National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 881609

History of Changes from the VAERS Wayback Machine

First Appeared on 9/14/2020

VAERS ID: 881609
VAERS Form:2
Age:78.0
Sex:Female
Location:Unknown
Vaccinated:2020-08-26
Onset:2020-08-28
Submitted:0000-00-00
Entered:2020-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUA3: INFLUENZA (SEASONAL) (FLUAD) / NOVARTIS VACCINES AND DIAGNOSTICS 279734 / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-08-28
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: MYCOPHENOLATE; SIMVASTATIN; ALOPURINOL; FUROSEMIDE; PREDNISONE; GABAPENTIN; HUMALOG; LANTUS; SYNTHROID; POTASSIUM CHLORIDE; METOPROLOL; AMLODIPINE; AZATHIOPRINE; BUMETANIDE; METOLAZONE
Current Illness:
Preexisting Conditions: Comments: None
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USSEQIRUS202004250

Write-up: The patient was found deceased; This is a spontaneous case, initially received from pharmacist via Med Communication (reference number: SEQW20-01021) on 28-Aug-2020 with two additional documents received on 31-Aug-2020 (being processed together), concerning a 78-year-old female patient. The patient''s medical history was not reported. The patient''s concomitant medications included mycophenolate, simvastatin, alopurinol, furosemide, prednisone, gabapentin, Humalog (insulin lispro), Lantus (insulin glargine), Synthroid (levothyroxine sodium), potassium chloride, metoprolol, amlodipine, azathioprine, bumetanide and metolazone, all for an unknown indication. On 26-Aug-2020, the patient was administered Fluad (TIV) [influenza vaccine, inactivated influenza virus surface antigen (subunit), egg-derived, MF59; batch number: 279734, anatomical location: deltoid, dose: 0.5 ml, route of administration: intramuscular and expiration date: 04-May-2021] for an influenza prophylaxis. On 28-Aug-2020, two days after taking Fluad (TIV), the patient died. The cause of death was unknown and it was unknown if autopsy was done. The case was assessed as serious due to seriousness criteria of death and medically significance. The reporter did not provide causality assessment to Fluad (TIV). Company comment: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Sender''s Comments: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Reported Cause(s) of Death: Unknown cause of death


Changed on 12/24/2020

VAERS ID: 881609 Before After
VAERS Form:2
Age:78.0
Sex:Female
Location:Unknown
Vaccinated:2020-08-26
Onset:2020-08-28
Submitted:0000-00-00
Entered:2020-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUA3: INFLUENZA (SEASONAL) (FLUAD) / NOVARTIS VACCINES AND DIAGNOSTICS 279734 / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-08-28
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: MYCOPHENOLATE; SIMVASTATIN; ALOPURINOL; FUROSEMIDE; PREDNISONE; GABAPENTIN; HUMALOG; LANTUS; SYNTHROID; POTASSIUM CHLORIDE; METOPROLOL; AMLODIPINE; AZATHIOPRINE; BUMETANIDE; METOLAZONE
Current Illness:
Preexisting Conditions: Comments: None
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USSEQIRUS202004250

Write-up: The patient was found deceased; This is a spontaneous case, initially received from pharmacist via Med Communication (reference number: SEQW20-01021) on 28-Aug-2020 with two additional documents received on 31-Aug-2020 (being processed together), concerning a 78-year-old female patient. The patient''s medical history was not reported. The patient''s concomitant medications included mycophenolate, simvastatin, alopurinol, furosemide, prednisone, gabapentin, Humalog (insulin lispro), Lantus (insulin glargine), Synthroid (levothyroxine sodium), potassium chloride, metoprolol, amlodipine, azathioprine, bumetanide and metolazone, all for an unknown indication. On 26-Aug-2020, the patient was administered Fluad (TIV) [influenza vaccine, inactivated influenza virus surface antigen (subunit), egg-derived, MF59; batch number: 279734, anatomical location: deltoid, dose: 0.5 ml, route of administration: intramuscular and expiration date: 04-May-2021] for an influenza prophylaxis. On 28-Aug-2020, two days after taking Fluad (TIV), the patient died. The cause of death was unknown and it was unknown if autopsy was done. The case was assessed as serious due to seriousness criteria of death and medically significance. The reporter did not provide causality assessment to Fluad (TIV). Company comment: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Sender''s Comments: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Reported Cause(s) of Death: Unknown cause of death


Changed on 12/30/2020

VAERS ID: 881609 Before After
VAERS Form:2
Age:78.0
Sex:Female
Location:Unknown
Vaccinated:2020-08-26
Onset:2020-08-28
Submitted:0000-00-00
Entered:2020-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUA3: INFLUENZA (SEASONAL) (FLUAD) / NOVARTIS VACCINES AND DIAGNOSTICS 279734 / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-08-28
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: MYCOPHENOLATE; SIMVASTATIN; ALOPURINOL; FUROSEMIDE; PREDNISONE; GABAPENTIN; HUMALOG; LANTUS; SYNTHROID; POTASSIUM CHLORIDE; METOPROLOL; AMLODIPINE; AZATHIOPRINE; BUMETANIDE; METOLAZONE
Current Illness:
Preexisting Conditions: Comments: None
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USSEQIRUS202004250

Write-up: The patient was found deceased; This is a spontaneous case, initially received from pharmacist via Med Communication (reference number: SEQW20-01021) on 28-Aug-2020 with two additional documents received on 31-Aug-2020 (being processed together), concerning a 78-year-old female patient. The patient''s medical history was not reported. The patient''s concomitant medications included mycophenolate, simvastatin, alopurinol, furosemide, prednisone, gabapentin, Humalog (insulin lispro), Lantus (insulin glargine), Synthroid (levothyroxine sodium), potassium chloride, metoprolol, amlodipine, azathioprine, bumetanide and metolazone, all for an unknown indication. On 26-Aug-2020, the patient was administered Fluad (TIV) [influenza vaccine, inactivated influenza virus surface antigen (subunit), egg-derived, MF59; batch number: 279734, anatomical location: deltoid, dose: 0.5 ml, route of administration: intramuscular and expiration date: 04-May-2021] for an influenza prophylaxis. On 28-Aug-2020, two days after taking Fluad (TIV), the patient died. The cause of death was unknown and it was unknown if autopsy was done. The case was assessed as serious due to seriousness criteria of death and medically significance. The reporter did not provide causality assessment to Fluad (TIV). Company comment: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Sender''s Comments: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Reported Cause(s) of Death: Unknown cause of death


Changed on 5/7/2021

VAERS ID: 881609 Before After
VAERS Form:2
Age:78.0
Sex:Female
Location:Unknown
Vaccinated:2020-08-26
Onset:2020-08-28
Submitted:0000-00-00
Entered:2020-09-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLUA3: INFLUENZA (SEASONAL) (FLUAD) / NOVARTIS VACCINES AND DIAGNOSTICS 279734 / UNK - / OT

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-08-28
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: MYCOPHENOLATE; SIMVASTATIN; ALOPURINOL; FUROSEMIDE; PREDNISONE; GABAPENTIN; HUMALOG; LANTUS; SYNTHROID; POTASSIUM CHLORIDE; METOPROLOL; AMLODIPINE; AZATHIOPRINE; BUMETANIDE; METOLAZONE
Current Illness:
Preexisting Conditions: Comments: None
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USSEQIRUS202004250

Write-up: The patient was found deceased; This is a spontaneous case, initially received from pharmacist via Med Communication (reference number: SEQW20-01021) on 28-Aug-2020 with two additional documents received on 31-Aug-2020 (being processed together), concerning a 78-year-old female patient. The patient''s medical history was not reported. The patient''s concomitant medications included mycophenolate, simvastatin, alopurinol, furosemide, prednisone, gabapentin, Humalog (insulin lispro), Lantus (insulin glargine), Synthroid (levothyroxine sodium), potassium chloride, metoprolol, amlodipine, azathioprine, bumetanide and metolazone, all for an unknown indication. On 26-Aug-2020, the patient was administered Fluad (TIV) [influenza vaccine, inactivated influenza virus surface antigen (subunit), egg-derived, MF59; batch number: 279734, anatomical location: deltoid, dose: 0.5 ml, route of administration: intramuscular and expiration date: 04-May-2021] for an influenza prophylaxis. On 28-Aug-2020, two days after taking Fluad (TIV), the patient died. The cause of death was unknown and it was unknown if autopsy was done. The case was assessed as serious due to seriousness criteria of death and medically significance. The reporter did not provide causality assessment to Fluad (TIV). Company comment: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Sender''s Comments: A 78-year-old female patient was administered Fluad (TIV) vaccine. Reportedly, the patient died two days after vaccination. The cause of death was not provided. It was unknown if autopsy was performed. Patient''s advanced maternal age may have contributed to development of the event. More information regarding medical history and autopsy results is needed. With information available, causality is unassessable.; Reported Cause(s) of Death: Unknown cause of death

New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=881609&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166