|
| 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), Noninfectious myocarditis/pericarditis (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: 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:, Torsade de pointes/QT prolongation (broad), 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. |
|