse
Allergies: Ampicillin sodium
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was coded and expired Code Blue: Patient was in dialysis, after 30 minutes his sbp dropped to 60s he was given 4 albumin. Patient who was responsive before that became unresponsive, had seizure like activity, lost pulse and spontaneous breathing. HD stopped. Code called. Cpr started. A few minutes into cpr patient started to profusely bleed - gi bleed and ventilation became very hard., intubation was very difficult and ventilation hard as we suctioned large amounts of aspirated blood. Patient was eventually intubated. More than 8 doses of epi ws given, sodium bicarbonate * 2 given with continuous cpr. It was mostly PEA with one shockable rhythym. And shock delivered for vfib. patient continued to profusely bleed, og insertion was not successful and effective ventilation was very tough due to massive aspiration,. Possible variceal rupture with cpr from his cirrhosis is likely scenario. After 30 minutes of unsuccessful ventilation and acls protocol. Code was stopped.
VAERS ID: 1024853 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-30
Onset: 2021-02-08
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Abdominal pain upper, Aspiration, Death, Fatigue, Haemorrhage, Nasopharyngitis, Nausea, SARS-CoV-2 test negative
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: Chemo
Current Illness: Essential Thrombocytopemia Alzheimer?s
Preexisting Conditions: Essential Thrombocytopemia Alzheimer?s
Allergies: None
Diagnostic Lab Data: No medical tests or laboratory exams provided. Medical Examiner declined to physically view the body on site. Through photos or phone video declared death to be natural. Death certificate was later filled out by primary care physician who again did not examine her body or even know the details of her death.
CDC Split Type:

Write-up: Feb 8 states she had a cold. Feb 9 added stomach ache and nausea. Feb 9 visited urgent care facility for exam and Covid-19 test. Rapid test results were negative. Appeared tired but fine. Told to go home and rest. Feb 10 at 9:00 am found dead on the floor in pool of blood and aspirated. Excessive blood in toilet, pooled on floor and hallway rug.
VAERS ID: 1025472 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: California  
Vaccinated: 2021-02-10
Onset: 2021-02-10
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Dialysis, Fatigue, Peripheral coldness, Pulse absent, Unresponsive to stimuli
SMQs:, Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 0
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:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received COVID19 vaccine at clinic at 11:52 am, discharge post treatment stable. Got home around 2:30 pm went to bed. He usually got tired post dialysis. He did not wake up at 6 pm. His wife went check on him. found patient cold and unresponsive. 911 pulseless PEA. ER Medical hospital. Pronounced death at 7:40 pm
VAERS ID: 1025079 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2021-02-09
Onset: 2021-02-10
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: albuterol-ipratropium 2.5mg-0.5mg/3mL nebulizer QID amiodarone 100mg PO daily amlodipine 2.5mg PO daily PRN high blood pressure aspirin 81mg PO daily Symbicort 160mcg-4.5mcg/inh 2 puffs BID calcitriol 0.25mcg PO on M-W-F carvedilol 12.5m
Current Illness: None known
Preexisting Conditions: Aortic Stenosis Coronary Artery Disease asthma Hypertension cardiac pacemaker COPD Chronic kidney disease diastolic heart failure hyperlipidemia thrombocytopenia
Allergies: No known allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient found by family in his home deceased on the morning of 02/10/2021.
VAERS ID: 1025081 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-02-04
Onset: 2021-02-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Arteriosclerosis, Autopsy, Condition aggravated, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: Amlodipine 5mg, asprin 81mg, atorvastin 10mg, cinacalet 120mg daily, sevelamer 800mg, Nephrocaps (MVT)
Current Illness:
Preexisting Conditions: ESRD on HD, HCV cirrhosis, refractory ascites, CAD, CHF (EF15%-20%), hyperparathyroidism
Allergies: Bactrin, NSAIDS
Diagnostic Lab Data:
CDC Split Type:

Write-up: No reported adverse reactions from 1st or 2nd vaccine doses Patient died on 2/6/2021 at Correctional facility- autopsy was performed at medical examiner''s office. The COD was artherosclerotic cardiovascular disease
VAERS ID: 1025299 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-02-07
Onset: 2021-02-10
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 RA / 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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Other- Patient died - cause unknown; 1 day
VAERS ID: 1025330 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-25
Onset: 2021-01-26
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Oxygen saturation decreased, Pneumonia aspiration, Vomiting
SMQs:, Acute pancreatitis (broad), Acute central respiratory depression (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 16 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5 mg po daily, docusate 100 mg BID,Eliquis 5 mg po BId, Omeprazole 20 mg po daily,Zinc 220mg po daily
Current Illness: None
Preexisting Conditions: Dementia
Allergies: None
Diagnostic Lab Data: I have been told by his daughter that he had aspiration pneumonia.
CDC Split Type:

Write-up: On 1/26 at breakfast table began vomiting. Continued thru am when at noon a caregiver did his O2 saturation and found it was 75%. This was confirmed, and resent sent to ER .
VAERS ID: 1025398 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-02-05
Onset: 2021-02-07
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 LA / 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: 2021-02-07
   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: COPD, type II diabetes, HTN
Allergies: Latex, Abilify, Gadolinium contrast media
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccine on 2/5. We were told on 2/9 that the patient visited another emergency department on 2/6 but no information was given as to what prompted that visit. She was sent home. Daughter found her on 2/6 or 2/ 7 unresponsive and she died.
VAERS ID: 1025493 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-02-09
Onset: 2021-02-11
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Multiple prescription medications, but drug/dose/directions are unknown.
Current Illness: Cancer
Preexisting Conditions: Cancer
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient expired on the morning of 2/11/2021. No known adverse events prior to death. Patient was observed for 20 to 25 minutes after administration of vaccine and reported experiencing no signs or symptoms of adverse events at that time.
VAERS ID: 1025579 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Louisiana  
Vaccinated: 2021-02-11
Onset: 2021-02-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Cardioversion, Death, Fall, Life support, Pulse absent, Screaming, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Supraventricular tachyarrhythmias (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: amlodipine 5 mg daily, aspirin 81 mg daily, atorvastatin 40 mg daily, candesartan 32 mg daily, fluoxetine 20 mg daily, furosemide 40 mg daily, calcium carbonate/vitamin D, ascorbic acid, latanoprost ophthalmic solution, metformin 500 mg da
Current Illness: none reported
Preexisting Conditions: coronary artery disease, history of CABG, history of MI, hypertension, COPD, polymyalgia rheymatica, hypercholesterolemia, hear failure, carotid artery stenosis, type 2 diabetes, morbid obesity, rheumatoid arthritis, panlobar emphysema (on 3L home O2)
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received the vaccine at an outside healthcare facility on 2/11/21. At approximately 1 pm she screamed out and fell out of her chair. EMS was called and patient was found to be in Vfib. ACLS was performed for approximately 42 minutes prior to arrival at ED. At that time the patient had been pulseless for 25 minutes. Patient received 450 mg of amiodarone, epinephrine x7, sodium bicarbonate x2, and 7 AED shocks. In the ED 3 more doses of epinephrine were given, one more dose of sodium bicarbonate, and 5 additional shocks. ROSC was not achieved and time of death was called at 1416.
VAERS ID: 1025641 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2021-01-11
Onset: 2021-01-18
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dizziness
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, Metformin, Tamsulosin
Current Illness: No other vaccinations no other illnesses
Preexisting Conditions: diabetes
Allergies: Aspirin, Simvistatin, Tamsulosin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Complained of dizziness on January 18,th seen by MD this date. Passed away on 22nd.
VAERS ID: 1026021 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Maryland  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -
PPV: PNEUMO (NO BRAND NAME) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Inappropriate schedule of product administration
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021120769

Write-up: a male patient received the pneumonia shot 12 days after the first dose of the vaccine; he had died; This is a spontaneous report from a contactable consumer or other non hcp. A 76 years old male patient received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for COVID 19 immunisation and received pneumococcal 13-val conj vac (dipht crm197 protein) (PNEUMOCOCCAL 13-VAL CONJ VAC (DIPHT CRM197 PROTEIN)), via an unspecified route of administration on an unspecified date 12 days after bnt162b2 at single dose for immunisation. The patient medical history and concomitant medications were not reported. The patient died on an unspecified date. It was not reported if an autopsy was performed. Pfizer is Marketing Authorization Holder of pneumococcal 13-val conj vac (dipht crm197 protein) in the reporter''s country. This may be a duplicate report in situations where another Marketing Authorization Holder of pneumococcal 13-val conj vac (dipht crm197 protein) has submitted the same report to the regulatory authorities. Information on lot and batch number has been requested. Follow-up: (08Feb2021): Lot/batch number is not available despite the follow-up attempts made. Follow-up attempts are completed. No further information is expected.; Reported Cause(s) of Death: a male patient received the pneumonia shot 12 days after the first dose of the vaccine; he had died
VAERS ID: 1026045 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Nebraska  
Vaccinated: 2021-02-01
Onset: 2021-02-07
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 2 RA / SC

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Malaise, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: COPD
Preexisting Conditions: COPD, history of stroke
Allergies: Sulfa, Hydroxizine,
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 2/7/21 resident complainted of not feeling well, nausea, vomiting and weakness sent to ER passed away.
VAERS ID: 1026095 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-16
Onset: 2021-02-12
   Days after vaccination: 27
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 - / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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 2/12/21
VAERS ID: 1026141 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-16
Onset: 2021-02-12
   Days after vaccination: 27
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 LA / IM

Administered by: Senior Living       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: 2021-02-12
   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: positive covid 19 2/2/21
CDC Split Type:

Write-up: death 2/12/21
VAERS ID: 1026233 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: North Dakota  
Vaccinated: 2021-01-18
Onset: 2021-02-02
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Immune thrombocytopenia, Platelet count decreased
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 9
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Plaquenil 200 mg bid/ mirtazapine 30 mg qhs / amlodipine 2.5 mg daily / atorvastatin 80 mg daily / Lasix 40 mg daily / imdur 30 mg qam/ losartan 100 mg daily / Plavix 75 mg daily/ NTG 0.4mg prn/ levothyroxine 150 mcg daily
Current Illness: none
Preexisting Conditions: hypothyroidism,/ acute on chronic diastolic heart failure / polymyalgia rheumatica / hx of cva / hx of CABG/ gerd / bph/ polyarthritis
Allergies: hayfever / Darvocet / norco
Diagnostic Lab Data: plt count of 1,000
CDC Split Type:

Write-up: patient developed autoimmune thrombocytopenia
VAERS ID: 1026270 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-02-11
Onset: 2021-02-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Resuscitation, 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: 2021-02-11
   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: Albeterol Inh Soln 0.083 % Calcium 600mg + D 400 IU One Daily Woman 50 + tablet Cetirizine HCL 10 mg Tablet Digozin 0.125 mg Tablet Levothyroxine 100 mcg tablet Metoprolol Tartrate 50 mg Tablet Esomeprazole Mag. Dr 40 mg Capsule Nitroglyc
Current Illness:
Preexisting Conditions: primary hypertension Mitral Valve regurgitation COPD Osteoporosis Kyphoscoliosis deformity of spine Rheumatoid factor positive GERD history of cellulitis of leg history of C-diff post ATB therapy Monoclonal gammopathy Iron deficiency anemia, unspecified Hypothyroidism, unspecified Hyperlipidemia, unspecified Coronary atherosclerosis due to lipid rich plaque Nonrheumatic tricuspid valve disorder, unspecified Chronic atrial fibrillation Allergic rhinitis, unspecified Barrett''s esophagus without dysplasia Other specified urinary incontinence
Allergies: Ceftin, Cefuroxine, Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: At 10:33 am Patient pushed her pendant for staff, staff arrived to her apartment and Patient was found unresponsive in her bathroom. Patient received her second COVID-19 Pfizer vaccine about 75 minuets prior to this, she had no adverse reaction''s within the first hour of receiving the second dose. CPR was started until paramedics arrived, they took over and tried to resuscitate. Patient was pronounced dead at 11:33 am at scene.
VAERS ID: 1026362 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-01-01
Onset: 2021-02-04
   Days after vaccination: 34
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Appetite disorder, Autopsy, Death, Migraine
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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:
Current Illness:
Preexisting Conditions: Duchenne muscular dystrophy
Allergies:
Diagnostic Lab Data: Autopsy 2/11 Medical Center
CDC Split Type:

Write-up: Patient stated he had a migraine after the vaccine. We were advised of a change in appetite on Thursday February 4th. Patient died on February 6th.
VAERS ID: 1026379 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-02-09
Onset: 2021-02-09
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 2 RA / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: OXYMETAZOLINE HCL 0.05% NASAL SPRAY DISCONTINUED 30 02/09/2021 02/09/2021 02/09/2021 1 USE 1 SPRAY NASAL TWICE A DAY MAX OF 3 DAYS OF USE** DOCUSATE NA 50MG/SENNOSIDES 8.6MG TAB DISCONTINUED 60 02/09/2021 01/20/2021 01/21/2021
Current Illness: HTN-Iron def-h/o PE-chronic renal failure
Preexisting Conditions: HTN-Iron def-h/o PE-chronic renal failure
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient 6 hours post vaccination
VAERS ID: 1026396 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Missouri  
Vaccinated: 2021-01-14
Onset: 2021-01-15
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Ageusia, Death, Decreased appetite
SMQs:, Taste and smell disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 8
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 experienced loss of taste and lack of appetite. Passed away on 1/23/21.
VAERS ID: 1026443 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Mississippi  
Vaccinated: 2021-02-09
Onset: 2021-02-09
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032L20A / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death, Pulseless electrical activity, Resuscitation, Syncope, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Amalodopine, Treesiba, Metoprolol, Prevastatin, Telmisarta-HTZ
Current Illness: Unknown
Preexisting Conditions: High Blood Pressure, Adult Onset Diabetes Mellitus
Allergies: None
Diagnostic Lab Data:
CDC Split Type: MS0152021

Write-up: Received first 1/15/2021 with no adverse reaction. Received 2nd dose 2/9 @ 0846 with no adverse reaction or report of feeling ill. Traveled to store and arrived approx. 2 hours after receiving vaccine. Daughter stated patient felt well and had to go to the restroom to have BM. Collapsed in bathroom. Transported by ambulance to Hospital @ 1439 in cardiac arrest. Was in PEA and went in v fib back to PEA. Resuscitation efforts initiated and patient expired with time noted at hospital records at 15:11.
VAERS ID: 1026451 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Indiana  
Vaccinated: 2021-02-01
Onset: 2021-02-02
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 2 UN / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident expired 2/2/2021 one day after the vaccine
VAERS ID: 1026492 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-02-11
Onset: 2021-02-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9809 / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Death, Dyspnoea, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (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? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The individual received the vaccine around 12:00pm on 02/11/21. Around 9pm the individual went to lay down on the couch at home and started to have difficulty breathing. Within 30 minutes the individual became week and unresponsive. She was transported to the hospital where she was pronounced deceased at 11:44 pm on 02/11/21.
VAERS ID: 1026499 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-02-05
Onset: 2021-02-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Body temperature increased, Cardio-respiratory arrest, Chills, Death, Pulse absent, Tremor, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (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), Parkinson-like events (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Lactulose, Lasix, Megestrol Acetate, Metoprolol Tartrate, Spironolactone, Lasix, Vitamin B12, Rifaximin, Milk Thistle, Tramadol
Current Illness: Enterococcus UTI, acute on chronic systolic and diastolic heart failure
Preexisting Conditions: ,chronic kidney disease stage 3, cirrhosis, HTN, hypomagnesemia, hypothyroidism, neurocognitive disorder, hx of hepatic encephalopathy
Allergies: Carvedilol, Tizanidine, Augmentin, ACE inhibitors, Bees
Diagnostic Lab Data: None done at facility
CDC Split Type:

Write-up: Resident reviewed for incident. Resident received the second dose of the Moderna Covid-19 vaccine lot# 016M20A Exp 5/2/2021 on 2/5/2021 from clinic through pharmacy. Resident had her temp/O2 taken on AM shift and was 98.6/93%, beginning PM shift 98.4/95%. A few hours later noted that resident to have chills and was shaking RN assessment completed and vitals taken resident noted to have temp of 102.2, oxygen 95%, pulse 110. Resident alert and oriented at that time and talking to staff. Reported findings to APNP with order to send to ER. 911 called, residents brother updated. Upon EMT arrival RN went down to residents room with EMT and resident had an emesis as resident was getting cleaned up resident went unresponsive. Pulse noted to still be present at that time, resident did briefly respond to sternal rub and then went unresponsive again. Resident full code and EMT transferred to gurney and said that if they lost a pulse in route that they would transfer to hospital B instead of hospital A being the closest facility. RN called brother and gave update. Facility notified from Hospital that resident had passed away.
VAERS ID: 1026534 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-02-03
Onset: 2021-02-05
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 2 RA / IM

Administered by: Senior Living       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: 2021-02-09
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: senna, pantoprazole, vit D2, fluoxetine, folic acid, melatonin, metoprolol
Current Illness:
Preexisting Conditions: , HTN, CKD, Alzheimer''s
Allergies: ciprodex
Diagnostic Lab Data:
CDC Split Type:

Write-up: resident had a stroke, sent to the hospital and died 4 days later
VAERS ID: 1026581 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: Washington  
Vaccinated: 2021-01-15
Onset: 2021-02-04
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: tetanus toxoid
Other Medications: Spironolactone, amlodipine, tamsulosin, losartan, pantoprazole, tadalafil, propranolol
Current Illness: He had sudden death on Feb 4th. Unclear if this could be related to vaccination but since it was close in timing report has been filed.
Preexisting Conditions: Hyperparathyroidism s/p surgical correction in 2020, MGUS, Idiopathic peripheral neuropathy, gout, OSA
Allergies: Erythromycin, PCN, Hmg-coa reductase inhibitors, nifedipine, tetanus toxoids, tetracyclines
Diagnostic Lab Data:
CDC Split Type:

Write-up: He had sudden death on Feb 4th. Unclear if this could be related to vaccination but since it was close in timing report has been filed. No known immediate reaction to vaccination.
VAERS ID: 1026671 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-06
Onset: 2021-01-07
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Agitation, Death, Intensive care, Malaise, Pneumonia
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hostility/aggression (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow)

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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none reported
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: Patient has not been reported as a COVID related death, no information on status of testing for COVID in the hospital.
CDC Split Type:

Write-up: The vaccine was administered at the patient''s residence in an assisted living facility. The morning following the vaccination staff report that she was very agitated and stated she did not feel well. They called an ambulance and she was transported to a local ER, staff report that it was not at the hospital that the patient is usually seen by when when she has issues and they were concerned that the facility did not have her medical history to treat her properly. The patient''s grandson reported back to the assisted living director that the patient was diagnosed with asymptomatic pneumonia, was transferred to the ICU and passed away in the night.
VAERS ID: 1026699 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-20
Onset: 2021-01-23
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Atrial fibrillation, Cerebrovascular accident, Death
SMQs:, Supraventricular tachyarrhythmias (narrow), 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: 2021-01-30
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Had a stroke 3 days after round one of Covid vaccine and subsequently died the next week due to complications of stroke. Upon admission to hospital, was in afib.
VAERS ID: 1026752 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-02-03
Onset: 2021-02-06
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20 / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Seizure, Ventricular fibrillation, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Convulsions (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Plavix Furosemide Amiodarone Humulin Lantus Levothyroxine NTG SL Pepsid Spironolactone Alprazolome Isosorbide Trazadone Nystatin topical Hydroxyuria Sertraline
Current Illness:
Preexisting Conditions: Heart Disease Hx of Triple Bypass surgery Atrial Fib CAD Diabetes GERD Hyperlipidemia HTN Hypothyroid Idiopathic Small Intestine Ulcers PAD Polycythemia
Allergies: Ace Inhibitor Allergy Morphine- Adverse Rxn
Diagnostic Lab Data:
CDC Split Type:

Write-up: Developed vomiting, seizure and cardiac arrest, V Fib
VAERS ID: 1026841 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Wyoming  
Vaccinated: 2021-02-11
Onset: 2021-02-12
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: Tylenol
Current Illness:
Preexisting Conditions: Dementia, Hyperlipidemia, Hypertension, Osteoarthritis, Cerebral Infarction, COPD
Allergies: Aloe, Tetracycline
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident passed away this morning. No signs or symptoms prior to his death of an issue with the vaccine. He was an end stage dementia resident at the nursing home.
VAERS ID: 1026980 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-22
Onset: 2021-01-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Computerised tomogram abdomen abnormal, Computerised tomogram pelvis abnormal, Computerised tomogram thorax abnormal, Death, Nausea, Pulmonary embolism, Thrombosis
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: METFORMIN, PIOGLITAZONE, NORTRIPTYLINE, TERAZOSIN, RISPERDONE, VIT D 3, DEPO-TESTOSTERONE, LOSARTAN, FLUTICASONE, NTG SL, CRESTOR, PROSCAR, ZOLOFT, MONTELUKAST, HYDROXYZINE, CARAFATE, OMEPRAZOLE, REGLAN, CENTRUM SILVER.
Current Illness: NONE
Preexisting Conditions: DIABETES, MOOD DISORDER, ELEV CHOL, CAD, HTN, BPH, DIABETIC NEUROPATHY, ENVIROMENTAL ALLERGIES, LOW VIT D, HYPOGONADISM, GERD
Allergies: NKDA
Diagnostic Lab Data: CT CHEST , CT ABDOMEN PELVIS, (01/23/2021) AUTOPSY 02/03/21??
CDC Split Type:

Write-up: Patient reported to Emergency room on 01/23/2021 with complaint of nausea. According to ER record patient reported he received a COVID 19 vaccine Pfizer the day before. Work up in the ER (CT ABD PELVIS) reveal a clotted of SMA. CT CHEST REVEALED BILATERAL PULMONARY EMBOLUS. THE PATIENT WAS TRANSFERRED TO THE STATE HOSPITAL. HE WAS SCHEDULED FOR EMERGENT VASCULAR SURGERY WHICH WAS CANCELLED AS THE PATIENT DIED SHORTLY AFTER HIS ARRIVAL.
VAERS ID: 1027051 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-12
Onset: 2021-02-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Cardioversion, Death, Dizziness, Eye movement disorder, Intraosseous access placement, Loss of consciousness, Resuscitation, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: Humulin 70/30 B 12 Aspirin 81 mg Hydralazine Plavix Isosorbide MN ER Metoprolol Simvastatin Lisinopril Women''s 1 a Day vitamin Calcium with D3 Iron Glucose Tablets
Current Illness: Patient not feeling well this morning prior to arrival, complaints of shortness of breath
Preexisting Conditions: Diabetes Status Post MI x 4 Status Post left stent Status Post right stent Breast CA Status Post Bilateral Mastectomy
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Few minutes post vaccination, after moving to observation area via wheelchair, the patient complained of dizziness. She took glucose tabs she had brought with her. Staff wheeled her to Triage # 1. Her eyes rolled back in her head and she lost consciousness. Staff (paramedics on site) transferred her to gurney and started compressions. AED placed, V- Fib was rhythm, Shock # 1 given, CPR resumed. Shocked again. Fire truck and additional EMT arrived on site and took over care. Epinephrine was given 3 times via intra-osseous route, Amiodarone given intra-osseous route. Additional defibrillation with on site AED for a total of 6-7 times. Patient had good chest rise with ambu-bag, no airway obstruction or peri-oral edema noted. Code called at 12:40 PM.
VAERS ID: 1027071 (history)  
Form: Version 2.0  
Age: 101.0  
Sex: Male  
Location: Washington  
Vaccinated: 2021-01-28
Onset: 2021-01-29
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 2 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Asthenia, Cerebrovascular accident, Death, Dysarthria, Hemiparesis
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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 11
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: BP meds x3, Statin, Thyroid, Aspirin, Multivit, Calcium, Vit D
Current Illness: Very elderly
Preexisting Conditions: Previous heart bypass surgery (1995) and later two stents between 1995-2000
Allergies: None
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Adverse reaction to the vaccine started with variable weakness beginning 1/29/2021. On 1/30/21 around 8:30pm, he needed assistance in the bathroom related to weakness and had what was later identified as a stroke with left side weakness and slurred speech. In accordance with his wishes, he had care at home. Due to his advanced age and frailty, a CT scan was not pursued. The 325 mg of aspirin that he was previously taking daily was discontinued. After the stroke, he needed total care. Hospice was established at home. Nursing assistant care was delivered by daughter. Death followed 9 days later (2/9/2021).
VAERS ID: 1027141 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Oregon  
Vaccinated: 2021-01-29
Onset: 2021-01-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acidophilus Capsule BID, Metamucil (Generic) 1 packet/day, Metformin HCL 500 Generic BID, Omeprazole 20 mg Daily, Potassium Cloride ER 20 MEQ tablet PO daily with breakfast, Prenatal Vitamin plus low iron daily with breakfast, Tamsulosin Hc
Current Illness: None, Last prior illness was November 2020 he had Cdiff and was at Hospital but per facility the patient was fully recovered from this.
Preexisting Conditions: Forgetfulness/Mild Dementia, Diabetes, Obese, Urinary Flow Issues all per facility and MAR
Allergies: NKDA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The patient reported feeling well. I discussed with him the Covid-19 vaccine and he was able to state that he wanted it and to sign his consent form. The facility reported they had discussed this with him and he had agreed prior to my visit.
VAERS ID: 1027158 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-10
Onset: 2021-02-12
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Malaise, Muscular weakness, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Peripheral neuropathy (broad), 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: 2021-02-12
   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 500 mg oral tablet, 500 mg= 1 tabs, Oral, TID, 1 refills ammonium lactate 12% topical lotion, 1 app, Topical, BID, 2 refills calcium (as carbonate)-vitamin D 600 mg-400 intl units oral tablet, 1 tabs, Oral, BID, 4 refills C
Current Illness: CKD-4 Dementia Incontinence of stool Insomnia Skin breakdown right gluteus
Preexisting Conditions: Chronic insomnia CKD Constipation Dementia Hepatitis B non-immune Onychomycosis Osteoporosis NOS Stool incontinence x2 ( 2 months and one week ago while out on stret) TIBC - Total iron binding capacity low Tinea pedis Vitamin B12 deficiency Vitamin D deficiency
Allergies: NKDA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: death. Per son pt was not feeling well after the vaccination "like her legs were weak." Son found the mom in her bed 1am on 2/12/2021 unresponsive.
VAERS ID: 1027258 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-22
Onset: 2021-01-22
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Dyspnoea, Nausea
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Eliques 2.5 mg, carvedilol 6.25, hydralazine 50 mg,tradjenta 5mg,
Current Illness: kidney failure, diabetic
Preexisting Conditions: congestive heart failure, dialysis
Allergies: no
Diagnostic Lab Data: all medical records at hospital where she died.
CDC Split Type:

Write-up: Resident was given the Pfizer vaccine on January 22, 2021, nausea and shortness of breath was taken to the Hospital on the 23rd of January and passed on the 24, 2021
VAERS ID: 1027300 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Kansas  
Vaccinated: 2021-02-06
Onset: 2021-02-11
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNKNOWN / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Asthenia, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None known
Preexisting Conditions: Aortic aneurysm, aortic stenosis, CAD, HTN, CHF, A-Fib, HLD, Ischemic heart failure, pacemaker, V-Fib, PVD, palpitations, hypotension, and small bowel obstruction.
Allergies: Unknown
Diagnostic Lab Data: None known.
CDC Split Type:

Write-up: Nausea, vomiting and generalized weakness.
VAERS ID: 1027502 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-01-14
Onset: 2021-01-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Resuscitation, 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: 2021-01-16
   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: Symbicort, Xanax, Albuterol, Flomax, Polyethylene glycol
Current Illness: N/A
Preexisting Conditions: COPD
Allergies: N/A
Diagnostic Lab Data: No tests were taken. No autopsy completed unless I paid them $5000
CDC Split Type:

Write-up: My dad received his first COVID vaccine on January 14, 2021. On January 16, 2021 he ate breakfast around 7:00 am and went back to his room. When the staff checked on him around 8:00 am they found my dad unresponsive. His blood pressure was over 220 and his pulse was 43. They began manual CPR until the paramedics arrived, but my dad died.
VAERS ID: 1027503 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Massachusetts  
Vaccinated: 2021-02-02
Onset: 2021-02-08
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died on 02/08/2021
VAERS ID: 1027619 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-02-10
Onset: 2021-02-11
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Pain in extremity, Peripheral swelling, Resuscitation, Unresponsive to stimuli
SMQs:, Cardiac failure (broad), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypotonic-hyporesponsive episode (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: no acute
Preexisting Conditions: Anemia, unspecified Congenital malformation syndromes predominantly associated with short stature Constipation, unspecified Dysphagia, unspecified Gastro-esophageal reflux disease without esophagitis Illness, unspecified Intermittent explosive disorder Moderate intellectual disabilities Neuromuscular dysfunction of bladder, unspecified Other iron deficiency anemias Other specified eating disorder Pica of infancy and childhood Thrombocytopenia,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Swollen leg/pain- taken to urgent care- became unresponsive - CPR initiated- expired
VAERS ID: 1027757 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-01-25
Onset: 2021-01-28
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   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
VAERS ID: 1027967 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-01-15
Onset: 2021-01-20
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Coagulopathy, Haemorrhagic stroke
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), 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: 2021-01-22
   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:
Current Illness: none
Preexisting Conditions: PMH: Acquired Deformity of toe- Hallux Rigidus, Actinic Keratosis, Anemia Macrocytic, Atherosclerosis, Atopic Dermatitis, Atrophy testis, Bph Local W/urinary Obstruct with LUTS, Cerumen Spondylosis, Cervicalgia, CKD stage 2, Colonic Diverticulosis, Dyspepsia, Dysphagia, Epitaxis, Esophageal Reflux, Hearing loss, Hepatic Cyst, Impaired fasting glucose, Lumbar spondylosis, Male Erectile Disorder, Microscopic Hematuria, Migraine,
Allergies: unconfirmed childhood allergy to penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received vaccination on 1/15/2021. Hemorrhagic Stroke on 1/20 , then diagnosed with complicated idiopathic coagulopathy
VAERS ID: 1028101 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-01-22
Onset: 2021-01-23
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood gases abnormal, Cardio-respiratory arrest, Death, Electrocardiogram abnormal, Hypoxia, Metabolic acidosis, Metabolic function test normal, Myocardial ischaemia, Pain in extremity, Peripheral swelling, Pulmonary embolism, Pulseless electrical activity, Resuscitation, SARS-CoV-2 test negative, Syncope, Troponin normal
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Cardiac arrhythmia terms, nonspecific (narrow), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Allopurinol 400mg Daily
Current Illness: Hyperuricemia Renal stone
Preexisting Conditions: Hyperuricemia Renal Stones
Allergies: Shellfish
Diagnostic Lab Data: ABG'' Met acidosis hypoxia EKG; Inf ischemia BMP; normal Troponin; Normal Covi 19 ;Neg
CDC Split Type:

Write-up: Pt develops left leg pain The day after vaccination in AM subsequently drove approximately 150 miles On his way back stopped at his brothers place for lunch. He then collapsed coning down the steps, EMS started CPR. took him to ER Resuscitated briefly but went into CardioPulm Arrest again and PEA Resucitaion for aprox 1 hour but was unsuccessful. Noted to have Left leg more swollen than Right by 3 to 4 CM presumed to have died from massive Pulmonary embolism and inferior wall myocardial ischemia
VAERS ID: 1028166 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-02-09
Onset: 2021-02-10
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram head abnormal, Death, Unresponsive to stimuli
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Haemorrhagic central nervous system vascular conditions (narrow), 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: 2021-02-10
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: See Continuation Page MEDICATION, DOSAGE, FREQUENCY Coreg,6.25 mg,Twice daily Hydralazine HCL,10 mg,Twice daily Isosorbide mononitrate ,30 mg,Once Daily Warfarin,20.5 mg,per week Acyclovir ,800mg,4x Daily Atropine Sulphate, 1% Op Sol,Tw
Current Illness: Glaucoma, corneal virus in right eye, IBS
Preexisting Conditions: IBS with Constipation/Diarrhea, atrial fibrillation, heart failure, and osteoporosis. Had a known brain aneurysm that had been scanned annually which showed no signs of change. Dr. was her primary care physician and has most of her medical records. CNA gave her cardiology care. Endocrinologist, treated her osteoporosis and gave her a Prolia injection twice yearly. Her newest medication was Acyclovir, 800mg, 4x Daily prescribed by doctor for her right eye.
Allergies: ALLERGIC to monopril
Diagnostic Lab Data: CT Scan
CDC Split Type:

Write-up: Patient was found unresponsive on her kitchen floor about 9:45 AM on February 10, 2021 approximately 18 hours after receiving her first Covid-19 vaccination. Exact time of the event is unknown. She was known to get up between 6:30 and 7:30 AM. It appeared that she had not eaten breakfast nor taken any medication that morning. She was taken by ambulance to Medical Center where a CT scan showed an unrecoverable massive brain hemorrhage. She died at approximately 3:50 PM after the respirator was removed. She was sent to the local Medical Examiner afterwards.
VAERS ID: 1028217 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-02-01
Onset: 2021-02-01
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / SYR

Administered by: Military       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Type 2 diabetes medication, Blood pressure Medication, arthritis medication. blood thinner medications
Current Illness: no
Preexisting Conditions: arthritis, type 2 diabetes, back issues, blood pressure.
Allergies: no
Diagnostic Lab Data: Pfizer covid vaccine. 1st injection
CDC Split Type:

Write-up: DEATH
VAERS ID: 1028476 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Arkansas  
Vaccinated: 2021-01-21
Onset: 2021-01-22
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ? / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Anaphylactic shock, Cardiac failure, Death, Dyspnoea, Intensive care, Loss of consciousness, Multiple organ dysfunction syndrome, Myocardial infarction, Road traffic accident
SMQs:, Torsade de pointes/QT prolongation (broad), Cardiac failure (narrow), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (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 (narrow), Hypoglycaemic and neurogenic shock conditions (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Sepsis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-28
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Don''t have a list
Current Illness:
Preexisting Conditions: A fib, type 2 diabetes, obesity
Allergies:
Diagnostic Lab Data: You will have to contact the Hospital.
CDC Split Type:

Write-up: She started having breathing problems/heart attack appearance. on 1/22/21 and went to the ER. Upon admittance was told it was an anaphylactic shock from the Covid shot. They kept her in ICU and released her 1/23/21. At 12:45 am on 1/24/21 she passed out and we called the ambulance. Hospital admitted her and worked through multiple organ failure issues and thought her numbers were under control. She was released on 1/27/21 and was driving on 1/28/21 around 4:15 pm and appears to have had heart failure and had a wreck. She passed away that day.
VAERS ID: 1028596 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: North Carolina  
Vaccinated: 2021-02-10
Onset: 2021-02-12
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041220A / 2 LA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood glucose increased, Death, Fatigue, Hypersomnia, Somnolence
SMQs:, Hyperglycaemia/new onset diabetes mellitus (narrow), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: insulin, cardizem, aggrenox, potassium, aspirin 81mg, zofran 4mg, trimethoprim, gabapentin, colon health, AREDS, biotin, gas-x, tylenol, vitamin D3
Current Illness:
Preexisting Conditions: diabetes, arthritis, PVC''s, macular degeneration, diseased colon, thyroid partially removed
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: *extreme* fatigue. could not awaken for more than few seconds. When briefly awake she was coherent and not confused. slept deeply from 4pm and could not wake to eat or drink. No fever, bp normal, blood oxygen ok. Blood sugar at 11pm was 230. Gave her 15u lantus at 11pm (normally 25u). Was sleeping at 2:30am but had died at next check at 3:30am.
VAERS ID: 1031176 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-02
Onset: 2021-02-12
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Hyperventilation, Muscle rigidity, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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 Narrative: Patient received Covid vaccine on 2/2/21, person reports his legs were more rigid with some sweating the day of the vaccination with leg rigidity that was slowly improving. No other adverse effects reported for following 7 days. Person states he had vomiting episode earlier this week, person states he had no other symptoms before or after the vomiting episodes. On morning of 2/12/21, person reports patient got up ready for breakfast with no issues. She says he asked for chorizo and oatmeal but she laughed and said don''t you mean chorizo and eggs. He said yes. They got him into W/C and he was rolling himself into dining room got stuck in hallway. She says he took several breaths then 3 very deep breaths and passed away. She called 911 they took his VS but he has passed. She told them to leave him along no resuscitation.
VAERS ID: 1031189 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-05
Onset: 2021-01-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Endotracheal intubation, Rheumatoid arthritis, SARS-CoV-2 test positive
SMQs:, Angioedema (broad), Arthritis (narrow), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (narrow), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 34
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: COVID 19 symptoms and a positive test was confirmed on 1/6, employee noted previous exposure to positive family members Narrative: Employee noted exposure to COVID prior to presenting for 1st dose of vaccine on 1/5/21. On 1/6/21 employee reported the onset of symptoms and was tested and was confirmed COVID positive that day. Positive result was reported to employee health on 1/8/21. Employee Health continued to track employees progress and was informed of the need for hospitalization on 1/14/21. Course of hospitalization noted the need for intubation and significant issue with comorbid condition (rheumatoid arthritis). Employee died on 2/9/2021. Unable to confirm a direct connection to Vaccine vs. COVID infection, but felt it should be reported.
VAERS ID: 1032193 (history)  
Form: Version 1.0  
Age: 83.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-01-30
Onset: 2021-01-31
   Days after vaccination: 1
Submitted: 2021-02-13
   Days after onset: 13
Entered: 2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 1 RA / -

Administered by: Other       Purchased by: Public
Symptoms: Cardio-respiratory arrest, Death, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received his first dose of Covid vaccine on Jan. 30, 2021. On Jan 31, 2021 at 6:08 AM, patient noted unresponsive per facility. Code blue was called and 911 dispatched. He expired in the ER.
VAERS ID: 1028778 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-10
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Chills, Death, Eye swelling, Fatigue, Peripheral coldness, SARS-CoV-2 test negative, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-13
   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: Anxiety and depression medication
Current Illness:
Preexisting Conditions: Arrhythmia 20 years ago
Allergies:
Diagnostic Lab Data: COVID-19 test after paramedics arrived which came back negative.
CDC Split Type:

Write-up: On December 17, 2020, my husband, received his first BioNTech BNT162b2 COVID-19 vaccination. On Thursday January 7, 2021, he received this second COVID-19 vaccination. The following three days after his second vaccination, he felt fine. The fourth day, on Sunday January 10, my husband felt extremely fatigued. On Monday the 11th and Tuesday the 12th, he worked a full shift but complained of extreme fatigue and extreme chills to the point that his teeth were chattering while on the phone with me. He decided to work through it. When he got home on Monday night, he started vomiting. On Wednesday January 13, he woke up and had swollen eyes. Once again, he felt extremely fatigued, even after a full nights rest. He had the day off but had an early meeting. After his meeting, he was still tired so he went back to sleep. I left to get lunch, and drop off our kids, and upon my return, I found him on the walk in closet floor, face up, having passed away. He felt as cold as ice. The rapid test done after they called the paramedics resulted in a negative COVID-19 test for him.
VAERS ID: 1028885 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: Florida  
Vaccinated: 2020-12-21
Onset: 2020-12-24
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Blister, Death, Fatigue, Haemorrhage, Pemphigoid, Pruritus, Scratch, Unresponsive to stimuli
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 46
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None know
Current Illness: No.
Preexisting Conditions: None known.
Allergies: None known.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient (now deceased) received 1st dose of Pfizer-BioNTech vaccine around December 21, 2020 and was noticed to be scratching, fatigued, and unresponsive by a family member on December 24, 2020. He received the second dose of the same vaccine around January 22, 2021. Pockmarks and bleeding scratch marks were noted by a family member on the patient''s face prior to this second dose. On January 28, 2021 a family member was alerted that the patient was suffering from severe bullous pemphigoid- a skin condition that has never been experienced by the patient, has been reported to be related to COVID-19 viral infection, and to T-cell responses promoted by vaccines. A corticosteroid was given, but did not work. Blisters developed to the point hands had to be dressed.
VAERS ID: 1028921 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-26
Onset: 2021-01-28
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Death, Dysphagia, Vomiting
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Carbo-Levodopa, Insulin, Lisinopril, Metorprol
Current Illness: Parkinsons, Type 2 Diabetes
Preexisting Conditions: Parkinsons, Type 2 Diabetes
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had no energy in the first 24 hours and then began a steady decline that started with vomiting after 48 hours, then an inability to swallow and ultimately the patients death on 2/5/21.
VAERS ID: 1029003 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-07
Onset: 2021-01-10
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Fatigue, Feeding disorder, General physical health deterioration, Hypersomnia, Moaning, Pain, Speech disorder, Unresponsive to stimuli, Wound secretion
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-22
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: advanced leukoaraiosis with moderate cerebral atrophy, htn, right breast carcinoma, spinal stenosis
Allergies: none
Diagnostic Lab Data: None. She was on hospice services since being admitted to the nursing home three years earlier.
CDC Split Type:

Write-up: I video chatted with her Thursday after receiving the vaccine. My mom was in poor health but she was talking in complete sentences and responded appropriately. She was upright in bed and made eye contact. She smiled and denied pain. By Sunday, she was extremely weak and unable to sip water with a straw. Her health had changed dramatically and rapidly. She moaned in pain and was very fatigued. Her condition continued to deteriorate over the week and she stopped talking and was constantly sleeping. They started antibiotics for the oozing cancer lesion and then morphine for pain and end of life care. She passed away on January 22nd which was 15 days post vaccination.
VAERS ID: 1029068 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-02-07
Onset: 2021-02-08
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Other       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: 2021-02-09
   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: N/A
Current Illness: Mental health, dementia
Preexisting Conditions:
Allergies: No known
Diagnostic Lab Data: Covid-19 positive
CDC Split Type:

Write-up: Patient was given vaccine the following day he died ,
VAERS ID: 1029335 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Iowa  
Vaccinated: 2021-02-09
Onset: 2021-02-14
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 - / IM

Administered by: Private       Purchased by: ?
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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Eplerenone Amiloride KCl Entresto Metolazone Bumex Tamsulosin ASA Docusate prn
Current Illness: none
Preexisting Conditions: Coronary Artery disease with 2 stents Congestive Heart Failure Hyperaldosteronism History of Pulmonary embolus HTN Hyperlipidemia
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Cardiopulmonary arrest
VAERS ID: 1029374 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-31
Onset: 2021-02-04
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / -

Administered by: Other       Purchased by: ?
Symptoms: Death, Eructation, Fatigue, Malaise, Myocardial infarction, Resuscitation, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 2/4/21, at around 3:00pm he began feeling very tired and he began burping in the evening. The following morning, he woke up early and was still burping and not feeling well. At around 5:00am, he collapsed. My mother called 9-1-1 and began giving CPR. The parademics arrived and tried to revive him, and transported him to the hospital but at 6:11am, he was pronounced dead of a heart attack. He was healthy.
VAERS ID: 1029412 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-02-02
Onset: 2021-02-04
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NA
Current Illness: None
Preexisting Conditions: None
Allergies: none
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Death
VAERS ID: 1029511 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Virginia  
Vaccinated: 2021-01-21
Onset: 2021-01-24
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: 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: 2021-02-08
   Days after onset: 15
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol 500mg as needed Zyrtec 10mg daily Lysine 500mg daily Nyquil/Dayquil as needed Pepcid 20mg at bedtime
Current Illness: None
Preexisting Conditions: None, never sick
Allergies: None
Diagnostic Lab Data: Jan. 27 2021 when taken to the E.R
CDC Split Type:

Write-up: Developed severe shortness of breath.
VAERS ID: 1029514 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-01-06
Onset: 2021-02-09
   Days after vaccination: 34
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: unknown
Current Illness: acid reflux
Preexisting Conditions: acid reflux
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: patient deceased
VAERS ID: 1029554 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-17
Onset: 2021-02-01
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient died suddenly on 2/1/21 from unknown causes according to his son.
VAERS ID: 1029744 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Oklahoma  
Vaccinated: 2021-01-18
Onset: 2021-01-18
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiomegaly, Chest X-ray abnormal, Chills, Death, Eosinophil count increased, Full blood count, Immediate post-injection reaction, Metabolic function test normal, Oedema peripheral, Pain, Peripheral swelling, SARS-CoV-2 test negative
SMQs:, Cardiac failure (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 26
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: tamsulosin, simvastatin, aspirin, doxazosin, colace, loratadine, vitamin b12, senna, vitamin b complex, omeprazole, alendronate, vitamin d3, calcium
Current Illness: none
Preexisting Conditions: hyperlipidemia, hypertension, digenerative disc disease, BPH, osteoporosis, skin cancers- removed, constipation, allergic rhinitis
Allergies: chlorpheniramine
Diagnostic Lab Data: covid swab neg, CBC with elevation eosinophils, CMP stable, chest xray with cardiomegaly no other acute findings 2/4/2021
CDC Split Type:

Write-up: right arm swelling immediately after injection. followed by bilateral lower leg edema, chills and body aches that continued daily at 2 weeks post immunization admin 2/4/21 treated with dexamethasone 6mg PO x 7 days- this resolved his s/s 2/13/21 patient passed away at facility
VAERS ID: 1029790 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-05
Onset: 2021-02-05
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH NOT PROVIDED TO / 2 - / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Escitalophram Over the Counter - B12, Iron, Calcium, Senna
Current Illness: Dementia
Preexisting Conditions: Anemia, Osteoporosis,
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Taken to Emergency about 8 hours later and died in ER
VAERS ID: 1030011 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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: ELIQUIS
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021149056

Write-up: taking Eliquis who died after receiving the Pfizer-BioNtech Covid-l9; This is a spontaneous report from a contactable consumer based on information received by Pfizer from Bristol-Myers Squibb (manufacturer control number US-BRISTOL-MYERS SQUIBB COMPANY-BMS-2021-014171), license party for apixaban (ELIQUIS). This spontaneous case was reported by a non-health professional and describes the occurrence of DEATH (taking Eliquis who died after receiving the Pfizer-BioNtech Covid-l9) in patient of an unknown age and gender who received apixaban (Eliquis) for an unknown indication. CO-SUSPECT PRODUCTS included Covid-19 Vaccine. On an unknown date, the patient started Eliquis (unknown route) and Covid-19 Vaccine (unknown route). DEATH occurred on an unknown date. The cause of death was not reported. It is unknown if an autopsy was performed. The doctor died after taking Eliquis with Covid-19 Vaccine. For Eliquis(Unknown), the reporter did not provide any causality assessments. This case was linked to US-BRISTOL-MYERS SQUIBB COMPANY-BMS-2021-012621 (Linked Report).; Sender''s Comments: BMS Medical Evaluation Comment: This patient died after receiving apixaban therapy. Patient also received COVID-19 vaccine. Based on the limited information available regarding the cause of death and autopsy details, it cannot be ascertained with the reasonable possibility that the apixaban could have caused the event.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1030025 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Oklahoma  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       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: Medical History/Concurrent Conditions: No adverse event (No adverse event history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient was died. The patient''s medical history was not provided. Concomitant product use was not provided. On an unknown date, the patient received his first dose of mRNA-1273 (Lot number unknown) for prophylaxis of COVID-19 infection. On an unknown date, the patient was died. Treatment of this event was not provided. The patient was died. The cause of death was not provided. Autopsy details were not provided.; Reporter''s Comments: This case concerns a male patient (unknown age), who experienced event of death (cause unknown). The event occurred on an unknown date after the first and last dose of mRNA-1273 vaccine administration. Autopsy and cause of death were not reported. Based on the current available limited information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded and the events are assessed as possibly related.; Reported Cause(s) of Death: Death
VAERS ID: 1030132 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebral haemorrhage, Death, Platelet count decreased
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: platelet count; Result Unstructured Data: Test Result:low platelet
CDC Split Type: USPFIZER INC2021135267

Write-up: a doctor died of low platelet and brain bleed 16 days after the vaccine; a doctor died of low platelet and brain bleed 16 days after the vaccine; The is a spontaneous report from a contactable consumer. A patient of unspecified age and gender received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on an unspecified date at single dose for COVID-19 immunization. The patient medical history was not reported. The patient''s concomitant medications were not reported. The patient (doctor) died of low platelet and brain bleed 16 days after the vaccine. It was not reported if an autopsy was performed. Information about lot/batch number has been requested.; Reported Cause(s) of Death: a doctor died of low platelet and brain bleed 16 days after the vaccine; a doctor died of low platelet and brain bleed 16 days after the vaccine
VAERS ID: 1030273 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 2020-12-28
Onset: 2020-12-30
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Death; A spontaneous report was received from a reporter concerning a patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. The patient received their first of two planned doses of mRNA-1273 on 28 Dec 2020 intramuscularly for prophylaxis of COVID-19 infection. On 30 Dec 2020, 2am the patient passed away. Administrator marked as natural causes. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. The outcome of the event was fatal. The patient died on 30 Dec 2020. The cause of death was reported as unknown. The reporter did not provide an assessment for the event, passed away.; Reporter''s Comments: This case concerns a patient of unknown age and gender. The medical history and concomitant medication is not provided. The patient experienced Death. The event occurred approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded. The benefit-risk relationship of Moderna''s COVID-19 vaccine is not affected by this report.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1030323 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-02-03
Onset: 2021-02-05
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / UNK - / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood potassium normal, Blood sodium normal, Carbon dioxide normal, Cardio-respiratory arrest, Death, Fall, Haemoglobin decreased, Laboratory test, Resuscitation, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haematopoietic erythropenia (broad), Haemorrhage laboratory terms (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), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Albuterol Alirocumab Asprin Atrorvastatin Calcium Budesonide-Formoterol Fumarate Calcitriol Calcium Acetate Carvedilol Clopidogrel Bisulfate Erogcalciferol Ezetimibe Fluticasone-Salmetrol Lasix Glucagon Hydralazine Insulin Ipratropium inhal
Current Illness: Asymptomatic COVID Hospital for Polymosis January
Preexisting Conditions: ESRD Diabetes Type 2 Heart disease CHF CAD CABG
Allergies: Niacin
Diagnostic Lab Data: 2/3 labs potassium 4.5, sodium 137, CO2 29, hgb 9.7
CDC Split Type:

Write-up: Patient had COVID vaccination on 2/3 with no adverse s/s before leaving unit. Upon coming to treatment Friday 2/5 he reported to the RN that he had fallen on thursday 2/4 due to "getting up fast" did not hit head or hurt anything per RN discussion. Began treatment without difficulty. About 3/4 way through treatment was talking with staff and became unresponsive - code was called and pt expired after 30 minute resuscitation efforts.
VAERS ID: 1030468 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2021-02-11
Onset: 2021-02-12
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Blood creatinine increased, Blood potassium increased, Brain natriuretic peptide increased, C-reactive protein increased, Death, Hyperkalaemia, Hypotension, Hypoxia, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (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 (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, Flomax, Sotalol, simvastatin, Xarelto, Requip, Omeprazole, symbicort, Albuterol Aerosol, Furosemide.
Current Illness: ACUTE KIDNEY FAILURE, QUESTION SEPSIS, CHF, ATRIAL FIBRILLATION, COPD, GERD, RESTLESS LEG SYNDROME, HISTORY OF PROSTATE CANCER, HYPERTENSION, CURENT TOBACCO USAGE
Preexisting Conditions: COPD, CHF, ATRIAL FIBRILLATION, GERD, RESTLESS LEG, HISTORY OF PROSTATE CANCER, HYPERTENSION
Allergies: none
Diagnostic Lab Data: potassium 7.2, creatinine 4.3, CRP 50. BNP 3230. WBC 10,200.
CDC Split Type:

Write-up: Pt presents to ER with increased weakness, hypoxia, history of COPD, but not oxygen dependent., hypotension. Acute Kidney failure noted in labs, not previously diagnosed , new hyperkalemia. BP 73/39, HR 67. dopamine initiated, and switched to Levophed. Oxygen Sat 86%, requiring 10 L O2. Transferred from this critical access hospital to another Hospital. Expires later 2-13-2021
VAERS ID: 1030557 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated: 2021-02-10
Onset: 2021-02-10
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Aortic aneurysm rupture, Death, Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Losartan/HCTZ 100/25mg Alendronate Sodium 70mg
Current Illness: none
Preexisting Conditions: Hypertension
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: According to her husband, approximately 3 hours after vaccine, patients clasped and was instantly unconscious. She was pronounced dead upon arrival to hospital and physician told husband that she had suffered a burst abdominal aneurysm and passed immediately. Nothing was out of ordinary during vaccination and during 15 minute wait time after.
VAERS ID: 1030586 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-02-11
Onset: 2021-02-14
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / ID

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: This individual''s employer informed our facility that he passed away at his home on 2/14/2021. Since he was not brought into our hospital, we do not have information regarding other health conditions or active medications. Since this individual received his second covid vaccine three days prior, this was reported to Moderna in addition to this VAERS report being completed. The coroner for County can be contacted.
VAERS ID: 1030599 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Wyoming  
Vaccinated: 2021-01-18
Onset: 2021-01-22
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Flushing, Hyperhidrosis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Hypersensitivity (broad), Hypoglycaemia (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Flushed / Sweating-Mild, Systemic: Other- Death-Severe
VAERS ID: 1030701 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-02-08
Onset: 2021-02-12
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 4 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: pregabalin, metoprolol succ, losartan, rosuvastatin, furosemide, duloxetine, Eliquis, ferrex, diltiazem, latanoprost
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: unknown, husband reported hospitalization 02/12 and deceased 02/15
VAERS ID: 1030712 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Michigan  
Vaccinated: 2021-02-09
Onset: 2021-02-10
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chills, Death, Decreased appetite, Depressed level of consciousness, Fatigue, Food refusal, Loss of consciousness, Pyrexia, Respiratory rate increased
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination
VAERS ID: 1030729 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-01-15
Onset: 2021-02-01
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   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: clopidogrel, levothyroxine, glipizide
Current Illness: n/a
Preexisting Conditions: kidney
Allergies: n/a
Diagnostic Lab Data: na
CDC Split Type:

Write-up: deceased, 2/1/21
VAERS ID: 1030787 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-04
Onset: 2021-02-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Echocardiogram abnormal, Electrocardiogram ST segment elevation, Nausea, Pulseless electrical activity, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Hypokalaemia (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: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still.
CDC Split Type:

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21
VAERS ID: 1030852 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died; A spontaneous report was received from a reporter concerning a unknown patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and passed away. The patient''s medical history was not provided. No relevant concomitant medications were reported. On an unknown date, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, the patient passed away. No treatment information was provided. Action taken with RNA-1273 in response to the event was not applicable. The patient died on unknown date. The cause of death was reported as unknown. Autopsy details were unknown.; Reporter''s Comments: This case concerns a patient of unknown age and gender. The patient''s medical history was not provided. The fatal, unexpected event of death occurred on an unknown date after the administration of the first dose of mRNA-1273 on an unknown date. The cause of death was reported as unknown. Autopsy details were unknown. Very limited information regarding this event has been provided at this time. Based on temporal association between the use of the product and the event, a causal relationship cannot be excluded. Additional information regarding the autopsy report, date of the mRNA administration, day of death, medical information and details of concomitant product are all required for further assessment of causality.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1030893 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-02-03
Onset: 2021-02-10
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Death, Decreased appetite, Fall, Food refusal, General physical health deterioration, Mobility decreased, Pyrexia, Restlessness, Urinary tract infection, Walking aid user
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: Acetaminophen, amlodipine, atorvastatin, clonazepam, furosemide, guaifenesin DM
Current Illness: Resident had a low grade fever day of vaccine and was not feeling well. Pharmacy stated it would be ok to have vaccine and administered in resident''s room.
Preexisting Conditions: Osteoporosis, type 2 diabetes, vitamin B deficiency, anxiety, achalasia of cardia, GERD, iron deficiency, atrial fibrillation, chronic kidney disease
Allergies: Fluoxetine and Metformin
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Resident had slight/slow decline in health prior to vaccine but continued to be able to walk around with walker at community. The day of the vaccine she had a fever. 2 days after vaccine resident did not get out of bed all day and refused to eat. She had small amounts of orange juice as her blood sugar level was low due to not eating. Resident was diagnosed with a UTI and began an oral antibiotic. 3 days after and on day 5 after vaccine resident began feeling weak and had a fall on each day. The following day again resident spent the day in bed. The next day she was quite restless, was on the edge of her bed attempting to self transfer often throughout the day. Resident continued to be restless on the 10th of Feb, had further decline on the 11th of Feb. Resident passed away early the AM of Feb. 12th.
VAERS ID: 1031494 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Iowa  
Vaccinated: 0000-00-00
Onset: 2020-12-20
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-20
   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: USPFIZER INC2021102836

Write-up: Spouse awoke 20Dec and found spouse dead; This is a spontaneous report from a Pfizer sponsored report Corporate (Pfizer) Social Media Platforms. A non-contactable consumer (patient''s husband) reported that a female patient of an unspecified age (Age: 89, Units: Unknown) received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Lot number: EH9899, Expiry date: unknown), intramuscular on an unspecified date at a single dose for COVID-19 immunisation. The patient''s medical history and concomitant medications were not reported. It was reported that spouse awoke and found spouse dead on 20Dec2020. Patient was not transferred to hospital. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Reported Cause(s) of Death: Spouse awoke 20Dec and found spouse dead
VAERS ID: 1031544 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-02-11
Onset: 2021-02-14
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Imaging procedure, Loss of consciousness, Subdural haemorrhage
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Alendronate 70mg tab Clopidogrel 75mg tab Donepezil 5mg tab Hydrochlorothiazide 12.5mg Lactobacillius tabs Levothyroxine 75mcg tab Lostartan 50mg tab Citrucel PO Metoprolol tartrate 25mg tab Pantoprazole 40mg tab Rosuvastsatin 10mg tab Tria
Current Illness: Diagnosed with subdural hemorrhage at time of incident
Preexisting Conditions: Hyperlipideia Hx stroke Hypothyroidism Gastric ulcer HTN Stress incontinence Uterine cancer Late onset Alzheimer''s Osteopenia Osteoarthritis Varicose veins in legs Venous insufficiency Adjustment disorder with anxiety
Allergies: Ibandronic acid- nausea and vomiting Sulfa- nausea and vomiting Risedronate Environmental- pollen Nitrofurantoin macro Ezetimibe-Simvastatin Codeine- anxiety Erythromycin- nausea
Diagnostic Lab Data: Imaging 2/13-2/14
CDC Split Type:

Write-up: Patient family had been noticing onset confusion for a few weeks prior to vaccine and event. Patient was taken to ED when found unconscious and died of a subdural hemorrhage a few days after vaccine clinic at retirement home.
VAERS ID: 1031593 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-02-11
Onset: 2021-02-13
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Hypersomnia
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: Calcitriol 0.25mcg, glyburide 2.5mg, atorvastatin 40mg, nitroglycerin 0.4mg, furosemide 40mg, isosorbide ER 60mg, warfarin 5mg, gabapentin 300mg, allopurinol 100mg
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On February 11, 2021 around 10:15 am, patient was given the Moderna brand COVID-19 vaccination. After his vaccination, he was instructed to wait around for 15 minutes after the administration of the vaccine. During this time, there were no reported issues with the patient. On February 15, 2021 around 9:15am, patient''s wife called the pharmacy and spoke with the pharmacist informing her that patient had passed away in his sleep on Saturday evening. Patient''s wife inquired about whether death may have been caused by an adverse reaction to the vaccine. During the call patient''s wife mentioned that patient slept a lot the day of the vaccine and the day after. patient''s wife mentioned that patient woke up Saturday to eat breakfast and lunch. She states that later that evening, she found patient asleep and cold which she then realized that he''d passed away.
VAERS ID: 1031595 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Kentucky  
Vaccinated: 2020-12-29
Onset: 2021-02-05
   Days after vaccination: 38
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood pressure increased, COVID-19, Heart rate increased, Renal failure, SARS-CoV-2 test positive, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Lasix, Digoxin, Eliquis, Metoprolol, Celexa, Plavix, Namenda
Current Illness: Covid + 1/6/2021
Preexisting Conditions: CHF, Heart Disease, Dementia, A Flutter HTN
Allergies: NKDA
Diagnostic Lab Data: Resident was sent to hospital for further evaluation. Medical records not available to this facility since resident did not return to us.
CDC Split Type:

Write-up: Unresponsive, Increase BP and H. Hospital Dx Renal Failure
VAERS ID: 1031629 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Iowa  
Vaccinated: 2021-02-08
Onset: 2021-02-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 7+ RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Death, Diet refusal, Fluid intake reduced, General physical health deterioration, Haematemesis, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Retroperitoneal fibrosis (broad), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Amlodipine, Fentanyl Transdermal, Gabapentin, Lorazepam, Metoprolol, Morphine, Omeprazole, ONdansetron, Miralax, Tylenol, Ibuprofen
Current Illness: Compression fracture
Preexisting Conditions: Abdominal Aortic Aneurysm, Constipation, Malnutrition, Peripheral Vascular Disease
Allergies: GI upset from Fentanyl, No other food or drug allergies
Diagnostic Lab Data: No lab or other tests performed at request of family as patient was on hospice palliative care.
CDC Split Type:

Write-up: Patient became nauseated about 10 minutes after vaccine administered, this subsided but returned several hours after the vaccine was given. She continued with intractable nausea and vomiting for about 24 hours. This patient was enrolled in hospice and she continued to decline and refused to eat or drink. She was taking Ibuprofen due to intractable back pain. Her emesis was coffee ground color. After this her condition continued to decline until her death
VAERS ID: 1031767 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-30
Onset: 2021-01-31
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aspiration pleural cavity, Confusional state, Death, Hypotension, Oxygen saturation decreased, Pleural effusion, Pneumonia, Septic shock, Staring
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Toxic-septic shock conditions (narrow), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Polyethylene Glycol 3350 Powder Calcium-Vitamin D Tablet 500-200 MG-UNIT (Calcium Carb-Cholecalciferol) Lidocaine Patch 4 % Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Melatonin Tablet 3 MG traMADol HCl Tablet 50 MG Ferrous Glucona
Current Illness: ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION POLYNEUROPATHY, UNSPECIFIED GENERALIZED ANXIETY DISORDER LOCALIZED EDEMA GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS INSOMNIA, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DYSPHAGIA, UNSPECIFIED DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED WEAKNESS MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING HYPERLIPIDEMIA, UNSPECIFIED AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OLD MYOCARDIAL INFARCTION HISTORY OF FALLING PERSONAL HISTORY OF PEPTIC ULCER DISEASE BARIATRIC SURGERY STATUS PRESENCE OF LEFT ARTIFICIAL KNEE JOINT PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
Preexisting Conditions: ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION POLYNEUROPATHY, UNSPECIFIED GENERALIZED ANXIETY DISORDER LOCALIZED EDEMA GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS INSOMNIA, UNSPECIFIED UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE DYSPHAGIA, UNSPECIFIED DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED WEAKNESS MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA DISPLACED INTERTROCHANTERIC FRACTURE OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING HYPERLIPIDEMIA, UNSPECIFIED AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE OLD MYOCARDIAL INFARCTION HISTORY OF FALLING PERSONAL HISTORY OF PEPTIC ULCER DISEASE BARIATRIC SURGERY STATUS PRESENCE OF LEFT ARTIFICIAL KNEE JOINT PRESENCE OF RIGHT ARTIFICIAL SHOULDER JOINT PRESENCE OF LEFT ARTIFICIAL SHOULDER JOINT
Allergies: Dilaudid
Diagnostic Lab Data: Resident hospitalized; Dx: pneumonia with septic shock. Thoracentesis for large pleural effusion performed in hospital. Resident expired on 2/4/2021.
CDC Split Type:

Write-up: 1/31/2021 12:50 Nursing Note Note Text: Res had low BP, low O2 sats, 30 breaths per minute, eyes open wide, making confused utterances. Started supplemental oxygen via NC, 2L, then 3L. Sats went up to 93% for a while, Sprvsr called. Unable to auscultate Left lung sounds. Called to update Res daughter. Called to page NP, writer went back to assess Res and O2 sats were 88%, turned O2 to 4LPM, called 911 for transport to Hospital ED. Left around 1030. NP called back afterwards, was updated. Family updated that Res was sent to Hospital ED. Note Text: Received phone call from daughter as well as information from hospital. Resident has pneumonia with septic shock. She is on abx and had thoracentesis performed for large pleural effusion. [linked]
VAERS ID: 1031780 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-23
Onset: 2021-02-01
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Oxygen saturation decreased, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (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: 2021-02-05
   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: Reported chronic lung disease. Additional details are unknown.
Allergies: Unknown
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Patient was not seen at our facilities prior to or after COVID-19 vaccination. Patient received first dose on 1/23/2021 and as reported by the family member, patient expired on 2/5/21. Symptoms were reported to have stared on 2/1/2021, 9 days after receiving the first dose with a drop in oxygen levels and fever. He was reported to also have a history of chronic lung disease. Patient''s family member to be contacted if necessary.
VAERS ID: 1031846 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Washington  
Vaccinated: 2021-02-11
Onset: 2021-02-12
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Autopsy, Cerebral haemorrhage, Condition aggravated, Coronary artery occlusion, Death, Hypertension, Resuscitation
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, arterial (narrow), Hypertension (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: HTN meds taken ''off and on'', UNK other medications etc.
Current Illness: UNK
Preexisting Conditions: HTN, other unk
Allergies: UNK
Diagnostic Lab Data: Autopsy ordered by Medical Examiner. Completed on day of death, Friday, Feb 12, 2021 (2/12/21) Findings reported to the family were that she had bleeding in the brain related to hypertension, and "90% of the main coronary artery was occluded" - per family. ME told family that death was unrelated to vaccine. Family believes this, but agreed to let me report this event in case there is a pattern and this data will help advance science.
CDC Split Type:

Write-up: Patient and her husband are elderly, but healthy and live independently. Patient took blood pressure medicine ''off and on'' according to family. She was 5''2", 120 pounds and slim and healthy and active, so was her husband, though he had pulmonary fibrosis so they had been staying home and not attending church etc, and masking when they did go out to protect against covid disease. They were both vaccinated with covid Pfizer vaccine (dose #1) on Thursday Feb 11. (02/11/2021) Thursday night as they went to bed they checked in with each other on how they each felt. Patient said she felt totally fine, and her husband said his arm was a bit sore. Patient woke before her husband on Friday Feb 12, went downstairs and, from what the family can tell, fixed herself a snack, then sat on the sofa. Patient''s husband found her deceased on the sofa. He called 911 and they asked him to do CPR until the paramedics arrived. Because of proximity to covid vaccine, the ME wanted to examine the body in the home and also ordered an autopsy. Autopsy was completed on the same day as death, Feb 12, 2021
VAERS ID: 1031909 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-08
Onset: 2021-01-30
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Back pain, Blood creatinine increased, Blood lactate dehydrogenase increased, Death, Haemoglobin decreased, Platelet count decreased, Red blood cell schistocytes, Reticulocyte count increased, Thrombotic thrombocytopenic purpura
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haemolytic disorders (narrow), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Renovascular disorders (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 15
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: Acetaminophen 650 mg PO q4h PRN for pain, amlodipine 10 mg PO daily, atenolol 100 mg PO daily, calcium carbonate/cholecalciferol 600 mg/200 mg PO BID, fluticasone 50 mcg per nare daily, HCTZ 25 mg PO daily, phentermine 37.5 mg PO AC breakfa
Current Illness: None known
Preexisting Conditions: Allergic rhinitis, insomnia, anxiety state, Sjogren''s disease, joint pain, GERD without esophagitis, hypertension, vulvar cysts, recurrent maxillary sinusitis, herpres
Allergies: amoxicillin (swelling), sulfur (swelling), loratadine (rash)
Diagnostic Lab Data: Hgb 5 g/dL Platelets 9k SCr 2 mg/dL LDH 1500 Elevated reticulocyte count
CDC Split Type:

Write-up: Pt received dose #1 of COVID-19 vaccine (Pfizer-BioNTech) on 12/18/20 and dose #2 ( Pfizer-BioNTech) on 1/8/21. On 1/30, patient was evaluated at urgent care due to back pain. No bloodwork done; metronidazole prescribed for 7 days. On 2/8, patient was admitted to outside hospital due to ongoing symptom progression. At time of admission, hgb 5 g/dL and plt 9k. Per Dr. (hematology/oncology), pt with schistocytes, LDH 1500, and elevated reticulocyte count consistent with thrombotic thrombocytopenic purpura (TTP). SCr $g2 mg/dL. Patient immediately treated with plasma exchange and steroids, however continued to decline. Patient expired on 2/14/21.
VAERS ID: 1031993 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-02-12
Onset: 2021-02-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Influenza like illness
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: Unkown
Current Illness:
Preexisting Conditions:
Allergies: KNDA or other allergies listed
Diagnostic Lab Data: When check on next morning by staff patient was deceased.
CDC Split Type:

Write-up: Patient reported mild flu like symptoms from vaccination later that evening. Next morning LTCF staff found pt deceased
VAERS ID: 1032161 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: New Hampshire  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Blood pressure decreased, Death, Decreased appetite, Fall, Food refusal, Lip blister, Oral mucosal blistering, Weight decreased
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Shingles - Glaxo 8/22/2020, resulted in hospitalization and LTC.
Other Medications: Vitamin D, Methotrexate
Current Illness: Dementia, Arthritis
Preexisting Conditions: Dementia, Arthritis
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: The day after the 2nd shot, patient developed blisters on his lips and mouth. The care facility said that he had a nut allergy -- but he had never been allergic to nuts. He stopped eating and drinking and his BP had dropped to 60/40. By Jan 16th they called to say he was dying and he passed away on 1/18/21. Patient had COVID19 from Oct 29th - early November. By Nov 21st he had lost 40 lbs. He was 6''3" and had gone from 189lbs to 149 lbs with COVID. By Nov 21st when we could visit, he had recovered from COVID, but was very thin and weak. He could not bathroom alone and kept falling. He didn''t seem to have a bad reaction to the 1st COVID shot, But he immediately reacted to the 2nd shot and passed away within 6 days.
VAERS ID: 1032163 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-16
Onset: 2021-02-01
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Asthenia, Computerised tomogram abnormal, Death, Disseminated intravascular coagulation, Haemoglobin decreased, Hepatic function abnormal, Metastases to liver, Oedema peripheral, Pain, Petechiae, Platelet count decreased, Purpura, Transfusion, Vaginal haemorrhage, White blood cell count increased
SMQs:, Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Angioedema (broad), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Guillain-Barre syndrome (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol 2.5 mg via nebulizer q4h PRN for SOB, alectinib 600 mg PO BID, apixaban 5 mg BID, bumetanide 2 mg q other day, calcium-vitamin D 500-200 mg BID, famoitidine 20 mg daily, ferrous sulfate 325 mg BID, methadone 5 mg q6h, midodrine 10
Current Illness: Progressive liver metastases seen on CT 1/26/21 in the setting of metastatic non-small cell lung cancer (diagnosed 9/2020)
Preexisting Conditions: HPV, iron deficiency anemia, abnormal uterine bleeding, history of COVID-19 hospitalization ( 8/2020), migraines, nonalcoholic fatty liver disease, GERD, pre-diabetes
Allergies: iodinated contrast (rash, itching)
Diagnostic Lab Data: On admission (2/6/21): WBC: 37.89k Hgb 5.7 g/dL Plt: 75k On 2/11: WBC 53k Hgb 8.1 Plt: 27k
CDC Split Type:

Write-up: Patient received dose #1 of COVID-19 vaccine on 1/16/21. Within 3 days, she developed petechiae up to ankles, later rising up to her knees. Pt admitted to hospital on 2/6/21 for symptomatic anemia 2/2 vaginal bleeding. Patient received 4 units FFP, 4 units PRBC, 1 unit cryoprecipitate, and vitamin K 5 mg IV. Also started on medroxyprogesterone 20 mg PO TID. Alectinib d/ced due to worsening liver function. Evalauted by OB/GYN and Hematology. Diagnosed with DIC. Patient with worsening bilateral lower extremity edema and purpura with pain and weakness. Palliative care consulted. Patient passed away on 2/11.
VAERS ID: 1032252 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-26
   Days after vaccination: 19
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: 2021-01-30
   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: MetFORMIN HCl Tablet 500 MG bid with meals GlipiZIDE Tablet 5 MG bid ac meals PROSTAT SUGAR FREE 30cc tid ROBITUSSIN DM 10ml q4hrs prn Lipitor Tablet 10 MG (Atorvastatin Calcium qd at 5pm NX: DIABETIC ICE CREAM (EXTRA DESSERT) two times a
Current Illness: Loss of appetite and generalized body weakness
Preexisting Conditions: DM Type 2
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident tested COVID-19 confirmed positive a few days after covid vaccination.
VAERS ID: 1032265 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-27
   Days after vaccination: 20
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Hypotension, Oxygen saturation decreased, SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Respiratory failure (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: PROSTAT SUGAR FREE Give 30 cc orally three times a day for SUPPLEMENT WITH MEDPASS TO PROVIDE 45G DSS 100 MG Give 1 tablet orally one time a day for (STOOL SOFTENER) HOLD FOR LBM HEALTHSHAKE 4OZ. PO three times a day for (SUPPLEMENT) BET
Current Illness: NONE
Preexisting Conditions: ANEMIA DEMENTIA HYPERLIPIDEMIA HYPERTENSION GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident tested NEGATIVE for COVID-19 last 1/25/2021. She was on monitoring for desaturation and low blood pressure on Jan. 27,2021
VAERS ID: 1032279 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-29
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: General physical health deterioration, SARS-CoV-2 test negative
SMQs:, COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-29
   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: Vitamin C Tablet 500 MG (Ascorbic Acid) Give 1 tablet orally two times a day for (SUPPLEME NX: ICE CREAM two times a day @ LUNCH AND DINNER HEALTHSHAKE 4OZ. PO three times a day for SUPPLEMENT BETWEEN MEALS ARTIFICIAL TEARS Instill 1 dr
Current Illness: NONE
Preexisting Conditions: ATHEROSCLEROTIC HEART DSE DEMENTIA HLD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Resident tested NEGATIVE for COVID-19 on 1/25/2021. She was on monitoring for declining in condition on 1/29/2021.
VAERS ID: 1032303 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Female  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-02-01
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Condition aggravated, Decreased appetite, General physical health deterioration, SARS-CoV-2 test negative
SMQs:, Guillain-Barre syndrome (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: PUREED diet, Pureed texture DIET: DOUBLE PORTION @ ALL MEALS DIET: EXTRA PROTEIN ENTREE three times a day @ BREAKFAST, LUNCH AND DINNER NX: GLUCERNA 1.5 120CC three times a day for (SUPPLEMENT) WITH MEDPASS Zinc Sulfate Tablet 220 (50 Zn)
Current Illness: On monitoring for declining in condition, loss of appetite and generalized body weakness on2/1/2021
Preexisting Conditions: Hemiplegia & Hemiparesis on left non-dominant side Atherosclerotic heart Dse. Type 2 Diabetes Mellitus Cerebral Infarction PAF Thyroid Disorder Hypertension Cerebral edema GERD Occipital Neuralgia
Allergies: NKA
Diagnostic Lab Data: labs were ordered prior rto admitting to Hospice Care. NEGATIVE for COVID-19 on 2/1/2021.
CDC Split Type:

Write-up: On monitoring for declining in condition, loss of appetite and generalized body weakness on2/1/2021. Was confirmed COVID-19 positive 4/23/2020.
VAERS ID: 1032321 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-07
Onset: 2021-01-19
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: 2021-01-20
   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: Regular diet, Regular texture NX: 2CAL HN 120CC 1 CAN PO three times a day WITH MEDPASS DIET: RICE PORRIDGE ALL MEALS PER RESIDENT''S REQUEST three times a day NX: 4OZ. HEALTHSHAKE PO three times a day BETWEEN MEALS Docusate Sodium Capsu
Current Illness: none
Preexisting Conditions: Wedge Compression Fracture of T-11-T12 Atrial Fibrillation BPH GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident has shortness of breath on 1/19/2021 and was transferred to Hospital 1/20/2021
VAERS ID: 1032327 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-04
Onset: 2021-02-11
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: SARS-CoV-2 test negative, Weight decreased
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: PUREED diet, Pureed texture NX: ICE CREAM (EXTRA DESSERT) two times a day @ LUNCH AND DINNER PROSTAT SUGAR FREE Give 30 cc orally two times a day for SUPPLEMENT WITH MEDPASS TO PROVIDE 30GRAMS PROTEIN AND 200CNX: HEALTHSHAKE 4OZ. PO thre
Current Illness: None
Preexisting Conditions: Heart Failure Chronic Kidney Dse. Dementia Atheroschlerotic Heart Dse. Anemia Hypothyroidism Major Depressive Disorder Nonrheumatic aortic valve stenosis Cardiomegaly Hypertension Dysphagia Osteoporosis
Allergies: Fosamax, Linzess
Diagnostic Lab Data: tested NEGATIVE for COVID-19 on 2/8/2021 Has completed and fully vaccinated last 1/7/2021 and 2/4/2021.
CDC Split Type:

Write-up: On monitoring for weight loss .
VAERS ID: 1032575 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Nevada  
Vaccinated: 2021-01-19
Onset: 2021-01-19
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Chills, Death, Dyspnoea, Malaise, Myalgia, Pyrexia, Respiration abnormal
SMQs:, Rhabdomyolysis/myopathy (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-21
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Two days later passed away; difficulty breathing, shortness of breath; difficulty breathing, gurgling; Not feeling well; Achiness; Severe fever; Chills; A spontaneous report was received from a physician concerning a 56-year-old female patient who received Moderna''s COVID-19 Vaccine (mRNA-1273) and developed fever, chills, achiness, shortness of breath, gurgling and unresponsive. The patient''s medical history was not provided. Concomitant product use was not provided. On 19 Jan 2021, prior to the onset of the events, the patient received their second of two planned doses of mRNA-1273 (Lot 042L20A) intramuscularly in the left arm for prophylaxis of COVID-19 infection. After receiving the vaccine on 19 Jan 2021, the patient experienced fever, chills, shortness of breath, gurgling and achiness. On 21 Jan 2021, the patient was found unresponsive. Emergency medical services were called to perform life saving measures however, they were unsuccessful. No further treatment information was provided. The patient died on 21 Jan 2021. The cause of death was reported as unknown. An autopsy was planned.; Reporter''s Comments: This case concerns a 56-year-old, female, who experienced a serious event of death, with many other events after receiving second dose of mRNA-1273 (Lot# 042L20A). Very limited information regarding these events has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1032662 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Utah  
Vaccinated: 2021-01-25
Onset: 2021-02-05
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 AR / SYR

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: Absolutely none. Unusually healthy for 86
Preexisting Conditions: None
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death
VAERS ID: 1032873 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-02-13
Onset: 2021-02-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Death, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: Aspirin, Lipitor, Calcium, Plavix, Cardura, Finasteride, Prozac, Metoprolol, Sinemet, Januvia, Flomax, Vitamin B12, Vitamin C, Vitamin D3
Current Illness: Had Covid 19 in Dec. 2020, Tested negative at beginning of Feb. 2021. No other illness.
Preexisting Conditions: Type 2 diabetes. Controlled hypertension.
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: He had rigors starting 6 pm the day after the vaccination. He was treated with one 500 mg tylenol. He had increased wheezing but did not complain of SOB. At 0400 the next morning, he died.
VAERS ID: 1032880 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-22
Onset: 2021-02-04
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Confusional state, Cough, Death, Dyspnoea, Hypertension, Lung carcinoma cell type unspecified stage IV, Respiratory failure, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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), Dementia (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow), Hypoglycaemia (broad), Non-haematological malignant tumours (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Proair , Pulmicort , Neds, Tegertol, Plavix , Flonase, Tofranil, Kepra , Protonix Trental Opdivo, Colace, Sim Vastatin, Vit E,
Current Illness: Hospice Chronic COPD
Preexisting Conditions: Cancer chest pain COPD Cough , HX of Radiation and Chemotherapy Hypercholestemia , HTN, Seizure , Shingles, SOB
Allergies: Phenergan, Codeine
Diagnostic Lab Data: Tested positive for Covid +
CDC Split Type:

Write-up: Received Pfizer 1/22/2021. RNA+ 2/4/2021. S/S SOB, cough, confusion. COVID assoc. resp. failure, stage 4 lung cancer, COPD, HTN, former smoker. patient in hospice and died 2/10/2021.
VAERS ID: 1033102 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: West Virginia  
Vaccinated: 2021-01-07
Onset: 2021-01-29
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Chest X-ray abnormal, Chills, Cough, Death, Dyspnoea, Feeling cold, Fibrin D dimer, Fibrin D dimer increased, Interstitial lung disease, Lung infiltration, Mobility decreased, Productive cough, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin, Lipitor, Cardura, Eliquis, Finasteride, Lasix Lisinopril Meloxicam Metoprolol Multivitamin Ranitidine
Current Illness:
Preexisting Conditions: CAD, CKD
Allergies: NKA
Diagnostic Lab Data: COVID-19 Rapid PCR positive (2/5/21), D-Dimer 3.58 (2/5/21), D-Dimer 8.00 (2/7/21), chest x-ray (2/5/21) New diffuse right lung and left mid and lower lung acute infiltrates.
CDC Split Type:

Write-up: Patient received first dose of vaccine on 1/7/21 at a community Public Health clinic. On 1/29/21 he received a second dose at the community Public Health clinic. On 2/5/21, the patient presented to the ED with complaints of shortness of breath worsening over the last 2 weeks. Patient reported that he had decreased exercise capacity and increased coughing with sputum production intermittently. Patient reported that he had been feeling chilled, but no fevers. Patient was admitted and treated with Decadron and Remdesivir. Patient experienced increased oxygen requirement. Patient was a DNI and did not want to be on life support. After discussion with the patient and family, patient was moved to comfort care. passed away on 2/11/21.
VAERS ID: 1033131 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-11
Onset: 2021-02-14
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Death, Pneumonia, Sepsis
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), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Alendronate Sodium aspirin atorvastatin cyanocobalamin (VITAMIN B-12) glipizide hydrochlorothiazide levothyroxine Losartan Potassium meloxicam metformin metoprolol succinate Mycophenolate Mofetil NITROGLYCERIN omeprazole prednisone Py
Current Illness: Unknown
Preexisting Conditions: Myasthenia gravis
Allergies: No known allergies
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient received initial COVID vaccine on 2/11/2021 at Clinic. Direct observation for 15 minutes and no documentation noting an adverse reaction. On 2/14/2021 was diagnosed with Sepsis secondary to pneumonia, started on antibiotic therapy, cardiac arrested, and expired on 2/14/2021 while at Hospital.
VAERS ID: 1033155 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: South Dakota  
Vaccinated: 2021-02-11
Onset: 2021-02-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cardiac arrest, Craniocerebral injury, Death, Endotracheal intubation, Fall, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone, Rosuvastatin, Prevacid, Zetia, ASA, MVI, Nitroglycerin, Metformin, Potassium, Bumex, Apixaban, Omega 3, Metoprolol, Midodrine,
Current Illness: Generalized ischemic myocardial dysfunction, lower leg edema with cellulitis
Preexisting Conditions: Ischemic Cardiomyopathy, Diabetes, Combined Systolic/Diastolic Heart Failure, Edema, Ventricular Tachycardia, Pacemaker, Stroke, Myocardial Infarction, Hyperlipidemia, Hypertension, Obesity, Coronary arteriosclerosis, Paroxysmal atrial fibrillation, Left ventricular thrombus, Cardiorenal Sydrome, Bilateral lower leg cellulitis
Allergies: No known allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccine given in clinic per protocol - patient monitored for 15 minutes, no adverse reactions noted at the time. Patient stated he felt fine following 15 minute monitoring time. Patient left facility- it was later reported that pt had a fall at home. Upon review of pt''s medical record - Pt''s wife had to initiate CPR and call EMS for transportation and life saving measures enroute to the Emergency Room. Pt was intubated as pt was in asystole upon arrival to the ER, ACLS was continued, pt was noted to have a traumatic brain injury from his fall at home, and pt was pronounced dead at 1620.
VAERS ID: 1033263 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-27
Onset: 2021-02-14
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: patient passed away within 60 days of receiving COVID vaccine
VAERS ID: 1033323 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-14
Onset: 2021-02-13
   Days after vaccination: 30
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1686 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient passed away within 60 days of receiving a COVID vaccine
VAERS ID: 1033444 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-16
Onset: 2021-01-25
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / UN

Administered by: Private       Purchased by: ?
Symptoms: Cardiac failure congestive, Condition aggravated
SMQs:, Cardiac failure (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   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: congestive heart disease medications
Current Illness: Addison''s disease, abdominal hernia
Preexisting Conditions: Congestive heart disease Addison''s disease
Allergies: sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: symptoms of ongoing congestive heart disease just progressed
VAERS ID: 1033448 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-01-26
Onset: 2021-01-27
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Dyspnoea, Pneumonia, Pyrexia
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Blood Thinners Pyschotropics
Current Illness: Had Covid-19 one month prior
Preexisting Conditions: Irregular Heart Asthma pneumonia prone
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever by the next day, difficulty breathing, pneumonia, and then DEATH within a few days. (Died 02/01/2021)
VAERS ID: 1033466 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Resuscitation
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)

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: Asthma/COPD, Diabetes mellitus (DM), Hypertension (HTN), Renal Disease (e.g. CKD, HD, ESRF), A-fib, pulmonary hypertension, chronic loculated empsyema, chronic aspiration pneumonitis, pacemaker, chronic anticoagulation
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 70 yo man with multiple severe medical comorbidities received his first dose of Moderna COVID-19 vaccination without incident. 8.5 hours later, he was noted by his family to be in his usual state of health. 9.5 hours after the vaccination, he was found down by his family in cardiac arrest. Resuscitation attempts were not successful, and the patient died.
VAERS ID: 1033472 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: Medical History/Concurrent Conditions: No adverse event (No reported medical history.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Resident coded and expired; A spontaneous report was received from a consumer concerning a patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and coded and expired. The patient''s medical history was not provided. No concomitant product use was reported. On an undisclosed date, the patient received their first of two planned doses of mRNA-1273 (Lot number: not provided) for prophylaxis of COVID-19 infection. On undisclosed date, the patient coded and expired. Treatment information was not provided. Action taken with mRNA-1273 in response to the events was not applicable. The patient died on an undisclosed date. The cause of death was not provided. Plans for an autopsy were not provided.; Reporter''s Comments: MEDICAL COMMENT: MOD 2021 009822 DEATH NOS This case concerns a patient of unknown age and gender who received their first of two planned doses of mRNA-1273 (Lot number: not provided) for prophylaxis of COVID-19 infection and had died. Very limited information regarding this event has been provided at this time to make a proper medical assessment, therefore, the causality is unlikely related to the vaccine in this case of death not otherwise specified. No contact information provided. Follow up is not expected.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1033607 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated: 2021-02-12
Onset: 2021-02-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 UN / -

Administered by: Military       Purchased by: ?
Symptoms: Death, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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: Metformin, anti depressant, baby aspirin.
Current Illness: Allergies
Preexisting Conditions: Diabetes, circulation problems, awaiting stent surgery on neck artery.
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vomiting, death.
VAERS ID: 1033682 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-02-04
Onset: 2021-02-05
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9269 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Arterial disorder, Contusion, Death, Dysphagia, Haematoma, Haemorrhage, Limb mass, Oedema peripheral, Peripheral swelling, Skin discolouration, Suture insertion, Thrombosis, Vein disorder
SMQs:, Cardiac failure (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Thrombophlebitis (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   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: metoprolol tartrate 25 mg, 81 mg aspirin, 10 mg lisinopril, 2 mg glimepride, 20 mg furosemide (lasix)
Current Illness: polycythemia vera, dementia, type 2 diabetes mellitus, HTN
Preexisting Conditions: Type II DM
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: L hand edema, hematoma which burst and caused bleeding sending pt to the ER for pressure dressing and 2 stitches. L hand and arm progressively got more edematous and bruised looking (severely black/blue/purple) and the hand continued to bleed and swell on 2/6/21. Severe arterial and venous issues and apparent blood clots. On 2/7/21 there were also lumps noted on left inner thigh. Pt. stopped eating or drinking on 2/8/21 and expired on 2/12/21.
VAERS ID: 1033873 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-01-20
Onset: 2021-02-01
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: VENLAFAXINE, LOSARTAN, TRAZODONE. THERE MAY BE OTHERS. SHE WAS PARTICIPATING IN A CLINICAL TRIAL
Current Illness:
Preexisting Conditions: CHRONIC KIDNEY DISEASE
Allergies: UNKNOWN
Diagnostic Lab Data: UNKNOWN
CDC Split Type:

Write-up: PATIENT PASSED AWAY ON 2-1-2021
VAERS ID: 1034055 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: Maryland  
Vaccinated: 2021-02-11
Onset: 2021-02-12
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 AR / IM

Administered by: Private       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: 2021-02-14
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: Kidney Failure- on dialysis
Preexisting Conditions: Kidney Failure- on dialysis
Allergies: UNKNOWN- none reported
Diagnostic Lab Data:
CDC Split Type:

Write-up: Associate developed SOB on 2/12/21. Taken to Hospital on 2/13/21. Reported deceased 2/14/21.
VAERS ID: 1034116 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Virginia  
Vaccinated: 2021-01-19
Onset: 2021-01-30
   Days after vaccination: 11
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Biopsy skin abnormal, Blister, Dermatitis, Epidermal necrosis, Rash, Skin exfoliation, Toxic epidermal necrolysis
SMQs:, Severe cutaneous adverse reactions (narrow), Anaphylactic reaction (broad), Malignancy related therapeutic and diagnostic procedures (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Skin tumours of unspecified malignancy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram 10mg tablet Novolin 70/30 Insulin Diazepam 2mg tablet Simvastatin 20mg tablet Acetaminophen 500mg tablet
Current Illness: Diabetes - Type 2 Dementia CVA s/p L-sided weakness Psychiatric disorder
Preexisting Conditions:
Allergies: Buspirone Morphine
Diagnostic Lab Data: Surgical Pathology reports: FINAL DIAGNOSIS: SKIN, RIGHT THIGH, BIOPSY: SUBEPIDERMAL BULLAE WITH EXTENSIVE EPIDERMAL NECROSIS AND MIXED INFLAMMATORY INFILTRATE. NO EVIDENCE OF MALIGNANCY. Comment: The clinical concern for toxic epidermal necrolysis is noted, and the histologic findings support this impression. Extensive subepidermal bullous formation with associated mixed inflammatory infiltrate composed of neutrophils, eosinophils, and lymphocytes is noted in the larger of the two skin fragments, while the smaller fragment shows diffuse epidermal necrosis, which is compatible with TEN.
CDC Split Type:

Write-up: Presented from clinic with 3-4 days of extensive rash. There were multiple areas of skin sloughing on bilateral upper extremities and abdominal wall.
VAERS ID: 1034146 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Arizona  
Vaccinated: 2021-02-13
Onset: 2021-02-14
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 01620A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-01
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: WAS NOT REPORTED AT TIME OF VACCINATION
Preexisting Conditions:
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC Split Type:

Write-up: ARRIVED AT EVENT, CONSENT FORM COMPLETED, DID NOT REPORT HE HAD BEEN ILL, DID NOT REPORT THAT HE TOOK ANY FEVER REDUCING MEDICATIONS
VAERS ID: 1034182 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-01-29
Onset: 2021-02-01
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN 5318 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaemia, Atrial fibrillation, Atrial flutter, Cardiac failure congestive, Condition aggravated, Coronary artery disease, Death, Dyslipidaemia, Essential hypertension, Left ventricular failure, Liver function test abnormal, Mitral valve incompetence, Renal failure, Renal tubular necrosis, Thrombocytopenia, Troponin increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Dyslipidaemia (narrow), Haematopoietic erythropenia (broad), Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (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), Hypertension (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Lipodystrophy (broad), Renovascular disorders (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort inhaler 2 puffs BID Cardura 8 mg PO daily Oxygen at night
Current Illness: OSA started on oxygen at night Dysphagia - work up
Preexisting Conditions: Sleep apnea Joint inflammation Hypoxia Past history of MI Hyperlipidemia Back pain Alcohol abuse Hearing loss Nodular hyperplasia of the prostate Asthma TIA Atrial fibrillation, new onset
Allergies: None Known
Diagnostic Lab Data: Primary diagnosis of systolic CHF, mitral valve regurgitation, renal failure with tubular necrosis, abnormal liver function tests, elevated troponin, anemia, thrombocytopenia, atrial fibrillation/flutter, essential hypertension, CAD, dyslipidemia. Work-up with TCU admission. Discharged home on hospice.
CDC Split Type:

Write-up: Approximately 2 weeks post vaccination developed rapid AF, CHF. Admitted to Medical Center. Discharged home on hospice. Patient died at home on 2/13/2021. Reported to this reporter at second dose clinic on 2/16/21. Other details not known. Unknown if related to vaccine.
VAERS ID: 1034192 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Colorado  
Vaccinated: 2021-02-01
Onset: 2021-02-03
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Cerebral small vessel ischaemic disease, Death, Intestinal infarction, Intestinal ischaemia, Intraventricular haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), 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), Ischaemic colitis (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Fosamax, Cosopt soln, Emollient, Xalantan soln, Effient, Zocor
Current Illness: Glaucoma, HLD
Preexisting Conditions: Glaucoma, HLD
Allergies: none
Diagnostic Lab Data: Too numerous to include
CDC Split Type:

Write-up: Patient presented with spontaneous IVH of small vessel origin with essentially no past medical history. She then acutely developed mesenteric ischemia. Died due to all dead small bowel which also appeared to be small vessel disease and not embolic/thrombotic. This process started one week after
VAERS ID: 1034349 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-10
Onset: 2021-02-12
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase increased, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bicarbonate increased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood gases abnormal, Blood glucose increased, Blood magnesium increased, Blood methaemoglobin, Blood potassium normal, Blood sodium decreased, Blood urea normal, Carbon dioxide decreased, Carboxyhaemoglobin decreased, Confusional state, Death, Differential white blood cell count, Electrocardiogram normal, Eosinophil count normal, Eosinophil percentage, Fibrin D dimer increased, Fraction of inspired oxygen, Full blood count, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Hypotension, Influenza A virus test negative, Influenza B virus test, International normalised ratio increased, Lymphocyte count, Lymphocyte percentage, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mental status changes, Metabolic function test, Methaemoglobin urine absent, Monocyte count decreased, Monocyte percentage, N-terminal prohormone brain natriuretic peptide increased, Neutrophil count, Neutrophil percentage, Nucleated red cells, Oxygen saturation normal, PCO2 decreased, PO2 increased, Platelet count decreased, Protein total normal, Prothrombin time prolonged, Red blood cell count decreased, Red cell distribution width normal, Respiratory distress, SARS-CoV-2 test negative, Troponin I increased, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 2.5 mg BID Metformin 500 mg BID Losartan 100 mg qd Simvastatin 10 mg qd Levothyroxine 50 mcg qd torsemide 20 mg qd
Current Illness: Unknown
Preexisting Conditions: Congestive heart failure Hypertension Type 2 Diabetes Chronic venous insufficiency Hypothyroidisn Coronary artery disease Dyslipidemia
Allergies: None
Diagnostic Lab Data: BLOOD GAS, ARTERIAL Result Value Ref Range Puncture Site Right Radial Allen''s Test Pos pH Measured 7.111 (LL) 7.350 - 7.450 pCO2, Measured 27.9 (L) 35.0 - 45.0 mmHg PO2 Measured 143.9 (H) 80 - 100 mmHg Bicarbonate 8.7 (LL) 20.0 - 26.0 mmol/L Base Deficit 19.4 (H) 0.0 - 3.0 mmol/L Carboxyhemoglobin 0.2 (L) 0.5 - 1.5 % Methemoglobin 0.0 0.0 - 1.5 % O2 Saturation 98 94 - 99 % FiO2 60 COMPREHENSIVE METABOLIC PANEL W GFR Result Value Ref Range Sodium 131 (L) 136 - 145 mmol/L Potassium 4.7 3.5 - 5.1 mmol/L Chloride 100 98 - 107 mmol/L CO2 (Bicarbonate) 10 (LL) 21 - 32 mmol/L Anion Gap 21 (H) 3 - 12 mmol/L Glucose 488 (HH) 70 - 99 mg/dL BUN 25 6 - 25 mg/dL Creatinine 2.01 (H) 0.40 - 1.00 mg/dL GFR Est-Other 21 (L) $g60 See Cmnt GFR Est-African American 25 (L) $g60 See Cmnt Calcium 9.0 8.2 - 10.2 mg/dL Total Protein 6.6 6.4 - 8.2 g/dL Albumin 3.2 3.2 - 4.7 g/dL Total Bilirubin 1.1 0.1 - 1.3 mg/dL Alkaline Phosphatase 71 26 - 137 U/L AST 47 (H) 0 - 37 U/L ALT 36 15 - 65 U/L TROPONIN I Result Value Ref Range Troponin I 0.09 (H) 0.00 - 0.05 ng/mL N-TERM PRO-BRAIN NATRIURETIC PEPTIDE (PROBNP) Result Value Ref Range NT Pro BNP 1,580 0 - 1,800 pg/mL MAGNESIUM Result Value Ref Range Magnesium 2.6 (H) 1.5 - 2.5 mg/dL CBC WITH AUTOMATED DIFFERENTIAL Result Value Ref Range White Blood Cell Count 6.8 4.0 - 11.0 K/uL Red Blood Cell Count 3.37 (L) 3.90 - 5.40 M/uL Hemoglobin 9.9 (L) 11.7 - 15.5 g/dL Hematocrit 30.9 (L) 35.0 - 47.0 % MCV 92 80 - 100 fL MCH 29.4 27.0 - 33.0 pg MCHC 32.0 31.0 - 36.0 g/dL RDW 14.1 <16.4 % Platelet Count 144 (L) 150 - 400 K/uL Differential Type Automated Neutrophil % 72 % Lymphocyte % 25 % Monocyte % 3 % Eosinophil % 0 % Basophil % 0 % Abs. Neutrophil 4.8 2.0 - 8.0 K/uL Abs. Lymphocyte 1.7 1.0 - 5.1 K/uL Abs. Monocyte 0.2 0.0 - 0.8 K/uL Abs. Eosinophil 0.0 0.0 - 0.5 K/uL Abs. Basophil 0.0 0.0 - 0.2 K/uL NUCLEATED RBC AUTO 0.0 0.0 /100 WBC PROTHROMBIN TIME/INR Result Value Ref Range Prothrombin Time 16.1 (H) 12.1 - 14.7 sec INR 1.3 (H) 0.8 - 1.2 PARTIAL THROMBOPLASTIN TIME Result Value Ref Range PTT 26.3 23.3 - 36.2 sec D-DIMER,QUANTITATIVE Result Value Ref Range D Dimer, Quant 2.70 (H) <0.50 ug(FEU)/mL INFLUENZA A & B NAAT Result Value Ref Range INFLUENZA A RNA Not Detected Not Detected INFLUENZA B RNA Not Detected Not Detected CORONAVIRUS 2019 NAA(COVID-19,SARS2) Result Value Ref Range SARS-COV-2, NAA Not Detected Not Detected ECG interpretation : junctional rhythm, regular, no ST elevation or depressions, diffuse T wave flattending, no marked QT prolongation. Interpreted contemporaneously by me.
CDC Split Type:

Write-up: Patient awoke on 2/12/21 with altered mental status, confusion, respiratory distress, was taken to hospital by ambulance. Per ED notes from ED attending Pt presented with hypotension and respiratory distress. DNR status, patient given comfort measures and passed away in ED at 11:24 am on 2/12/21.
VAERS ID: 1034985 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Kentucky  
Vaccinated: 2021-01-04
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / OT

Administered by: Unknown       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: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: 4 Nurshing home patients Died; A Spontaneous report was received from a pharmacist concerning 4 nursing home patients of unspecified age and gender who received Moderna''s COVID-19 vaccine (mRNA-1273) and died. The patients'' medical histories were not provided. No relevant concomitant medications were reported. On unspecified dates, 4 nursing home patients received their first of two planned doses of mRNA-1273 (Lot # 039K20A) for prophylaxis of COVID-19 infection. A pharmacist reported that they just learned 4 nursing home patients died after the first dose of the Modern vaccine. The patients were buried, and no autopsies were conducted. The pharmacist suspected latent Covid-19 on the patients and that the vaccine precipitated this outcome. No treatment information was provided. Action taken with the second dose of mRNA-1273 in response to the event was not applicable. The event 4 nursing home patients died was fatal.; Reporter''s Comments: This case concerns 4 nursing home patients of unspecified age and gender who received their first dose of Moderna''s COVID-19 vaccine (mRNA-1273)Lot # 039K20A) and died. Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: died
VAERS ID: 1035505 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       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: Medical History/Concurrent Conditions: COVID-19
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away with an hour to hour and 1/2 of receiving vaccine; A spontaneous report was received from a consumer concerning a patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and passed away with an hour to hour and 1/2 of receiving vaccine. The patient''s medical history, as provided by the reporter, included COVID-19. No relevant concomitant medications were reported. On unknown date, prior to the onset of the events, the patient received their first of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On an unknown date, the patient passed away within an hour and a 1/2 of receiving the vaccine. Per the nursing home staff, they did not expect the patient to make it many more days. The patient was unresponsive in the room when the shot was given. The patient was 14+ days post COVID. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on an unknown date. The cause of death was unknown.; Reporter''s Comments: This case concerns a patient, who experienced event of death (unknown cause). The event occurred an hour to hour and 1/2 after the first and last dose of mRNA-1273 vaccine administration. Based on the current limited available information and temporal association between the use of the product and the start date of the event, a causal relationship cannot be excluded and the event is assessed as possibly related. However, Per the nursing home staff, the patient was 14+ days post COVID and they did not expect the patient to make it many more days. The patient was unresponsive in the room when the shot was given.; Reported Cause(s) of Death: unknown cause of death
VAERS ID: 1035539 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-19
Onset: 2021-01-01
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 1 RA / -

Administered by: Private       Purchased by: ?
Symptoms: Acute myeloid leukaemia, Fall, Fatigue, Full blood count, Pain in extremity, Sepsis
SMQs:, Accidents and injuries (narrow), Tendinopathies and ligament disorders (broad), Haematological malignant tumours (narrow), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 37
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ATORVASTATIN; ASPIRIN [ACETYLSALICYLIC ACID]; CALCIUM; GABAPENTIN; LOSARTAN; NAMENDA
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Cognitive impairment; Hyperlipidemia; Hypertension; Osteoarthritis
Allergies:
Diagnostic Lab Data: Test Date: 202102; Test Name: cell lines; Result Unstructured Data: Test Result:down
CDC Split Type: USPFIZER INC2021137924

Write-up: Fall; fatigued; arm pain; AML; Sepsis secondary to AML; This is a spontaneous report from a contactable consumer. An 88-year-old female patient received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, lot# EL3249), via an unspecified route of administration on 19Jan2021 17:30 in right arm at single dose for covid-19 immunization. Medical history included hypertension, hyperlipidemia, OA (osteoarthritis), cognitive impairment. No other vaccine in four weeks was administrated. Concomitant medication in two weeks included atorvastatin, aspirin, calcium, gabapentin, losartan and memantine hydrochloride (NAMENDA). The patient previously took lisinopril and tetracycline and both experienced allergies. The patient had no covid prior vaccination. The patient initially had no symptoms but arm pain in Jan2021, no bleeding or bruising from injection. On 31Jan2021 19:00, patient felt fatigued. Patient suffered fall on 01Feb2021. She was admitted to hospital. All cell lines were down in Feb2021. She was diagnosed with AML (acute myeloid leukemia) in 2021. She expired 07Feb2021. Events resulted in emergency room/department or urgent care, hospitalization, life threatening illness (immediate risk of death from the event) and patient died. The patient received the treatment of blood and platelet transfusions, bone marrow biopsy, cytogenetic testing, antibiotics, intubation for events. The patient died on 07Feb2021 due to sepsis secondary to AML. An autopsy was not performed. Outcome of events were fatal.; Reported Cause(s) of Death: arm pain; fatigued; fall; Sepsis secondary to AML; Sepsis secondary to AML
VAERS ID: 1035542 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Utah  
Vaccinated: 2021-02-08
Onset: 2021-02-08
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN9581 / 1 RA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Heart valve replacement; Oxygen supplementation (On Oxygen at night)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021138559

Write-up: passed away; This is a spontaneous report from a contactable consumer (patient''s granddaughter). An 82-year-old male patient received first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, Batch/lot number: EN9581), via an unspecified route of administration on 08Feb2021 at 14:30 into right arm at single dose for COVID Prevention. Medical history included Heart valve replacement from 5 years before 09Feb2021 (2016), on Oxygen at night (reporter did not know the liter amount that the patient used at night). The patient''s concomitant medications were not reported. Patient had no other vaccines on the same day as the COVID vaccine. It was reported that patient received his first dose of the Pfizer vaccine around 14:30 on 08Feb2021 and he was fine before that, and by 16:30, he had passed away on 08Feb2021. Reporter reported that the cause of death was unknown at this time and that the family would be having an autopsy performed but that it had not yet been performed. No investigation assessment could provide. The patient died on 08Feb2021 at 16:30. An autopsy was not performed.; Reported Cause(s) of Death: passed away
VAERS ID: 1035545 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: New York  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021139379

Write-up: Death; This is a spontaneous report from a contactable consumer. A 42-year-old male patient received Covid 19 Vaccine (UNSPECIFIED TRADE NAME), via an unspecified route of administration from an unspecified date to an unspecified date at single dose for covid-19 immunization.The patient medical history was not reported. The patient''s concomitant medications were not reported. The reporter was calling about the Covid 19 Vaccine. Reporter stated that she gets information every day from the nursing home. Reporter stated that she will provide the name of the Nursing home, she just forgot to put it down. The patient, within 2 days dead from it, he was perfectly healthy. The patient died on an unspecified date. It was not reported if an autopsy was performed. Information on Lot/batch number has been requested.; Reported Cause(s) of Death: Death
VAERS ID: 1035546 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-16
Onset: 2021-01-31
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cerebrovascular accident, Investigation, SARS-CoV-2 test
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), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Hypertension (Took medication)
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 2021; Test Name: Investigation; Result Unstructured Data: Test Result:Brain bleed and discovered she had a stroke; Test Date: 202102; Test Name: COVID-19 virus test; Test Result: Negative
CDC Split Type: USPFIZER INC2021140448

Write-up: Stroke; This is a spontaneous report from a contactable consumer. A 94-year-old female patient received the 1st dose of bnt162b2 (BNT162B2, Manufacturer Pfizer-BioNTech), via an unspecified route of administration, on 16Jan2021, at single dose, for COVID-19 immunisation. Medical history included ongoing hypertension (took medication). Patient did not have COVID-19 prior to vaccination. Concomitant included unspecified medication for hypertension. The patient experienced stroke on 31Jan2021. The patient was brought to the emergency room and hospitalized due to the event on 31Jan2021. No therapeutic measures were taken as a result of the event. The patient underwent lab tests and procedures which included COVID-19 virus test: negative in Feb2021 (a week before report); investigation: brain bleed and discovered she had a stroke (on unknown date in 2021). The patient died on 03Feb2021 due to stroke and old age. An autopsy was not performed. Patient''s family did not attribute her death to the vaccine at all. The information on the Lot/Batch number has been requested.; Reported Cause(s) of Death: stroke; Old age
VAERS ID: 1035549 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Blood bilirubin, Blood osmolarity, Blood pressure measurement, Blood urea, Monocyte count, Platelet count, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Systemic lupus erythematosus (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: blood bilirubin; Result Unstructured Data: Test Result:1.50; Test Name: osmolality; Result Unstructured Data: Test Result:297; Test Name: blood pressure; Result Unstructured Data: Test Result:159/106; Test Name: Blood urea (BUN); Result Unstructured Data: Test Result:22.3; Test Name: monocytes; Test Result: 12.1 %; Test Name: platelet count; Result Unstructured Data: Test Result:Thrombocytopenia; Test Date: 20201221; Test Name: platelet count; Result Unstructured Data: Test Result:platelet count decreased again to 0
CDC Split Type: USPFIZER INC2021144615

Write-up: Thrombocytopenia; This is a spontaneous report from a contactable consumer (patient''s wife). A male patient of unspecified age received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) via an unspecified route of administration on an unspecified date at single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. The patient experienced thrombocytopenia on an unspecified date, the seriousness of the event reported as death. The patient died two weeks after receiving a COVID-19 vaccine. Patient''s wife said that he died from a condition known as thrombocytopenia, marked by a shortage of the blood platelets that help stop bleeding, after he received BNT162B2. The patient underwent lab tests and procedures which included blood bilirubin: 1.50, blood osmolarity: 297, blood pressure measurement: 159/106, blood urea: 22.3, monocyte count: 12.1 %, platelet count: thrombocytopenia, platelet count: platelet count decreased again to 0 on 21Dec2020. The patient died on an unspecified date. It was unknown if an autopsy was performed. The outcome of the events was fatal. No follow-up attempts are possible; information about lot/batch number cannot be obtained.; Reported Cause(s) of Death: Thrombocytopenia
VAERS ID: 1035552 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 2020-12-29
Onset: 2020-12-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature, Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-29
   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: GABAPENTIN; MEMANTINE
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Anxiety; Aphasia; Asthenia; Dementia; Iron deficiency; Major depressive disorder; Osteoporosis; Penicillin allergy; Polyneuropathy; Type II diabetes mellitus
Allergies:
Diagnostic Lab Data: Test Name: temperature; Result Unstructured Data: Test Result:98 Fahrenheit
CDC Split Type: USPFIZER INC2021146318

Write-up: approxmately 1:30 Pm the resident passed away; This is a spontaneous report from a Pfizer sponsored program. A non-contactable consumer reported that a female patient of an unspecified age (reported as 85 without unit) received the 1st dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Lot number: EL0140), intramuscular at left arm on 29Dec2020 11:29 at single dose for COVID-19 immunization. Medical history included dementia, aphasia, type 2 diabetes mellitus (DM), iron deficiency, asthenia, osteoporosis, polyneuropathy, anxiety, Major depressive disorder (MDD). Concomitant medication included gabapentin, memantine. The patient had allergies to codiene, phenobarbital, penicillin. The vaccine was administrated with no immediate adverse reaction at 11:29. Vaccine screening questions were completed and resident was not feeling sick and temperature was 98F. At approximately 13:30 on 29Dec2020, the resident passed away. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected. ; Reported Cause(s) of Death: approxmately 1:30 Pm the resident passed away
VAERS ID: 1035553 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-01-19
Onset: 2021-01-25
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 - / OT

Administered by: Private       Purchased by: ?
Symptoms: Abdominal wall haematoma, Abdominal wall haemorrhage, Acute respiratory failure, COVID-19 pneumonia, Death, Hypotension
SMQs:, Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (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), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 9 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Suspected COVID-19
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021146397

Write-up: Pt passed soon after; shortly after progressed with other covid symptoms and was admitted / acute resp failure, COVID pneumonia; acute resp failure, COVID pneumonia; Became hypotensive due to massive hamatoma 2'' bleeding into abd rectus muscle.; Became hypotensive due to massive hamatoma 2'' bleeding into abd rectus muscle.; Became hypotensive due to massive hamatoma 2'' bleeding into abd rectus muscle.; This is a spontaneous report from a non-contactable Pharmacist. A 76-years-old non-pregnant female patient received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE lot number EL3247), intramuscular on 19Jan2021 at single dose for COVID-19 immunisation. The patient medical history included COVID symptoms from 16Jan2021 and ongoing. Concomitant medications were not reported. The patient with acute resp failure, COVID pneumonia, that developed symptoms 9 days prior to admit and ultimately received first vaccine 6 days prior to a admit, then shortly after progressed with other covid symptoms and was admitted on 25Jan2021. She decompensated while intp and was transferred to ICU for rising O2 needs, ultimately had to be intubated. Became hypotensive due to massive hamatoma 2'' bleeding into abd rectus muscle. Sx and IR consulted and did beside exploration of hematoma. Initially blood pressure responded but overnight continued with refractory hypotension. Maxed out vasopressin and levophed, hemodynamics deteriorated. The patient died on 02Feb2021. It was not reported if an autopsy was performed. No follow-up attempts are possible. No further information is expected.; Sender''s Comments: Based on temporal association, the causal relationship between bnt162b2 and the events death, COVID-19 pneumonia, acute respiratory failure, hypotension, abdominal wall haematoma and abdominal wall haemorrhage cannot be excluded. The information available in this report is limited and does not allow a medically meaningful assessment. This case will be reassessed once additional information becomes available. 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: Pt passed soon after
VAERS ID: 1035597 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2020-12-30
Onset: 2021-01-17
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   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: unknown
Preexisting Conditions: Unknown. Patient died on 01/17/2021. Related to vaccine? I do not know but am reporting because I sent an email to VAERS and never received an answer whether it should be reported or not. So, erring on the side of caution, I am reporting.
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death on 1/17/2021. Found at home deceased.
VAERS ID: 1035641 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-24
Onset: 2021-02-09
   Days after vaccination: 16
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   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: Azathioprine 50mg po qd Bupropion XL 300mg po qam Furosemide 40mg po qd Nadolol 20mg po qd Omeprazole 20mg po qd Prednisone 20po qd Spironolactone 25mg po qd
Current Illness: Tobacco Use - 0.5 pack per day cigarette use Autoimmune Hepatitis - flare in 2020, improved with increased immunosuppressants per GI note 12/15/20 Bilateral leg swelling 1/21/21 - Primary care office visit
Preexisting Conditions: Tobacco Use - 0.5 pack per day cigarette use Autoimmune hepatitis Essential Hypertension Migraine Mood disorder Allergic Rhinitis
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Healthcare was advised that this patient expired approximately two weeks after receiving her initial COVID vaccination
VAERS ID: 1035841 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-02-03
Onset: 2021-02-08
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: Home Medications Current 2/3/2021: Albuterol-Ipratropium as needed; Allopurinol daily; Aspirin 81mg daily; B complex plus vitamin C daily; Budesonide as needed; Calcitriol 4 times per week; Diphenoxylate-Atropine as needed for diarrhea; Eut
Current Illness: Diarrhea with Cdiff etiology, seen in the Wound Center on 2/3/2021 for a pressure ulcer; Seen in ER on 1/14 with diarrhea, fatigue, cough and shortness of breath labs revealed BUN 20; Cr 1.68; GFR 29; Alk Phos 152.
Preexisting Conditions: AAA with stent; COPD; Dyslipidemia; Hypertension; Kidney Disease; Murmur; Osteoarthritis; Home oxygen use; Stroke; Parkinson''s; Former Smoker; Lung Cancer.
Allergies: Gluten; NSAIDS; Penicillin; Sulfa
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Death on 2/8/2021 unknown signs and symptoms at time of death; multiple co-morbidities
VAERS ID: 1035845 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Wisconsin  
Vaccinated: 2021-02-03
Onset: 2021-02-11
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-11
   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: Unknown
Current Illness: Not sick at time of vaccination, unknown prior.
Preexisting Conditions: Unknown
Allergies: none
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: We were informed by EMS that the patient was found deceased on 2/11/2021 at her home. EMS states she was dead for some time, no medical care given.
VAERS ID: 1035850 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: North Carolina  
Vaccinated: 2021-02-04
Onset: 2021-02-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 UN / IM

Administered by: Work       Purchased by: ?
Symptoms: Cerebrovascular accident, Computerised tomogram, Echocardiogram, Laboratory test, Magnetic resonance imaging, Neurological symptom, Thrombosis
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), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Advair 250-50mcg Allegra-D 24 hour 180-240mg Amlodipine 2.5mg Buspirone 10mg Carvedilol 12.5mg Montelukast 10mg Prednisone 20mg Albuterol Zoloft 100mg Spiriva Nasacort AQ
Current Illness: Sinus Infection being treated with steroids and antibiotics
Preexisting Conditions: Asthma Allergies Chronic Sinus infections Depression History of heart attack
Allergies: Aspirin Erythromycin
Diagnostic Lab Data: Multiple CT scans, MRI''s, echo''s, labs
CDC Split Type:

Write-up: Patient woke up on the morning of 2/6 with symptoms of a stroke. Rushed to hospital where clot found in brain. Recovered from initial stroke but then had another major stroke on 2/8 and never recovered.
VAERS ID: 1035866 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-11
Onset: 2021-02-15
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death, Myalgia
SMQs:, Rhabdomyolysis/myopathy (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: DOXAZOSIN TAB,ORAL 2MG TAKE TWO TABLETS BY MOUTH TWICE A DAY FOR BLOOD PRESSURE DABIGATRAN CAP,ORAL 150MG TAKE ONE CAPSULE BY MOUTH TWICE A DAY LABETALOL TAB 200MG T
Current Illness: None
Preexisting Conditions: Chronic atrial fibrillation [Chronic atrial fibrillation, unspecified] Hyperlipidemia [Hyperlipidemia, unspecified] Benign essential hypertension [Essential (primary) hypertension] GERD - Gastro-esophageal reflux disease [Gastro-esophageal reflux disease without esophagitis] Carcinoma of colon [Carcinoma in situ of colon] Rosacea [ROSACEA]
Allergies: Simvastatin Influenza
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt died on 2/15/21. On 2/13/21, pt complained of muscle aches.
VAERS ID: 1035872 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Texas  
Vaccinated: 2021-02-11
Onset: 2021-02-12
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 043L20A / 2 LA / 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: 2021-02-12
   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: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive at 8 am on 2/12; patient was deceased
VAERS ID: 1035878 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Missouri  
Vaccinated: 2021-02-13
Onset: 2021-02-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 03M20A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: Aspirin, Atorvastatin
Current Illness: AIED; CHF; Type 2 DM; HTN; Chronic Renal Failure; Lung CA
Preexisting Conditions: See above
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Daughter called to report that the patient died on 02/15/2021. No report of symptoms from the vaccine on 02/13/2021
VAERS ID: 1035897 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Nebraska  
Vaccinated: 2021-02-02
Onset: 2021-02-01
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Condition aggravated, Coronary artery disease, Death, Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Other ischaemic heart disease (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 6
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xarelto (20MG Tablet, 1 (one) Oral daily, Taken starting 09/18/2020) Active. Spironolactone (25MG Tablet, 1 tab Oral daily, Taken starting 01/08/2021) Active. Sertraline HCl (100MG Tablet, 1 tab Oral daily, Taken starting 12/28/2020) Act
Current Illness: Acute chronic diastolic CHF exacerbation one month prior One oxygen for stage IV COPD
Preexisting Conditions: Diastolic CHF, Stage 3 chronic kidney disease, adrenal adenoma, COPD stage IV, Coronary artery disease with stents, diabetes mellitus, chronic atrial fibrillation, chronic hypertension, osteopenia.
Allergies: Jardiance: Caused a yeast injection
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her vaccine on 2/2/2021 in the morning. She was observed for over 15 minutes and had no history of any anaphylactic reaction of any sort. She felt fine and went home. 2/15/2021 we were notified by her family that she had passed away on 2/7/2021 at home. The cause of death was stated as myocardial infarct secondary to coronary artery disease. We do not think it had to do with the vaccine administration. The patient had many comorbidities.
VAERS ID: 1035943 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: California  
Vaccinated: 2021-02-11
Onset: 2021-02-13
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9262 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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:
Current Illness:
Preexisting Conditions: Incomplete Quadriplegic. Wheelchair bound after accident where he sustained brain damage after being knocked over by a wave and hitting his head on a sand swell.
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had no reaction at the time of vaccination. Waited the required 15 minutes and was allowed to go home.
VAERS ID: 1035950 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-21
Onset: 2021-02-15
   Days after vaccination: 25
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   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: Unknown
Current Illness: none reported
Preexisting Conditions: non reported
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient found deceased at home on 2/15/2021. There was no known cause of death with no significant medical history.
VAERS ID: 1036047 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-01-16
Onset: 2021-01-24
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Cardiac assistance device user, Death, Pulse absent, Resuscitation, Seizure like phenomena, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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), Convulsions (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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 (TYLENOL) 325 MG tablet Apixaban (ELIQUIS) 5 MG TABS tablet atorvastatin (LIPITOR) 40 MG tablet B-Complex TABS cetirizine (ZYRTEC) 10 MG tablet Chlorhexidine Gluconate (BIOPATCH PROTECTIVE DISK/CHG) (Dressing) MISC Cholecalcif
Current Illness: Hospitalized 12/20 - 12/24/2020 Discharged to home with home care services Hospital Course 12/20 - 12/24/20: 74-year-old male with multiple medical problems presented to the ED with sudden shortness of breath and some palpitations. He was seen in the emergency room after being transported to the ED on CPAP was found to be febrile to 101 tachycardic tachypneic put on BiPAP in ED. EKG showed atrial flutter with left bundle branch block no ST segment elevations COVID-19 was negative RSV and flu was negative chest x-ray showed pneumonia in the right lower lobe. Subsequent chest x-ray showed bilateral lower lobe airspace disease consistent with pneumonia Patient also had a CT abdomen in the ED showing left pleural effusion . The CT report is attached which also showed a right renal cyst with calcification and needs to be followed up in 6 months with a renal protocol CT rest of it was negative. He was started on supplemental oxygen IV antibiotics. Patient was started on Rocephin and azithromycin is significantly improved but off the oxygen and is very eager to leave today patient also had an echocardiogram which revealed an EF of 55 to 60% LV wall motion was normal left atrium was severely dilated. Status post bioprosthetic aortic valve replacement which was in place. He was continued on Eliquis During his hospital course there were no complications. Discharged home today with follow-up. I have elected to send him home on 5-7 days of Levaquin patient reports he is does not tolerate Augmentin well
Preexisting Conditions: Anxiety ? Atrial fibrillation ? CHF (congestive heart failure) ? COPD (chronic obstructive pulmonary disease) ? Coronary artery disease ? Diabetes mellitus, type II ? Gangrene of toe of left foot ? GERD (gastroesophageal reflux disease) ? Hyperlipidemia ? Hypertension ? Insomnia ? Myocardial infarction Oct 2012 ? Osteoarthritis ? Peripheral vascular disease
Allergies: penicillin diazepam
Diagnostic Lab Data:
CDC Split Type:

Write-up: Short version The patient has long-standing health issues. The patient received the first dose of Moderna COVID-19 vaccine on 1/16/2021 (unknown location). The patient suffered an event in his home on 1/24/2021. CPR and treatment was begun and he was transported to the ED. He was pronounced dead in the ED at 0846. Long version 70-year-old male with past medical history of CAD with pacemaker, A. fib, COPD, hypertension/hyperlipidemia presenting in cardiac arrest. 911 call at 0724. Per EMS, patient was witnessed by family to have seizure-like activity and then collapsed and became unresponsive. Patient was noted by family to be pulseless and CPR was started right away. Patient received two doses of epi by police were on scene first (AED defibrillation x2) and six doses of epi (plus 6 more AED shocks) by EMS when they arrived. Patient had CPR performed for 45 minutes prior to arriving at the hospital. On route, patient had episodes of paced rhythm and V. fib. Patient received one amp of bicarb and one amp of calcium en route. Patient also received 300 mg of amiodarone en route. Arrived in ED at 0810 Patient received ongoing compressions, shocks and additional medications (epinephrine x6, lidocaine IV, sodium bicarbonate) until time of death called at 0846 in the ED.
VAERS ID: 1036098 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Arkansas  
Vaccinated: 2021-01-31
Onset: 2021-02-07
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Haemorrhage, International normalised ratio increased, Urinary tract infection, Urine analysis abnormal
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: coumadin 5 mg, clopidogrel 75 mg, atorvastatin 20 mg, citalopram 10 mg, levothyroxine 75 mcg, lisinopril-hctz 20-12.5 mg, melatonin 5 mg
Current Illness:
Preexisting Conditions: Hypothyroidism; History of coronary artery stent placement; Essential hypertension; Current use of long term anticoagulation
Allergies: NKDA
Diagnostic Lab Data: INR test on 2/10/2021- results INR 12 Urinalysis 2/10/2021- results- abnormal
CDC Split Type:

Write-up: Patient received the vaccine on 1/31/2021. Patient complained of bleeding 2/7/2021. Went to clinic where labs were conducted. Patient had an INR of 12. Previous INR results were normal prior to vaccination. Patient was also diagnosed with UTI and given antibiotics. Patient was encouraged to go to ER. Patient died on 2/12/2021.
VAERS ID: 1036174 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-06
Onset: 2021-02-07
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac disorder, Death, Discomfort, Dyspepsia, Flank pain, Hypotension, Myocardial infarction
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific dysfunction (narrow), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
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: At midnight developed heart burn, low BP but normal O2; at 4am took Antacid then felt better and BP was normal. Then around 7am asked to go to ER because the discomfort became pain and moved to the side. Went to ER, mild Cardiac issue and at 3pm had heart attack and passed away.
VAERS ID: 1036182 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-02-12
Onset: 2021-02-12
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Agonal rhythm, Areflexia, Coma, Coma scale abnormal, Computerised tomogram head abnormal, Cough, Death, Hunt and Hess scale, Intracranial aneurysm, Intracranial pressure increased, Intraventricular haemorrhage, Mechanical ventilation, Ophthalmoplegia, Posthaemorrhagic hydrocephalus, Posturing, Pupillary light reflex tests abnormal, Pupillary reflex impaired, Ruptured cerebral aneurysm, Subarachnoid haemorrhage, Syncope, Unresponsive to stimuli, Ventricular drainage
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Peripheral neuropathy (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dystonia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (narrow), Cardiomyopathy (broad), Retinal disorders (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Ocular motility disorders (narrow), Neonatal disorders (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   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: Not verified. EMR states 1/4/2021 SINEMET 25-100 mg tablet.
Current Illness: Unknown
Preexisting Conditions: Not verified. Problem list in EMR includes: Cerebellar ataxia Noted 7/28/2017, Parkinson''s disease Noted 10/11/2019, Peripheral polyneuropathy Noted 7/29/2017, Lumbar radiculopathy Noted 10/29/2020, Throat clearing Noted 1/22/2018, Oropharyngeal dysphagia Noted 10/11/2019, Aortic ectasia Noted 10/6/2019, Anterior communicating artery aneurysm Noted 7/28/2017, Essential hypertension Noted 7/28/2017, Constipation Noted 10/23/2019, Nocturia Noted 10/11/2019, Dupuytren''s disease of palm of both hands Noted 10/11/2019, Alcohol intake above recommended sensible limits with complication Noted 7/29/2017, Major depressive disorder, single episode, mild Noted 10/11/2019, Hoarseness Noted 1/22/2018.
Allergies: NKA
Diagnostic Lab Data: CT Head w/o contrast - extensive subarachnoid & intraventricular hemorrhage most probably related to a bleeding anterior communicating artery aneurysm.
CDC Split Type:

Write-up: Patient received 2nd dose of the COVID-19 Pfizer vaccine, was observed in office x 15+ minutes, and released home. Pt and his son exited the building and when they got to the car, the pt shouted out "oh no!" and collapsed to the ground. The patient was unconscious experiencing agonal respirations, and unresponsive to painful stimuli. There is an Emergency Room at the same location. Their staff came out and helped to transfer the pt to the ED for further evaluation. It was found that the patient had a known Anterior communicating artery aneurysm (7/28/2017) that seemed to have ruptured. The patient was stabilized and transported to our local hospital and upon arrival, he was effectively comatose with a GCS 3. CT Head notated an extensive subarachnoid and intraventricular hemorrhage most probably related to a bleeding anterior communicating artery aneurysm. Neuro-Interventional Radiologist dictation reads "Hunt Hess 5 Fisher grade 4 extensive subarachnoid hemorrhage with intraventricular hemorrhage and early hydrocephalus secondary to rupture of a known anterior communicating artery aneurysm. Initial ICP after EVD placement noted to be in the 120s now 68 treatment complicated by aneurysm rerupture after admission and increased volume of blood although large volume of hemorrhage was seen on initial scan and no change in the patient''s clinical exam on her scale was noted due to this rerupture. Patient''s exam and prognosis are poor giving extensor posturing lack of extraocular movements to doll''s maneuver and weak pupillary reflex as well as cough and gag. Follows no commands or instructions at this time with no spontaneous movement on ventilator set at 12 overbreathing at 14-16 at this time without any sedation." The family opted to discontinue any further treatment to include surgical intervention given the findings. The patient was given comfort care with son and daughter at the bedside. The patient was extubated and expired at 1545h on 2/13/2021.
VAERS ID: 1036345 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Florida  
Vaccinated: 2021-01-29
Onset: 2021-01-30
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Ageusia, Death, Lethargy, Malaise, Nausea, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (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: levothyroxine
Current Illness: none
Preexisting Conditions: thyroid issues
Allergies: crab allergy, none others
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed lethargy and malaise several hours after vaccine with a low grade fever. The following morning she reported to her husband inability to taste food or drink. She developed nausea and vomiting which persisted from 1/30/21 through her death. She was found deceased in bed by her husband this morning.
VAERS ID: 1036418 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-21
Onset: 2021-01-25
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal wall oedema, Acute kidney injury, Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood potassium increased, Blood urea increased, Cardiac arrest, Central venous catheterisation, Computerised tomogram abnormal, Death, General physical health deterioration, Generalised oedema, Glomerular filtration rate decreased, Hypotension, Lung opacity, Oedema, Platelet count decreased, Pleural effusion, Pneumonia, Pulmonary oedema, Pulse absent, Resuscitation, SARS-CoV-2 test negative, Syncope, Troponin increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic thrombocytopenia (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-25
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Meds as of 1/20/21: Aspirin 81 daily; Carvedilol changed to Metoprolol XL; CoQ10 daily; digoxin 3xweek; fluticasone propionate daily; furosemide 80 mg twice daily; Iron 325mg daily; L-Carnitine daily; lisinopril 2.5 daily; Metamucil plus; M
Current Illness: Outpatient hospital admit 12/20-12/21 with CHF exacerbation; BNP 2510, platelet count 99; total bili 2.3; BUN 26, Cr 1.42 and GFR 47. Repeat labs 12/31/20 BUN 28; Cr 1.52; GFR 44; 1/2/21 total bili 2.6; platelet count 89. PCP visit 1/7 noted pitting edema BLE and wife stated more confused lately diagnosis hypertension, elevated bilirubin, thrombocytopenia and shortness of breath, CXR 1/7 cardiomegaly, central vascular congestion, tiny bilateral pleural effusions and mucous plugging. Cardiologist visit 1/20/2021 with med changes.
Preexisting Conditions: Anemia, CABG, apnea; CHF; dysrhythmia; pacemaker/defibrillator; cardiomegaly; heart disease; aortic valve replacement; former smoker; ischemic cardiomyopathy; perivalvular leak of prosthetic heart valve
Allergies: No Known allergies
Diagnostic Lab Data: 1/25/21 Rapid COVID negative; Troponin 0.87; platelet count 92; BUN 50, Cr 2.96; GFR 20; SGOT 132; SGPT 102; Potassium 5.5 CT revealed ground glass opacities representing pneumonia versus pulmonary edema; diffuse body wall edema and pleural effusions. Pacemaker/defibrillator interrogated with no shocks or other events noted.
CDC Split Type:

Write-up: ER visit 1/25/21 patient walked into a prompt care and collapsed, witnessed and pulseless CPR with ROSC after 6-7mins, no shock no meds. Awake and speaking upon arrival to ER. 2 plus pitting edema ble ER diagnosis Anasarca, cardiac arrest, hypotension, elevated troponin I levels, Acute kidney injury and syncope. ER notes reveal a syncopal episode in the shower prior to collapse at prompt care. Central line placed and plan to ship to another facility, patient continued to decline despite dopamine and dobutamine expired in ER prior to transfer.
VAERS ID: 1036437 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2021-01-26
Onset: 2021-02-17
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: None reported
Preexisting Conditions: None reported
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient is deceased. Family called the pharmacy on 2-17-21 to let us know he would not be coming for his second appointment. When the pharmacist tried to call the family back for more info, the phone number on file doesn''t work.
VAERS ID: 1036440 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Georgia  
Vaccinated: 2021-01-15
Onset: 2021-01-27
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Bladder cancer stage IV, Condition aggravated, Death
SMQs:, Non-haematological malignant tumours (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   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 names of medication, chemo medications, HBP, CHF medications
Current Illness: Stage 4 bladder cancer
Preexisting Conditions: Stage 4 bladder cancer, CHF
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died at home in hospice care from complications of stage 4 bladder cancer
VAERS ID: 1036460 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-02
Onset: 2021-02-05
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: liver cancer
Preexisting Conditions: liver cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: death 2-5-21
VAERS ID: 1036479 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-03
Onset: 2021-02-08
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Abdominal injury, Acute myocardial infarction, Bilevel positive airway pressure, Blood alkaline phosphatase increased, Blood creatinine increased, Blood lactic acid decreased, Blood urea increased, Brain natriuretic peptide increased, Cardiac failure congestive, Chest X-ray abnormal, Chest injury, Computerised tomogram normal, Contusion, Death, Dyspnoea, Fall, General physical health deterioration, Glomerular filtration rate decreased, Hypoxia, Lung opacity, Platelet count decreased, SARS-CoV-2 test negative, Troponin I increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Liver related investigations, signs and symptoms (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Acute central respiratory depression (broad), Biliary system related investigations, signs and symptoms (broad), Pulmonary hypertension (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 0
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: Allegra daily as needed; Ambien 5mg daily at bedtime; Aspirin 81 daily; Digoxin daily; hydrocodone-acetaminophen 5-325 as needed pain; Pravastatin 20 daily; ramipril 2.5 daily; zoloft 200 daily
Current Illness: Fell 2/4 and struck abdomen and ribs with large amount bruising Brought to ER 2/7 due to increased shortness of breath since COVID vaccine. Patient was admitted with CHF, hypoxia, possible aspiration pneumonia; NSTEMI (refused transfer for cardiology).
Preexisting Conditions: Dementia; CABG; HTN; MI; esophageal varices; Former smoker; liver cirrhosis; absent kidney
Allergies: Sulfa and vicodin
Diagnostic Lab Data: 2/7-2/8 hospital labs: BUN 29 Cr 1.43 GFR 48 Alk Phos 151 Lactic Acid 2.5 BNP 203 Troponin I 1.28 platelet count 78 COVID-19 Rapid Negative. Chest x-ray with hazy airspace opacities, CT Negative.
CDC Split Type:

Write-up: Fall 2/4 hospital admission 2/7/21 with death on 2/8/2021. Patient continued to decline on Bipap he was a DNR/DNI and family decided on comfort measures and he expired 2/8/2021.
VAERS ID: 1036480 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-26
Onset: 2021-02-02
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Cough, Death, Endotracheal intubation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-02
   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: amlodipine, aspirin, levothyroxine, losartan, metformin, metoprolol, pravastatin, polyethlyene glycol
Current Illness: had a cough since 2/17/21
Preexisting Conditions: diabetes type 2, hypertension, hypothyroid, hyperlipidemia, MRSA,
Allergies: Sulfa causes a rash
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient passed away on 2/2/21 after being admitted on 1/31/21 after receiving COVID19 Moderna Vaccine on 1/26/21. On initial report to the hospital patient reported having a cough for over 2 weeks (starting approx. 1/17/21). He had a postive COVID19 PCR on 1/31/21. Intubated on 1/31/21 and passed away on 2/2/21
VAERS ID: 1036519 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-02-16
Onset: 2021-02-17
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Death, Dyspnoea, Loss of consciousness, Nausea, Resuscitation, Unresponsive to stimuli
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), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Albuterol-ipratropium, warfarin, hydrochlorothiazide-triamterene, budesonide-glycopyrroltate-formoterol, atorvastatin.
Current Illness:
Preexisting Conditions: Severe COPD, cor pulmonale, history of pulmonary embolism, chronic hypoxemic respiratory failure.
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received first SARS-CoV2 vaccination yesterday at local store Experienced new symptoms of chills, nausea as well as worsening from baseline dyspnea at night. Wife states he had rough morning breathing and had sudden loss of consciousness and unresponsiveness and failed to respond to bystander CPR. He expired at his home.
VAERS ID: 1036532 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-02-15
Onset: 2021-02-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9268 / 2 AR / SYR

Administered by: Senior Living       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: 2021-02-16
   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: Patient was found unresponsive the following day and then pronounced deceased
VAERS ID: 1036585 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Rhode Island  
Vaccinated: 2021-02-13
Onset: 2021-02-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 2 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Aortic aneurysm, Arteriosclerosis, Asthenia, Cardiac arrest, Death, Hyperhidrosis, Myocardial infarction, Pulmonary embolism, Pulse absent, Resuscitation, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, venous (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Metformin, Fenofibrate, Simvastatin, Terazosin
Current Illness: Unknown at this time; nothing noted on vaccine screening form
Preexisting Conditions: Essential HTN, Mixed hyperlipidemia, Diabetes Type 2, Osteoarthritis, Heart Murmur,
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient called EMS approximately 1pm on 2/15 with complaints of generalized weakness. Upon arrival EMS found her to be diaphoretic and she had a witnessed syncopal episode with question of v-fib and seizures. She became unresponsive and had no pulse. CPR was begun and she was transported to ED. She remained asystole throughout. CPR was initially continued in the ED for approximately 30 minutes and then stopped with Time of Death noted at 13:27. ED notes noted "suspect given history that patient experienced massive MI, PE or ruptured AAA". Death certificate notes indicate "signficant conditions contributing to death after cardiac arrest; ASCVD".
VAERS ID: 1036634 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Maryland  
Vaccinated: 2021-02-08
Onset: 2021-02-14
   Days after vaccination: 6
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Body temperature increased, Death, Foaming at mouth, Pain in extremity, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: buspar, depakote, keppra, norvasc, synthroid, zoloft
Current Illness: none
Preexisting Conditions: HTN, dementia, Downs syndrome
Allergies: NKDA
Diagnostic Lab Data: no medical testing done per family wishes
CDC Split Type:

Write-up: Patient had COVID in Sept. Minimal symptoms. Received 1st dose 1/18 without adverse reactions. Second dose on 2/8-had complaints of arm soreness several days after then appeared in usual state of health. On 2/14 @ 2 hours after having lunch, patient was found unresponsive with Respirations 60, pulse 130, PO 84%, blood pressure 105/68. Patient with lots of white foam coming out of mouth. Temperature to 101.3. Patient DNR B and family deferred transfer, wanted comfort measures only. Nursing received order for MSIR. Patient continued with temps in 99-100 range with tylenol suppositories. Patient passed on 2/16.
VAERS ID: 1036655 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Illinois  
Vaccinated: 2021-01-13
Onset: 2021-01-31
   Days after vaccination: 18
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood albumin decreased, Blood alkaline phosphatase increased, Blood creatinine increased, Blood urea increased, Death, Globulins increased, Lymphocyte percentage decreased, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   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: Doxycycline twice daily; gabapentin daily; multivitamin daily; apresoline daily; cyanocobalamin; ascorbic acid; ergocalciferol; eliquis; nitrostat prn; allopurinol; famotidine; isosorbide; labetalol; tylenol; humalog
Current Illness: Chronic Stage IV sacral decubitis ulcer infected with necrotic tissue. Inpatient admit 1/14-1/27 for infected decubitis ulcer, osteomyelitis; bacteremia and possible cirrhosis and underwent multiple debridements while hospitalized.
Preexisting Conditions: ESRD on Dialysis; heart cath; anemia; bells palsy; CHF; Uterine Cancer s/p hysterectomy; CKD; DM; dyslipidemia; HTN; Obesity; AFib.
Allergies: Captopril, lisinopril and plavix
Diagnostic Lab Data: Hospital labs 1/14-1/27 WBC 36.53; BUN 58; Cr 4.48; Albumin 1.5; Globulin 5.7; Alk Phos 667; SGOT 194; SGPT 77; Lymph 0%
CDC Split Type:

Write-up: Death on 1/31/2021 multiple comorbidities
VAERS ID: 1036675 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Female  
Location: Michigan  
Vaccinated: 2021-01-28
Onset: 2021-02-04
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9261 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Blood creatinine increased, Blood culture negative, Blood urea increased, Brain natriuretic peptide increased, Cerebral haemorrhage, Chest X-ray abnormal, Computerised tomogram head abnormal, Condition aggravated, Culture negative, Death, Diarrhoea, Dyspnoea, Endotracheal intubation, Immunoglobulin therapy, Lung opacity, Nausea, Oesophagogastroduodenoscopy, Oxygen saturation decreased, Paralysis, Procalcitonin increased, Pupillary disorder, Pupillary light reflex tests abnormal, Respiratory failure, SARS-CoV-2 test negative, Troponin increased, Ventricular drainage, Viral test negative, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haemorrhage terms (excl laboratory terms) (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Retroperitoneal fibrosis (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), Pseudomembranous colitis (broad), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Retinal disorders (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Hypokalaemia (broad), Sepsis (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 11 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: acyclovir (ZOVIRAX) 200 MG capsule Take 1 capsule by mouth 2 times daily. albuterol HFA (PROVENTIL HFA, VENTOLIN HFA, PROAIR HFA) 108 (90 Base) MCG/ACT inhaler Take 2 puffs by inhalation Every 4 hours as needed for Wheezing (shortness of br
Current Illness:
Preexisting Conditions: Bilateral Lung Transplant due to Advanced Lymphoangioleiomymatosis Immunosuppressed status (HCC) Antibody mediated rejection of lung transplant (HCC) Bronchiolitis obliterans syndrome, grade 0P (HCC) Major depressive disorder with single episode, in full remission (HCC) RLS (restless legs syndrome) Chronic insomnia Long term current use of systemic steroids OSA (obstructive sleep apnea) Iron deficiency anemia Bilateral sciatica Pure hypercholesterolemia Hoarseness of voice Memory change Laryngeal stridor Senile nuclear cataract, bilateral Myopia of both eyes Osteoporosis without current pathological fracture, unspecified osteoporosis type Dry eyes, bilateral
Allergies: Voriconazole, NSAIDs
Diagnostic Lab Data:
CDC Split Type:

Write-up: 61 yo F with history of bilateral lung transplant 6/23/17 presented to ED on 2/4/21 with chief complaint of worsening shortness of breath, nausea and diarrhea for past week since receiving since receiving COVID-19 vaccine (Pfizer) on 1/28/21. Upon arrival to triage she was obviously dyspneic with significantly low oxygen saturations. O2 sats on arrival were 65%, improved to mid 90''s with O2 6 liters per NC. Admitting diagnosis: hypoxic respiratory failure post COVID vaccine. Lab work shows an elevation of the BUN and creatinine at 31 and 1.71 which is slightly higher than her usual baseline levels. BNP is elevated at 2 448 with a mildly elevated troponin. Procalcitonin is also elevated. Patient''s white blood cell count is 11.07. Full viral panel including COVID-19 is not detected. All blood cultures and respiratory cultures were negative. Patient chest x-ray shows numerous bilateral patchy opacities which is significantly different from her previous chest x-ray here. Empiric rejection treatment initiated including high dose methylprednisolone, plasmapheresis, IVIG, Thymoglobulin. She continued to decline and ultimately required intubation, proning and paralyzing on 2/8/2021 and then VV ECMO cannulation on 2/13/2021. EGD done 2/14/2021 as unable to pass the TEE probe during cannulation prior day (unable to complete due to abnormal anatomy). Acute pupil exam change in the early am hours of 2/15/2021 prompted urgent head CT which revealed catastrophic brain bleed. Brainstem reflexes were lost soon after. Despite placing an EVD emergently at bedside, brain stem reflexes were not recovered. GOL engaged and patient not an organ donation candidate. Therefore discussion with sister at bedside resulted in decision for cessation of life support. Patient expired shortly after support withdrawn and pronounced dead on 2/15/2021 at 11:11 AM.
VAERS ID: 1036678 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated: 2021-02-14
Onset: 2021-02-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac failure, Death, End stage renal disease, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: Amlodipine bes 5 mg ta 1 tab q am, baclofen 10 mg tab ? q am and pm, carvedilol 25 mg 1 tab q am and pm, clonidine hcl 0.3 mg tab q morning, afternoon and evening, escitalopram 20 mg 1 tab q am, floranex tab by mouth 3 times weekly, hydral
Current Illness: pneumonia-recent infection
Preexisting Conditions: chronic kidney disease-stage 4, schizophrenia, heart disease, COPD, hypertensive heart disease with heart failure, myalgia, nonrheumatic aortic valve stenosis
Allergies: hydantoins, lipitor, phenytoin, statins-hmg-coa, reductase inhibitors
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident did not exhibit any side effects from the vaccine. Staff spoke with him in his room at approximately 7:20am and returned to his room just a few minutes later and he was unresponsive. When the RN got to the room he had CTB. Physician documented heart failure and end stage kidney disease on the death certificate.
VAERS ID: 1036683 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: New York  
Vaccinated: 2021-02-15
Onset: 2021-02-17
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER - / UNK - / SYR

Administered by: Private       Purchased by: ?
Symptoms: Cardiac 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), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: none
Preexisting Conditions: HTN, DM, aortic stenosis, iron deficiency anemia, hypothyroidism, HLD, atrial fibrillation
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: cardiac arrest in the home.
VAERS ID: 1036685 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-02-13
Onset: 2021-02-15
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Chest discomfort, Chest pain, Death, Pain
SMQs:, Anaphylactic reaction (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Body Aches Generalized-Medium, Systemic: Chest Tightness / Heaviness / Pain-Medium, Additional Details: Unknown if patient experienced adverse effects 2-13 or 2-14, patient called facility 2-15 reporting body aches and chest pressure and was told by facility to seek medical attention, she passed later that day
VAERS ID: 1036697 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-03
Onset: 2021-02-08
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3246 / 2 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: lactobacillus; amlodipine; ascorbic acid; ativan; augmentin; ferrous sulfate; furosemide; mag oxide; mirtazapine; norco; potassium chloride; MVI; prosource liquid; protonix; sennosides-docusate; seroquel; tizanidine; vancomycin; zinc sulfat
Current Illness: Stage 4 sacral pressure ulcer with osteomyelitis with indwelling urinary catheter and peripherally inserted central catheter. IV Vancomycin
Preexisting Conditions: Neurogenic bladder, traumatic brain injury; metabolic encephalopathy; aphasia; Tourette''s; Hypertension; insomnia; apraxia; GERD; Pseudobulbar affect; chronic pain; anxiety; major depressive disorder
Allergies: No Known Allergies
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: Multiple co-morbidities history of COVID-19 6/8/2020 and 12/28/2020. At time of vaccination fighting osteomyelitis. 1st dose 1/13/21, 2nd dose 2/3/2021 expired 2/8/2021.
VAERS ID: 1036731 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Female  
Location: New Hampshire  
Vaccinated: 2021-02-04
Onset: 2021-02-14
   Days after vaccination: 10
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Dyspnoea, Dyspnoea exertional, Nausea, Oxygen saturation decreased
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF, venous stasis ulcers
Preexisting Conditions: HTN, polycythemia vera, anxiety disorder, ataxia, backache unspecified chronicity, hyperlipidemia, seizure d/o, h/o skin cancer, osteoporosis, incontinence, arthralgias, dizziness and giddiness
Allergies: Novacaine, ampicillin, sulfa
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: SOB, DOE, oxygen desaturation, nausea. Ems transport to ER for eval
VAERS ID: 1036748 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-13
Onset: 2021-01-18
   Days after vaccination: 5
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Alanine aminotransferase increased, Albumin globulin ratio abnormal, Aspartate aminotransferase increased, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bilirubin increased, Blood creatinine increased, Blood pressure decreased, Blood urea increased, Condition aggravated, Death, Dialysis, Globulins increased, Loss of consciousness, Lymphocyte percentage decreased, Pneumonia, Protein total normal, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Haematopoietic leukopenia (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: Tylenol prn; aspirin daily; atorvastatin daily; calcium carbonate daily; cholecalciferol twice daily; diltiazem; eliquis; ferrous sulfate; norco; melatonin; miralax; namenda; tamsulosin; tramadol every 6hrs.
Current Illness: ER visit 1/7 due to fall, CT negative current Dialysis, pneumonia, hospice patient.
Preexisting Conditions: DVT, dementia, hep c, hyperlipidemia; occlusion of internal carotid artery; paroxysmal Afib; traumatic brain injury
Allergies:
Diagnostic Lab Data: 1/14/21 WBC 25.38; bun 23; cr 2.92; total protein 7.7; albumin 2.0; globulin 5.7; a/g ratio 0.4; total bili 3.6; alk phos 1743; SGOT 193; SGPT 82; lymph 7%
CDC Split Type:

Write-up: Sent to ER 1/14/2021 due to drop in blood pressure with LOC during dialysis. Imaging revealed right lower lobe pneumonia given script for amoxicillin. According to staff patient was on dialysis had pneumonia and was on hospice, dialysis stopped resulting in death.
VAERS ID: 1036770 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-19
Onset: 2021-02-10
   Days after vaccination: 22
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 RA / SYR

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: generic multi vitamin
Current Illness: none
Preexisting Conditions: none, very healthy
Allergies: none
Diagnostic Lab Data: None, she was found in her bed dead in the morning. She had no prior health issues.
CDC Split Type:

Write-up: Feb 10th died in her sleep. No apparent reason.
VAERS ID: 1036787 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Female  
Location: Minnesota  
Vaccinated: 2021-02-03
Onset: 2021-02-05
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   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: late stage dementia
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: passed away 2 days after vaccine was given
VAERS ID: 1036874 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2020-12-17
Onset: 2020-12-20
   Days after vaccination: 3
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK5730 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Pneumonia, Pseudomonal bacteraemia
SMQs:, Eosinophilic pneumonia (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (narrow), Sepsis (broad), Opportunistic infections (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2020-12-27
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: COPD
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed pneumonia Admitted to hospital on 12/25. Determined to have pseudomonas bacteremia and passed away on 12/27.
VAERS ID: 1036881 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2021-01-11
Onset: 2021-01-20
   Days after vaccination: 9
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Myocardial infarction
SMQs:, Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Multiple cardiac medications including anticoagulation; medications for chronic lung condition
Current Illness:
Preexisting Conditions: Chronic cardiac conditions, chronic lung. Chronic smoker
Allergies: Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: Myocardial Infarction
VAERS ID: 1036935 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated: 2021-01-12
Onset: 2021-01-25
   Days after vaccination: 13
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH E10140 / UNK - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   Days after onset: 16
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 17 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Treatment for recent eye procedure. Took blood pressure med, lasix, albuterol inhaler, oxygen at night time, antibiotic eye drops, pain med as needed. Received B12 injection once month. Took folic acid, used nasal spray, probiotic
Preexisting Conditions: Diastolic heart failure Edema to lower extremities Anemia Hyperparathyroidism due to rental insufficiency Chronic Kidney disease stg. 3 & 4 Chronic hyponatremia Essential hypertension Hx. of pacemaker, breasts lumpectomy
Allergies: Dairy products Tetracycline
Diagnostic Lab Data:
CDC Split Type:

Write-up: unkown
VAERS ID: 1036993 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Iowa  
Vaccinated: 2021-02-16
Onset: 2021-02-16
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Death, Headache
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: Known Prescription Meds dispensed at pharmacy: Oxycodone/Acet Prn, Gabapentin, Metoprolol, Pantoprazole, Tamsulosin, Atorvastatin, Clopidogrel, Montelukast, Trazodone, Do not have info on OTC or Dietary supplements
Current Illness:
Preexisting Conditions: Hx of migraine headaches
Allergies: noted on admin form: Ibuprofen
Diagnostic Lab Data: Daughter said there was going to be an autopsy because there was no apparent cause
CDC Split Type:

Write-up: Patient reported at review of questionnaire had headache that day. Temp was taken, 97.8, okay. proceeded. Conversing customer friend in store afterward. When timer went off, said he was fine, he and his wife left. Daughter called to store Wednesday morning, said Pt had passed away Tuesday, that it was unknown the cause, and just wanted to let us know. We did not take down her phone number and last name. The patient was a long time customer.
VAERS ID: 1037051 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Female  
Location: California  
Vaccinated: 2021-02-08
Onset: 2021-02-10
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Diarrhoea, Fall, Fatigue
SMQs:, Pseudomembranous colitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: Pyelonephritis, Nephrostomy in 2019
Preexisting Conditions: HTN, ASTHMA
Allergies: Ampicillin, Penicillin, shellfish,seafood
Diagnostic Lab Data:
CDC Split Type:

Write-up: Diarrhea , fatigue on 2/10 Fall 2/12 out to hospital Resident Expired 2/14
VAERS ID: 1037076 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Nebraska  
Vaccinated: 2021-01-26
Onset: 2021-01-30
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3200 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Death, Fall, Hip fracture, Hip surgery, Laboratory test, X-ray
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Hypoglycaemia (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Albuterol, Eliquis, Ativan, Gabepentin, Lasix, & others.
Current Illness: Hx Lung CA, COPD, dementia, A. Fib, Anxiety, edema, SOB
Preexisting Conditions: Lung Cancer, COPD, dementia, A. Fib, Anxiety, Edema, shortness of breath, neuropothy of lower limbs, hypertension
Allergies: Orange Juice
Diagnostic Lab Data: x-rays and labs completed during ER visit and hospitalization from 01/30/2021-02/03/2021
CDC Split Type:

Write-up: Resident developed increased confusion on 01/30/2021 that may have been related to vaccine or to residents other medical conditions including dementia, anxiety, shortness of breath, history of lung cancer, and COPD. Sustained a fall with fracture and was transferred to Hospital. Surgical intervention performed to repair hip. Resident returned to Skilled Nursing facility. Did not recover after surgery and family chose palliative measures. Resident died/ expired on 02/09/2021.
VAERS ID: 1037124 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: New Jersey  
Vaccinated: 2021-02-04
Onset: 2021-02-16
   Days after vaccination: 12
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 UN / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Loss of consciousness, Resuscitation, Unresponsive to stimuli, Ventricular fibrillation
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: Plavix 75 mg daily lipitor 20 mg daily aspirin omeprazole
Current Illness: none
Preexisting Conditions: Coronary artery disease, stent placed GERD
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was at a gym watching his daughter. He slumped over unconscious. EMS was called. He was found to be in fine ventricular fibrillation and resuscitation efforts failed. He was brought to Hospital ED where he was pronounced dead. He had underlying cardiac disease but his family requested I report this event as possibly related to the recent COVID vaccination.
VAERS ID: 1037207 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Female  
Location: Utah  
Vaccinated: 2021-02-01
Onset: 2021-02-02
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Death, Incoherent, Injection site pain, Liver function test abnormal, Malaise, Nausea, Pyrexia, Urinary retention, Vomiting
SMQs:, Liver related investigations, signs and symptoms (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-05
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: birth control, and she did do botox
Current Illness: none,
Preexisting Conditions: trigeminal neuralgia - has been in remission since she started doing botox
Allergies: sulfa drugs
Diagnostic Lab Data: contact shock trauma center and the medical examiner
CDC Split Type:

Write-up: She had pain in the injection site Tuesday night and then during Tuesday she got worse with nausea and some fever. By Wednesday she was complaining that she could not pee even though she was drinking a lot of fluids. She continued to complain it was the worst she ever felt and then at 0600 Thursday morning she woke us up and said she needed to go to the hospital. We arrived at the hospital just before 0700 and she immediately threw up in the trash can. We went into a treatment room and they took blood and started fluids as she became incoherent. She said she had taken Tylenol so they started a drug to counter that but her liver function was all wrong and they started to look for a hospital that could transplant a liver. She was air evade about 0930 to Medical center and just over 30 hours latter she was dead. There is a pending autopsy. She was a healthy 39 year old mother who got the shots because she worked as a surgical tech and she was the single mother of a 9 year old little girl.
VAERS ID: 1038633 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-02-09
Onset: 2021-02-10
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / UNK LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Pulse absent
SMQs:, Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-10
   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: Moderna COVID vaccine administered 2/9/21. Patient expired in home on 2/10/21, at around 2100. Patient had h/o CVA in2001 with long standing sequelae. On day of administration, team attempted to draw lab specimen with vein finder, but patient was possibly Narrative: Moderna COVID vaccine administered 2/9/21. Patient expired in home on 2/10/21, at around 2100. Patient had h/o CVA in2001 with long standing sequelae. On day of administration, team attempted to draw lab specimen with vein finder, but patient was possibly dehydrated. CG/wife reported to APRN on 2/10/21, patient was sleeping and snoring and then began to sleep more quietly. She checked on patient and found that he had no pulse and had passed away
VAERS ID: 1037720 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Completed suicide
SMQs:, Suicide/self-injury (narrow)

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: Medical History/Concurrent Conditions: No adverse event
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Suicide; A spontaneous report was received from a consumer concerning a patient, of unknown age/gender, who received Moderna''s COVID-19 vaccine and experienced suicide. The patient''s medical history was not provided. Concomitant product use was not provided by the reporter. On unknown date, the patient received mRNA-1273 (Lot number: unknown) intramuscularly for prophylaxis of COVID-19 infection. On an unknown date the patient experienced suicide. Treatment information was not provided. Action taken with the mRNA-1273 in response to the event was not reported. The patient died on unknown date. The cause of death was reported as suicide. Plans for an autopsy were not provided.; Reporter''s Comments: Very limited information regarding this event has been provided at this time. Further information has been requested.; Reported Cause(s) of Death: Suicide
VAERS ID: 1037865 (history)  
Form: Version 2.0  
Age: 89.0  
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-10
Onset: 2021-01-27
   Days after vaccination: 17
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Drug ineffective, Respiratory failure, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), 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), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Hypokalaemia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210127; Test Name: Nasal Swab; Result Unstructured Data: Test Result:COVID-19 virus test positive
CDC Split Type: USPFIZER INC2021148032

Write-up: respiratory failure from COVID19; presented to the ER with COVID symptoms and was diagnosed/died on 09Feb2021 from respiratory failure from COVID19; presented to the ER with COVID symptoms and was diagnosed/died on 09Feb2021 from respiratory failure from COVID19; This is a spontaneous report from a contactable physician. An 89-year-old male patient received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration in 10Jan2021 at 12:00 at a single dose for COVID-19 immunization. The patient''s medical history and concomitant medications were not reported. The patient had no COVID prior to vaccination. The patient received one dose of Pfizer vaccine on 10Jan2021. The patient was presented to the ER with COVID symptoms and was diagnosed on 27Jan2021. Patient subsequently died on 09Feb2021 from respiratory failure from COVID19. It was unknown if autopsy was done. The patient was tested for COVID post vaccination via nasal swab: covid-19 virus test positive on 27Jan2021. The events resulted in emergency room/department or urgent care, hospitalization, and patient died. No follow-up attempts are possible, information about batch number cannot be obtained. No further information is expected.; Sender''s Comments: The Company cannot completely exclude the possible causality between the reported COVID post vaccination and respiratory failure with fatal outcome, and the administration of COVID 19 vaccine, BNT162B2, based on the reasonable temporal association. More information on the underlying medical condition in this 89-year-old male patient is required for the Company to make a more meaningful causality assessment. 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 RA, IEC, as appropriate.; Reported Cause(s) of Death: presented to the ER with COVID symptoms and was diagnosed on 27Jan. Patient subsequently died on 09Feb from respiratory failure from COVID19; presented to the ER with COVID symptoms and was diagnosed on 27Jan. Patient subsequently died on 09Feb from
VAERS ID: 1037867 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021153879

Write-up: Caller''s mother received both doses of the Pfizer covid vaccine; within a month of receiving the vaccine, the caller''s mother died.; This is a spontaneous report from a contactable consumer reported for the mother. A female patient of unknown age received both doses of vaccine BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), on unknown dates at single dose for COVID-19 immunization. Medical history and Concomitant medications were not reported. Within a month of receiving the vaccine, the patient died. It was unknown if an autopsy was performed. Information on the Lot/Batch number has been requested ; Reported Cause(s) of Death: within a month of receiving the vaccine, the caller''s mother died
VAERS ID: 1037878 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Male  
Location: Ohio  
Vaccinated: 2020-12-22
Onset: 2020-12-30
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / UNK RA / OT

Administered by: Senior Living       Purchased by: ?
Symptoms: Death, Heart rate, Heart rate decreased, Oxygen saturation, SARS-CoV-2 test
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-03
   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: ASPIRIN EC; ATENOLOL; ATORVASTATIN CALCIUM; FINASTERIDE; FLOMAX [TAMSULOSIN HYDROCHLORIDE]; LANTUS; LITHIUM CARBONATE; LOSARTAN POTASSIUM; LURASIDONE HYDROCHLORIDE; OMEPRAZOLE; SERTRALINE HCL; SYNTHROID; VIT D; HALOPERIDOL; KEPPRA; TYLENOL
Current Illness: Morbid obesity (Onset Date: Admission 22Oct2020); Type 2 diabetes mellitus (Onset Date: Admission 22Oct2020)
Preexisting Conditions: Medical History/Concurrent Conditions: Anxiety; BPH; Cardiac disorder; COVID-19 virus test positive; Depression; Diarrhea; Dry eyes; Epilepsy; Essential hypertension; Fall; GERD; Hyperlipidemia; Hypertension; Hypothyroidism; Pain; Restlessness; Schizophrenia
Allergies:
Diagnostic Lab Data: Test Date: 20201230; Test Name: pulse; Result Unstructured Data: Test Result:low; Test Date: 20210103; Test Name: O2; Result Unstructured Data: Test Result:increased over time; Test Date: 20201221; Test Name: Covid; Result Unstructured Data: Test Result:Positive (+)
CDC Split Type: USPFIZER INC2021157678

Write-up: Is patient deceased: Yes; Low pulse; This is a spontaneous report from two contactable nurses reporting for a patient. A 70-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE; lot number EL0140 expiration date Mar2021) intramuscular on 22Dec2020 at 10:30 at single dose in right arm for COVID-19 immunisation. The patient was vaccinated at Nursing Home. Patient age at time of vaccination was 70 years. Patient''s Medical History included ongoing Type 2 Diabetes Mellitus Without Complication onset date: admission 22Oct2020, ongoing morbid obesity due to excess calories onset date: admission 22Oct2020, cardiac disorder, essential hypertension, hypertension, schizophrenia, hyperlipidemia, benign prostatic hyperplasia (BPH), Gastrooesophageal reflux disease (GERD), depression, hypothyroid, epilepsy, pain, dry eyes, anxiety, restlessness, 17Jan2020 Slid out of chair to floor, no injury, on 27Jan2020, 28Jan2020, 29Jan2020 diarrhea noted. Concomitant medications included acetylsalicylic acid (ASPIRIN EC) for Cardiac Health, atenolol (ATENOLOL) for Essential Hypertension, atorvastatin calcium (ATORVASTATIN CALCIUM) for hyperlipidemia, finasteride (FINASTERIDE) for benign prostatic hyperplasia, tamsulosin hydrochloride (FLOMAX) benign prostatic hyperplasia, insulin glargine (LANTUS) for diabetes mellitus, lithium carbonate (LITHIUM CARBONATE) for Schizophrenia, losartan potassium (LOSARTAN POTASSIUM) for hypertension, lurasidone hydrochloride (LURASIDONE HYDROCHLORIDE) for Schizophrenia, omeprazole (OMEPRAZOLE) for gastrooesophageal reflux disease, sertraline hcl (SERTRALINE HCL) for depression, levothyroxine sodium (SYNTHROID) for hypothyroid, ergocalciferol (VIT D) for supplement, haloperidol (HALOPERIDOL) for Schizophrenia, levetiracetam (KEPPRA) for epilepsy, paracetamol (TYLENOL EXTRA-STRENGTH) for pain, propylene glycol (ARTIFICIAL TEARS) for dry eyes, lorazepam (ATIVAN) for a anxiety or restlessness. As antipyretic use was reported Tylenol ES (500 mg) Tab, 2 Tabs by Mouth Routine use three times a day given at time of vaccination and after. It was reported the patient was Covid+. He was tested on 21Dec2020 and was not admitted to hospital. Event Onset Date was reported as 24Dec2020 (clarification pending). On 30Dec2020 the patient was started on O2 at 2L for low pulse. O2 was increased over time to eventually O2 at 8L on 03Jan2021. Morphine Sulfate was started on 03Jan2021 at 5 mg sl/by mouth every 2 hours as needed for pain or airhunger. The patient deceased on 03Jan2021. The cause of death was unknown. It was not reported if an autopsy was performed. The AEs did not require a visit to Emergency Room or Physician Office. Outcome of Low pulse was unknown.; Sender''s Comments: Based on the information available the events Death (unknown cause) and Heart rate decreased are attributed to patient''s multiple underlying medical conditions including Type 2 Diabetes Mellitus, morbid obesity, cardiac disorder, hypertension, epilepsy etc. However, based solely on a vaccine-event chronological association, contributory role of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) to the above mentioned events cannot be completely excluded. The case will be reevaluated should additional information, including the cause of death, become available. 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: Is patient deceased: Yes
VAERS ID: 1038042 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-02-05
Onset: 2021-02-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / UNK RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Arteriosclerosis, Death, Hypertension
SMQs:, Neuroleptic malignant syndrome (broad), Hypertension (narrow)

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:
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Patient expired 02/06/2021. COD as ruled by Coroner "Hypertensive and Atherosclerotic Cardiovascular Disease."
VAERS ID: 1038147 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Tennessee  
Vaccinated: 2021-01-28
Onset: 2021-01-30
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Atrial fibrillation, Cerebrovascular accident, Death, Intensive care
SMQs:, Supraventricular tachyarrhythmias (narrow), 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: 2021-02-11
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 10 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine, propranolol, levothyroxine
Current Illness: None
Preexisting Conditions: Hypertension, hypothyroidism
Allergies: Sulfa drugs
Diagnostic Lab Data: Admitted to the hospital Monday 2/1. Received 24 hours of ICU care, then transitioned to comfort measures. Passed away 2/11
CDC Split Type:

Write-up: Patient went into new-onset atrial fibrillation, resulting in a catastrophic stroke. Patient passed away on 2/11 as a result of the stroke.
VAERS ID: 1038225 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Alaska  
Vaccinated: 2021-01-11
Onset: 2021-02-17
   Days after vaccination: 37
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: Metoprolol, Pramipexole, Furosemide, Aspirin, Haloperidol, Lorazepam, Morphine
Current Illness: G60.9, D72.1,
Preexisting Conditions: G60.9, D72.1,
Allergies: Tomato, cheese
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death, 2-17-21 at 1802 hours
VAERS ID: 1038234 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Female  
Location: Massachusetts  
Vaccinated: 2021-01-14
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Condition aggravated, Death, Dementia, Mental impairment, Pyrexia, Urinary tract infection, Wrong product administered
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Cephalexin Spiriva, Nitro, Probiotic, Albuterol, Vitamin D3, Multivitamin Aspirin, Glucosamine, Metamucil, Tylenol, Cranberry, Claritin, Quetiapine
Current Illness: Dementia with mental status change Urinary tract infection
Preexisting Conditions: Dementia Hypertension, Chronic UTI Hyperlipidemia, h/o Alcohol Abuse in Remission
Allergies: Sulfa, Aricept
Diagnostic Lab Data:
CDC Split Type:

Write-up: First dose Pfizer given at assisted living on 1/14/21 she was subsequently admitted to hospital and got her second dose but Moderna was given instead of Pfizer on 2/8/21. She had been improving but in the days following the Moderna vaccine she developed fever and then her mental status declined. She was discharged back to assisted living. Suspected UTI, and moderate dementia, placed on hospice (2/12/21). Died on 2/13/21.
VAERS ID: 1038253 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Florida  
Vaccinated: 2021-01-12
Onset: 2021-01-13
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Death
SMQs:

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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No medical history reported.)
Allergies:
Diagnostic Lab Data:
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Died the next day; A spontaneous report was received from a consumer concerning a male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and died the next day. The patient''s medical history was not provided. Concomitant medication use was not provided by the reporter. On 12 Jan 2021, approximately one day prior to the event, the patient received one of two planned doses of mRNA-1273 intramuscularly for prophylaxis of COVID-19 infection. On 13 Jan 2021 the patient died. No additional information was provided in regards to the event. Action taken with mRNA-1273 in response to the event was not applicable. The patient died on 13 Jan 2021. The cause of death was unknown.; Reporter''s Comments: This case concerns a male patient of unknown age. The medical history and concomitant medication were not provided. The patient died approximately one day after receiving their first of two planned doses of mRNA-1273 (Lot unknown). Very limited information regarding this event has been provided at this time.; Reported Cause(s) of Death: Unknown cause of death
VAERS ID: 1038257 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New Mexico  
Vaccinated: 2021-01-14
Onset: 2021-01-16
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Body temperature abnormal, Death, Dyspnoea, Fatigue, Feeling abnormal, Limb discomfort, SARS-CoV-2 test, Swelling, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (narrow), Angioedema (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: CALCIUM ACETATE; RENVELA; GLIPIZIDE; OMEPRAZOLE; ASPIRIN (E.C.); VITAMIN D NOS; LOSARTAN; FUROSEMIDE; RIFAMPIN; SENSIPAR
Current Illness: Dialysis; TB
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Date: 20210113; Test Name: COVID test; Test Result: Negative ; Result Unstructured Data: negative; Test Date: 20210118; Test Name: COVID test; Test Result: Positive ; Result Unstructured Data: per coroner
CDC Split Type: USMODERNATX, INC.MOD20210

Write-up: Passed away; tired; nonresponsive; cold; difficulty breathing; swelling; sore arm; feeling weird and funny; A spontaneous report (United States) was received from a consumer concerning a 63 year old male patient who received Moderna''s COVID-19 vaccine (mRNA-1273) and the patient experienced limb discomfort, feeling abnormal, dyspnea, fatigue, swelling, unresponsive to stimuli, body temperature abnormal and the patient passed away . Medical history included treatment for tuberculosis and dialysis. Concomitant medication included calcium acetate, Renvela, glipizide, omeprazole, aspirin, vitamin D, losartan, furosemide, rifampin, and Sensipar. On 14 Jan 2021, the patient received the first of their first planned doses of mRNA-1273 (lot number 030L20A) for prophylaxis of COVID-19 infection. On 13 Jan2021, the patient tested negative for COVID-19). On 16 Jan 2021, the patient experienced a sore arm, and feeling weird/funny. On 17Jan2021, the patient experienced difficulty breathing and swelling. On 18 Jan 2021, the patient declined dialysis, was tired and wanted to lay down. At 8 am, the patient was found nonresponsive and cold and is believed to have passed away around 4 am. The coroner tested the deceased for COVID-19 and the test was positive. No autopsy was reported. No death certificate was issued at the time of the report but the reporter believes it will list cause of death as COVID complications. Action taken with the mRNA-1273 was not applicable. The outcome of the events of limb discomfort, feeling abnormal, dyspnea, fatigue, swelling, unresponsive to stimuli, body temperature abnormal, was fatal. On 18 Jan 2021, the patient was died. Cause of death was COVID-19. Autopsy details were not provided.; Reporter''s Comments: The events developed on four days after first dose of mRNA-1372. Dyspnea, unresponsive to stimuli, and death were consistent with infection in pandemic set up confounded by age of patient and refusal of dialysis Cause of death was reported as COVID-19. Autopsy details were not provided. Based on reporter''s causality the events are assessed as unlikely related to mRNA-1273.; Reported Cause(s) of Death: COVID-19
VAERS ID: 1038290 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-02-03
Onset: 2021-02-03
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Death, Glomerular filtration rate, Lymphocyte percentage decreased, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Haematopoietic leukopenia (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-03
   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: Amlodipine-benazapril; atorvastatin; basaglar Kwikpen; citalopram; clopidrogel; coreg; fenofibrate; glipizide; hydrochlorothiazide; metformin; pantoprazole; ropinirole
Current Illness: Outpatient admission 1/25-1/27 with Hypertension urgency and inability to care for self at home, discharged to Agency; 1/28/21 had a choking episode and continued to decline from there. ER 1/31 and 2/1 for low grade fever and continued decline returned to SNF and wife placed patient on hospice.
Preexisting Conditions: Apnea; diabetes; dyslipidemia; ischemic stroke; prostate disorder; multiple CVAs with residual weakness
Allergies: Sulfa
Diagnostic Lab Data: ER 1/31-2/1 WBC 10.62; Lymph 11.3%; BUN 35; Cr 1.58; GFR 44;
CDC Split Type:

Write-up: Death on same day as vaccination
VAERS ID: 1038442 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Illinois  
Vaccinated: 2021-01-04
Onset: 2021-01-06
   Days after vaccination: 2
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Other       Purchased by: ?
Symptoms: Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Death, Drug screen positive, Glomerular filtration rate decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Retroperitoneal fibrosis (broad), Drug abuse and dependence (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-06
   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: Hospital discharge medications 12/28/20: Tylenol prn; ativan prn; morphine prn; scopolamine prn all other medications were discontinued
Current Illness: Inpatient 12/21/20 with COVID (+ test 12/17/20) and cellulitis of leg treated with antibiotics. Readmitted 12/25-12/28 with seizures and acute kidney injury discharged to SNF on hospice care.
Preexisting Conditions: Obesity, TBI, quadriplegia secondary to GSW; COPD; seizures; gout; neurogenic bowel and bladder; major depressive disorder; dextroscollosis; DM
Allergies: NKA
Diagnostic Lab Data: 12/25 Dilantin level low 9.2 and drug screen positive for barbituates 12/28: glucose 149; BUN 28; Cr 3.39; Bun/Cr ratio 7.9; GFR 19; Na 150; chloride 114 12/27: Potassium 6.2 down within normal range on 12/28 4.2
CDC Split Type:

Write-up: Death within thirty days of vaccine. Multiple co-morbidities and placed on hospice 12/28/20.
VAERS ID: 1038517 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Minnesota  
Vaccinated: 2021-02-03
Onset: 2021-02-17
   Days after vaccination: 14
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Death, SARS-CoV-2 test negative
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), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-17
   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: COVID negative via rapid test
CDC Split Type:

Write-up: Pt. received vaccine on 2/3/2021. Coded at home on 2/17/2021.
VAERS ID: 1038527 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: South Dakota  
Vaccinated: 2021-02-17
Onset: 2021-02-17
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cardiac arrest, Death, Dyspnoea, Endotracheal intubation, Myoclonus, Resuscitation
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Angioedema (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), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: Unsure. Possibly the following from hospital EHR: albuterol sulfate 90 mcg/actuation inhalation 2 times daily PRN amlodipine besylate 10 mg oral Daily aspirin 81 mg oral Daily atorvastatin calcium 40 mg oral Daily carvedilol 6.25 mg oral 2
Current Illness: Arthritis hands Cardiovascular disease dyslipidemia Chronic bronchitis COPD (chronic obstructive pulmonary disease) Coronary artery disease History of transfusion Hypertension Myocardial infarction stent Peripheral vascular disease Psychiatric illness "feels depressed" on ocassion Renal artery stenosis TIA (transient ischemic attack) "short spurts" of tingling on face Urge incontinence of urine
Preexisting Conditions: Arthritis hands Cardiovascular disease dyslipidemia Chronic bronchitis COPD (chronic obstructive pulmonary disease) Coronary artery disease History of transfusion Hypertension Myocardial infarction stent Peripheral vascular disease Psychiatric illness "feels depressed" on ocassion Renal artery stenosis TIA (transient ischemic attack) "short spurts" of tingling on face Urge incontinence of urine
Allergies: epinephrine, penicillin, procaine per EHR
Diagnostic Lab Data:
CDC Split Type:

Write-up: Per EMS/Hospital report patient had difficulty breathing and cardiac arrest with prolonged CPR (greater than 45 mins in the ER) who was resuscitated. Family subsequently arrived including son and daughter and all family members were in the ER room are in agreement that patient would not want further aggressive cares given her extremely poor prognosis in light of chronic debilitation with numerous medical issues and now a very long period of CPR. Hospital Course After updating family they stated patient would not want further aggressive cares given her grim prognosis and chronic severe and debilitating medical issues. She continued to have myoclonic jerking. She was extubated to comfort cares in the ER and did not pass immediately therefore brought to a room. She received comfort cares and passed away at 0450 with family present.
VAERS ID: 1038561 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Colorado  
Vaccinated: 2021-02-15
Onset: 2021-02-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / -

Administered by: Other       Purchased by: ?
Symptoms: Asthenia, Death, Pain, Respiratory tract congestion, Secretion discharge
SMQs:, Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: Trazodone
Current Illness: AAA, GERD,HTN, CAD, CA, arthritis
Preexisting Conditions: AAA, GERD, HTN, CAD, CA, arthritis
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: (02/15/2021): vaccine (02/16/2021) : severe body aches and weakness, increased congestion and mucous production. (02/16-17/2021) : death possibly during the night
VAERS ID: 1038579 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-02-15
Onset: 2021-02-16
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 AR / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   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: prednisone
Current Illness: COPD HTN Lung Cancer
Preexisting Conditions: COPD HTN Lung Cancer Prostate Cancer
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Death
VAERS ID: 1038635 (history)  
Form: Version 2.0  
Age: 97.0  
Sex: Female  
Location: South Dakota  
Vaccinated: 2021-02-05
Onset: 2021-02-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / UN

Administered by: Unknown       Purchased by: ?
Symptoms: Arrhythmia, Cardiac arrest, Death, Dementia, Fall, Hip arthroplasty, Hip fracture, Hypothyroidism
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), Dementia (narrow), Acute central respiratory depression (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypothyroidism (narrow), Cardiac arrhythmia terms, nonspecific (narrow), Osteoporosis/osteopenia (broad), Osteonecrosis (broad), Arthritis (broad), Respiratory failure (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-07
   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: Aspirin 81 mg enteric-coated q a.m. Plavix 75 mg po at bedtime Iron, Ferrex-150 25/1/150 tid with meals Folic acid 1 mg bid Metoprolol tartrate 25 mg bid MiraLAX 8.5 gm daily Synthroid 100 mcg a day Tamsulosin 0
Current Illness: A fall occurred on the day after vaccination; she fractured her hip in this fall. The physician reports she went into sudden and unexpected cardiac arrest during surgery and died. Patient had COVID-19 approx 11/06/2020. Possible urinary tract infection on admit for the fall
Preexisting Conditions: History of breast cancer (bilateral; patient is post-bilateral masectomy) Hypothyroid Dementia ("always confused about time and place") Recurrent urinary tract infections The patient was admitted August 2020 with suspected seizure but this was attributed to UTI and/or dementia) Hypertension Diffuse Arthritis Resident of assisted living facility
Allergies: Erythromycin Codeine
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient fell the day after receiving the Moderna COVID-19 vaccine. She broke her hip in this fall. During surgery to correct the broken hip, she went in to sudden and unexpected cardiac arrest. The anesthetist did not notice any ST changes or A fib; dysrhythmia was very unexpected. The patient had a DNR. She died at 13:00 on 02/07/2021. Causes of death are listed as 1. Cardiac Arrest 2. Recent hip fracture with hip placement 3. History of Breast Cancer 4. Hypothyroid and 5. Dementia
VAERS ID: 1038658 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: D.C.  
Vaccinated: 2021-02-01
Onset: 2021-02-08
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Aphasia, Death, Decreased appetite, Dyskinesia, Gait inability, Oxygen therapy, SARS-CoV-2 test negative
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Dyskinesia (narrow), Dystonia (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Respiratory failure (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   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: atenolol, docusate, calcium/vitamin D, furosemide, tamoxifen, multivitamin, trazodone, vitamin b12, vitron C
Current Illness: ankle/leg wound healing and being treated topically
Preexisting Conditions: history of TIA, breast neoplasm, dementia
Allergies: none
Diagnostic Lab Data: Unclear if the Moderna vaccine was #1 or #2. Vaccination form states is was vaccine #1. But patient checked the box that she had received a vaccine in the past 2-8 weeks on the form. Patient had gone to hospital around 1/4/2021 for fever and had a negative covid test per nursing notes in chart.
CDC Split Type:

Write-up: 86yo female alert, stable with ankle abrasion eating 100% prior to vaccine in assisted living facility. On 2/1/2021, received Moderna vaccine. Starting thereafter, eating 50% on 2/2/21. Temperature was 98 tympanic. On 2/3, the leg abrasion started having moderate bleeding. On 2/4, the caregiver noted patient "not looking good, unable to talk, arms moving aimlessly, grasping". BP 95/41, temperature 98, oxygen on room air 92-93%. POA did not want hospital transfer. 2/5 Hospice started, oxygen given, morphine given. 2/5-2/8 comfort care given, patient responsive to tactile stimuli, resting, not taking oral medications or food. 2/8/2021 patient expired.
VAERS ID: 1038719 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Arizona  
Vaccinated: 2020-01-30
Onset: 2021-01-18
   Days after vaccination: 354
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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 attributed to unknown cause
VAERS ID: 1038720 (history)  
Form: Version 2.0  
Age: 99.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-02-17
Onset: 2021-02-18
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Death
SMQs:, Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-18
   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: Resident complained about back pain in the middle of the night and when they went to do a blood pressure examination, she passed away at 2:40 am.
VAERS ID: 1039028 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Indiana  
Vaccinated: 2021-02-17
Onset: 2021-02-17
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardioversion, Death, Resuscitation
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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: no issues during observation period-Severe, Additional Details: patient received moderna immunization during the morning of 2/17/2021. patient was found by facility staff at 2:38pm with no pulse CPR was started, aed was used and ems was called. time of death 3:15pm
VAERS ID: 1039090 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: South Dakota  
Vaccinated: 2021-02-02
Onset: 2021-02-03
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Anxiety, Blood pressure increased, Breath sounds abnormal, Cardiac arrest, Coronary artery disease, Death, Malaise, Pain in extremity, Resuscitation, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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 (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypertension (narrow), Cardiomyopathy (broad), Other ischaemic heart disease (narrow), Hypotonic-hyporesponsive episode (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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:
Preexisting Conditions: GERD (Gastroesophageal Reflux Disease) Hypertension Previous Squamous Cell Skin Cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient came to the Emergency Room at approx 3:30 am on 02/03/2021 with pain in right arm (same arm the COVID vaccine had been administered in approx 12 hours earlier) and feeling generally unwell. Patient was concerned about possibility of gout flare or that something was wrong with her arm. Elevated blood pressure was noted; this was attributed to anxiety. She was evaluated, given 500 mg Tylenol, and discharged since the pain was decreasing and blood pressure was stabilized. Patient instructed to follow-up with physician. The next day, on 02/04/2021, the patient arrived at the Emergency Room by ambulance; cardiac arrest was the chief complaint. The patient''s daughter stated the patient had been "feeling generally poor and then suddenly collapsed." Daughter described "gurgling respirations" and being unresponsive. 911 was called, police arrived within 5 minutes and initiated CPR. Epinephrine, atropine, lidocaine and bicarb administered after arrival to Emergency Room. Shockable rhythm never demonstrated. Patient never recovered spontaneous respiration or movement. The death was called at 23:04. Coronary artery disease with cardiac arrest is the cause from the ER records; the coroner is putting COVID-19 vaccination in Part 1 of the death certificate.
VAERS ID: 1039250 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Washington  
Vaccinated: 2021-01-30
Onset: 2021-02-14
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 UN / IM

Administered by: Senior Living       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: 2021-02-18
   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:
Preexisting Conditions: dementia
Allergies: unknown
Diagnostic Lab Data: Medical Examiner''s Office will perform postmortem COVID-19 testing at this time.
CDC Split Type:

Write-up: Daughter of decedent reported that he quickly declined within 2 weeks of receiving vaccine and developed shortness of breath. Decedent received vaccine 1/30/2021 and died 2/15/2021. Only received first dose of series.
VAERS ID: 1039271 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Male  
Location: Wisconsin  
Vaccinated: 2021-02-11
Onset: 2021-02-11
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Fall, Head injury, Injection site ulcer, Malaise, Neck pain
SMQs:, Accidents and injuries (narrow), Extravasation events (injections, infusions and implants) (broad), Arthritis (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Gentleman received his 1st Moderna dose on Thu. 2/11 at 0849. Vaccination protocol was completed. Pt reported feeling fine, no fever, and that he had no allergies which would prevent him from getting the vaccine. Pt played cards with friends later that day 2/11, but left at 1930 (normally plays late into evening) telling his companions he didn''t feel well and his neck hurt. A welfare call was completed on Sat. 2/13, and the patient was found deceased in the bathroom by his son. It appears patient fell off toilet and hit his head on the tub. Pressure ulcer present under injection site. The presumed time of death was Thur. evening.
VAERS ID: 1039304 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: California  
Vaccinated: 2021-01-29
Onset: 2021-02-02
   Days after vaccination: 4
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood sodium normal, Blood urea increased, Body temperature increased, Death, Dysphagia, Gastrointestinal tube insertion, Pneumonia, Respiratory tract congestion, SARS-CoV-2 test negative, White blood cell count increased
SMQs:, Acute renal failure (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-15
   Days after onset: 13
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amantadine HCl Tablet 100 MG, Fluticasone Propionate Suspension 50 MCG/AC, Metoprolol Tartrate Tablet,Rotigotine Patch 24 Hour 6 MG/24HR, Magnesium Oxide Tablet 400 MG, Heparin Sodium (Porcine) Solution 5000 UNIT/ML,Aspirin EC Tablet Delaye
Current Illness: Parkinson''s disease, S/P GT Placement, HTN, Allergic Rhinitis, Protein Calorie Malnutrition, Herpes Viral Infection, Dysphagia, S/P Pacemaker Insertion
Preexisting Conditions: End Stage Parkinson''s Disease
Allergies: Flomax
Diagnostic Lab Data: 01/31/21 Rapid Test (-) COVID 02/02/21 Rapid Test (-) COVID 02/04/21 Rapid Test (-) COVID 02/02/21- WBC 20.92, Na 142, BUN 59- MD was notified
CDC Split Type:

Write-up: Resident getting rehab therapy in the facility and has a long history of Parkinson''s Disease. On 01/29/21, he received the COVID vaccine on left deltoid, resident was recently hospitalized due to Pneumonia and was on antibiotic IV and was recently placed on GT feeding due to severe dysphagia from his Parkinson''s disease. On 01/31/21, started having increased congestion. On 02/02/21, started having increased temperature and WBC went up $g20,000 on 02/03/21, started on Vancomycin IV on 02/04/21 but was transferred to the hospital. Facility was notified today (02/18/21) that resident expired in the hospital.
VAERS ID: 1039597 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: Unknown  
Vaccinated: 2021-01-30
Onset: 2021-02-14
   Days after vaccination: 15
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK4176 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death, Decubitus ulcer, Pneumonia aspiration, Sepsis
SMQs:, Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-14
   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 Narrative: Patient received first dose of COVID vaccine on 1/30/21. Reported by his wife to agency that he passed away at an outside hospital on 2/14/21. By report of his wife: "due to sepsis (related to bed sores) and aspiration pneumonia"
VAERS ID: 1039922 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: Unknown  
Vaccinated: 2021-02-05
Onset: 2021-02-06
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Fall, SARS-CoV-2 test
SMQs:, Accidents and injuries (narrow), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-06
   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: COPD (on oxygen as needed, but not every day); Oxygen therapy
Allergies:
Diagnostic Lab Data: Test Name: COVID test; Test Result: Negative
CDC Split Type: USPFIZER INC2021122838

Write-up: death was from natural causes; collapsed; This is a spontaneous report from a contactable consumer. A 73-year-old female patient received the first dose of the bnt162b2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE), via an unspecified route of administration on 05Feb2021 at 73-years-old at a single dose for COVID-19 immunization. The patient''s medical history included chronic obstructive pulmonary disease (COPD) from an unknown date and unknown if ongoing (on oxygen as needed, but not every day), oxygen therapy from an unknown date and unknown if ongoing. Concomitant medications were not reported. The patient previously received the influenza vaccine (MANUFACTURER UNKNOWN) for immunization on unknown dates (Gets flu shot every year around October). On 06Feb2021, the patient collapsed (medically significant) and experienced death was from natural causes (death, medically significant). The clinical course was reported as follows: The reporter stated that his grandmother received the first dose of the Pfizer COVID-19 vaccine on 05Feb2021 and passed away on the morning of 06Feb2021. The patient went to bed and woke up in the middle of the night around 03:00 to use the bathroom and collapsed and died within 10-15 minutes of collapsing. The patient was pronounced dead at the scene. The reporter asked: "What do you know about the news in the media about reports of death in nursing home elderly patients?" The reporter wanted to know the ingredients of the Pfizer COVID-19 vaccine. The reporter wanted to know about the use of the Pfizer COVID-19 vaccine in patients with underlying conditions. The patient had COPD and was on oxygen as needed, but not every day. The Medical examiner said the death was from natural causes and the family was not doing an autopsy. The patient had been tested for COVID and was negative. The patient underwent lab tests and procedures which COVID test: negative on an unspecified date. The clinical outcome of the event, death was from natural causes, was fatal. The clinical outcome of the event, collapsed, was unknown. The patient died on 06Feb2021 due to death was from natural causes. An autopsy was not performed. The batch/lot numbers for the vaccine, bnt162b2, were not provided and will be requested during follow up.; Reported Cause(s) of Death: death was from natural causes
VAERS ID: 1039952 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Death, Off label use
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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021155151

Write-up: Two report of death related to the vaccine were reported in a young premature baby and 25-year-old young person who dies 15 minutes after receiving the vaccine.; a young premature baby received BNT162B2; This is a spontaneous report from a Pfizer-sponsored program. A contactable consumer reported similar event for 2 patients. This is 1st of 2 reports. A patient of unspecified age and gender (reported as a young premature baby) received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via unspecified route of administration on an unspecified date at single dose for COVID-19 immunization. The relevant medical history and concomitant medications were not reported. The consumer stated his main concern was even though the vaccine had been authorized. The vaccine was only given vaccine on the side of the road. People were dying from the vaccine more than from the virus. He gave out some percentage of people that could die from the virus vs from the vaccine. The percentage of death rate was 0.00045% from the virus. The percentage of death from the vaccine was 6.6%. There were many people reporting side effects such as bell''s palsy, whole body convulsion. Two report of death related to the vaccine were reported in a young premature baby and 25-year-old young person who died 15 minutes after receiving the vaccine. He said it''s sad these were front line worker who were facing all these side effects. The outcome of the event was fatal. Information on the lot/batch number has been requested.; Sender''s Comments: Linked Report(s) : US-PFIZER INC-2021157531 same reporter, drug, event, different patient; Reported Cause(s) of Death: Two report of death related to the vaccine were reported in a young premature baby and 25-year-old young person who dies 15 minutes after receiving the vaccine.
VAERS ID: 1039954 (history)  
Form: Version 2.0  
Age:   
Sex: Unknown  
Location: Unknown  
Vaccinated: 0000-00-00
Onset: 0000-00-00
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Unknown       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:
Diagnostic Lab Data:
CDC Split Type: USPFIZER INC2021157531

Write-up: Two report of death related to the vaccine were reported in a young premature baby and 25-year-old young person who dies 15 minutes after receiving the vaccine.; This is a spontaneous report from a Pfizer-sponsored program. A contactable consumer reported similar event for 2 patients. This is 2nd of 2 reports. A 25-year-old patient of unspecified gender received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via unspecified route of administration on an unspecified date at single dose for COVID-19 immunization. The relevant medical history and concomitant medications were not reported. The consumer stated his main concern was even though the vaccine had been authorized. The vaccine was only given vaccine on the side of the road. People were dying from the vaccine more than from the virus. He gave out some percentage of people that could die from the virus vs from the vaccine. The percentage of death rate was 0.00045% from the virus. The percentage of death from the vaccine was 6.6%. There were many people reporting side effects such as bell''s palsy, whole body convulsion. Two report of death related to the vaccine were reported in a young premature baby and 25-year-old young person who died 15 minutes after receiving the vaccine. He said it''s sad these were front line worker who were facing all these side effects. The outcome of the event was fatal. Information on the lot/batch number has been requested.; Sender''s Comments: Linked Report(s) : US-PFIZER INC-2021155151 same reporter, drug, event, different patient; Reported Cause(s) of Death: Two report of death related to the vaccine were reported in a young premature baby and 25-year-old young person who dies 15 minutes after receiving the vaccine.
VAERS ID: 1040005 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: New York  
Vaccinated: 2021-02-16
Onset: 2021-02-17
   Days after vaccination: 1
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 2 LA / IM

Administered by: Pharmacy       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: 2021-02-17
   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: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was found unresponsive and had passed away.
VAERS ID: 1040170 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Oregon  
Vaccinated: 2021-02-06
Onset: 2021-02-13
   Days after vaccination: 7
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Abnormal behaviour, Agonal rhythm, Alanine aminotransferase increased, Analgesic drug level therapeutic, Aspartate aminotransferase increased, Blood creatinine increased, Blood glucose decreased, Blood lactic acid increased, Blood magnesium increased, Blood potassium increased, Cardiac arrest, Cyanosis, Endotracheal intubation, Erythema, Pain, Peripheral coldness, Pyrexia, Respiration abnormal, Resuscitation, Troponin increased, White blood cell count increased
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (narrow), Anaphylactic reaction (narrow), Angioedema (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Conduction defects (narrow), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Hypoglycaemia (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, calcium citrate, antifungal cream to stoma, Bisacodyl suppository as needed, calcium citrate, tube feeds, lansoprazole, reglan, centrum multivitamin, polyethylene glycol every other day, norgestimate-estradiol daily, trazodone, tiz
Current Illness: none. she had been very stable on her medication regimen and in her living arrangement for years. No issues whatsoever. Caregivers had been caring for her for as long as 19 years.
Preexisting Conditions: cerebral palsy, spastic quadriplegia, dysphagia with g-tube in place, developmental delay - minimally verbal, tube feed dependency, intrathecal baclofen pump, osteoporosis, white coat hypertension, candidiasis of skin..
Allergies: reclast - caused fever in 2014, leading to hospitalization, seizure from the fever.. tegretol (no reaction noted)
Diagnostic Lab Data: labs from ER on 2/13/2021 - trop 2.49; WBC 55, lactate 21.5, creat 1.29, postassium 6.2, mag 3.4, glucose 57, AST 3024, ALT 3088, acetaminophen < 10, salicylate < 1.
CDC Split Type:

Write-up: Received vaccine on 2/6/2021. was a bit off all week per caregivers - low grade temp and reporting pain which they treated with Tylenol. She was pretty much herself on morning of 2/13/2021 - got up, had shower. caregivers noted her extremities were cool and face was red. temp was 97.4. She was placed in wheelchair with book in the living room. caregivers noted she was not turning pages of the book as she usually would. She was tracking, so they don''t think she had a seizure. Caregiver moved her back to bed with blanket and noted that her lips were blue and at that point called 911. She was found with agonal breathing, CPR started, intubated by EMS, taken to the ER and diagnosed with cardiac arrest upon arrival. CPR was continued until family could be reached and decision was made to stop resuscitation.
VAERS ID: 1040183 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Ohio  
Vaccinated: 2021-01-29
Onset: 2021-01-29
   Days after vaccination: 0
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 UN / -

Administered by: Unknown       Purchased by: ?
Symptoms: Coronary artery disease, Death, Myocardial infarction, Swelling face
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Myocardial infarction (narrow), Embolic and thrombotic events, arterial (narrow), Other ischaemic heart disease (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   Days after onset: 6
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:
Current Illness: CHF
Preexisting Conditions: CHF, Diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had swelling around her jaw after her second shot of the covid , Pfizer vaccine ( .5 ml IM) on the Friday morning, January 29th, I took her to a follow up appointment with the cardiologist at 3:00 pm, as a follow up to a small heart attack event with hospitalization two weeks previously, at the cardiologist she was given the ok/all is well. That next morning early, she had a 911 event at her assisted living apartment and was sent back to the hospital, having had another heart attack. Patient died on the following Thursday, February 4, 2021. I do not know if the vaccination had any cause for my mothers death; but I feel it is necessary to report this series of heart attacks after she received the pfizer vaccine. Her Certificate of Death records the cause of death as "Coronary Artery Disease".
VAERS ID: 1040574 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Georgia  
Vaccinated: 2021-01-08
Onset: 2021-01-16
   Days after vaccination: 8
Submitted: 0000-00-00
Entered: 2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Cardiac arrest, Death, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (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)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   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: Patient collapsed and could not be revived. There was no prior warning. She was otherwise in good condition for her age. The death was listed as probable cardiac arrest but no autopsy was performed. Since it occurred so close to the vaccine shot I thought someone may want to know.

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