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This is VAERS ID 1333122

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History of Changes from the VAERS Wayback Machine

First Appeared on 7/9/2021

VAERS ID: 1333122
VAERS Form:2
Age:70.0
Sex:Male
Location:Foreign
Vaccinated:2021-03-28
Onset:2021-04-13
Submitted:0000-00-00
Entered:2021-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001442 / 1 - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: HYDROXYCARBAMIDE CAPSULE 500MG / Brand name not specified; PANTOPRAZOL TABLET MSR 20MG / Brand name not specified; ACETYLSALICYLZUUR TABLET 80MG / Brand name not specified
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': NLMODERNATX, INC.MOD20211

Write-up: Unknown cause of death; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 12-May-2021 and was forwarded to Moderna on 12-May-2021. This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of DEATH (Unknown cause of death) in a 70-year-old male patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001442) for COVID-19 vaccination. Concomitant products included HYDROXYCARBAMIDE CAPSULE 500MG / Brand name not specified from 04-Mar-2021 to an unknown date, PANTOPRAZOL TABLET MSR 20MG / Brand name not specified and ACETYLSALICYLZUUR TABLET 80MG / Brand name not specified for an unknown indication. On 28-Mar-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) 1 dosage form. Death occurred on 13-Apr-2021 The patient died on 13-Apr-2021. The cause of death was not reported. An autopsy was not performed. The action taken with mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown) was unknown. For mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown), the reporter did not provide any causality assessments. This is a case of death in a 70-year-old male subject with a possible medical history of chronic myelogenous leukemia (because of concomitant HYDROXYCARBAMIDE), who died 16 days after receiving the first dose of vaccine. Very limited information has been provided at this time. No follow up is possible. Most recent FOLLOW-UP information incorporated above includes: On 13-May-2021: A follow up received on 13 May 2021 has no new information; Sender''s Comments: This is a case of death in a 70-year-old male subject with a possible medical history of chronic myelogenous leukemia (because of concomitant HYDROXYCARBAMIDE), who died 16 days after receiving the first dose of vaccine. Very limited information has been provided at this time. No follow up is possible.; Reported Cause(s) of Death: unknown cause of death

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