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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1339948

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Case Details

VAERS ID: 1339948 (history)  
Form: Version 2.0  
Age: 100.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-05-01
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-05-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Acute respiratory failure, COVID-19 pneumonia, Drug ineffective
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), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-17
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:
Allergies:
Diagnostic Lab Data:
CDC Split Type: PEPFIZER INC2021562761

Write-up: acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus; acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus; acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus; This is a spontaneous report from a contactable pharmacist. A 100-year-old female patient received BNT162B2 (COMIRNATY, batch/lot number was not reported), via an unspecified route of administration on 01May2021 (at 100-year-old) at 1st dose, single for COVID-19 immunisation. The patient did not receive the second dose of the vaccine. The patient medical history and concomitant medications were not reported. The patient died on 17May2021. The cause of death was reported as acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus. It was unknown if the autopsy was performed. Information on the lot/batch number has been requested.; Sender''s Comments: Based on available information, a possible contributory role of the subject product, BNT162B2 vaccine, cannot be excluded for the reported events of COVID-19, acute respiratory insufficiency, viral pneumonia and suspected LOE. There is limited information provided in this report. This case will be reassessed once additional information is 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: acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus; acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus; acute respiratory insufficiency / viral pneumonia / unidentified COVID-19 virus


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