VAERS 2021 Database www.vaers.hhs.gov

Main Page | All 2021 Deaths | Videos
VAERS Updated: 11/12/2021
** VAERS DATABASE Last updated: November 12, 2021**
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Manufacturers

Total Manufacturer
199,106MODERNA
36,710JANSSEN
5,381PFIZER\BIONTECH
2,555GLAXOSMITHKLINE BIOLOGICALS
1,469UNKNOWN MANUFACTURER
897MERCK & CO. INC.
627SEQIRUS, INC.
112DYNAVAX TECHNOLOGIES CORPORATION
91SANOFI PASTEUR
75NOVARTIS VACCINES AND DIAGNOSTICS
40EMERGENT BIOSOLUTIONS
14PAXVAX
12TEVA PHARMACEUTICALS
12PROTEIN SCIENCES CORPORATION
9PFIZER\WYETH
4BERNA BIOTECH, LTD.
4SMITHKLINE BEECHAM
3INTERCELL AG
1MEDIMMUNE VACCINES, INC.
1CSL LIMITED

COVID19 Lot Number

VAX LOT Total
2S9CL7,949
7,473
2,547
1,506
1,187
1,051
1,049
s0294561,043
866
IMM209861
816
UT7065MA766
657
579
U62828AA563
557
538
U6737AA516
515
S034636506
4F472471
458
P100253275449
444
276563436
429
418
4BH32414
MENVEO404
PP9L5362
UJ446AA337
319
306
290
271
49TM3270
R1B252M253
4F472179
933622147
C5763AA144
CW3116134
3Y7NL126
UNK114
113
ARBA141A105
104
103
96
300057A90
79
1F4EB73
R1B743M62
56
UJ090AA55
51
UH894AB46
45
UNK44
UNK42
42
EJ168638
Unknown36
35
34
32
32
26
el128424
24
A115A22
22
EN620222
21
UNK20
20
19
Z127A19
19
17
JEV18K95E15
12
111798PI12
10
A739088
No batch number8
3333324181078
6
6
TAR356
5
5
U6935AA5
UNK5
4
unknown4
3
2
55RB72
2
2
2
2
2
U7124AA2
JEV18A68E2
2
ABYB05BA1
1
1
1
1
AMVA436A1
1
1
TJ3521
A130A; VIS give1
1
U7140BB1
1
1
SP UP016AA1
1
1808P08802/ESV01
037K20A300,947
EL1284288,578
57,766
1,432

Incidents per State

State Total
82,750
CA62,821
FL38,209
TX36,512
NY34,921
PA23,646
IN23,622
IL20,597
MI19,590
OH19,426
NJ18,413
NC16,769
GA15,932
WA15,351
VA15,234
MA14,876
AZ14,206
MN12,940
MD12,656
CO11,908
WI11,425
MO10,240
TN9,685
OR8,768
KY8,437
CT8,300
SC6,700
OK6,293
AL5,692
LA5,025
IA4,825
KS4,821
UT4,637
NV4,374
NM3,967
AR3,807
ME3,161
NH3,096
NE2,918
MS2,859
ID2,785
WV2,469
HI2,459
PR2,417
MT2,414
RI2,076
DE1,868
AK1,830
VT1,734
DC1,715
ND1,388
SD1,269
WY866
GU118
VI69
AS47
MP29
MH8
XB6
FM4
QM3
XV2
XL1

ID: 1656513
Sex: M
Age: 34
State: NY

Vax Date: 08/23/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 037K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Gave blood sample at doctors office.

Allergies: None

Symptom List: Dysphagia, Epiglottitis

Symptoms: Various body parts started feeling itchy on Thursday, 8/26. Thought initially it may have been mosquito bites. The next day, my arms and legs were covered in red bumps and patches. Took Benadryl that night but symptoms became worse the next morning. Irritated areas included my arms, legs, back and feet. Went to my primary care doctor on Saturday, 8/28. Doctor told me it was urticaria (hives). Prescribed Zyrtec and Prednisone which I began taking that day.

Other Meds: None

Current Illness: None

ID: 1656514
Sex: M
Age: 57
State: MN

Vax Date: 05/20/2021
Onset Date: 08/28/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025L20A
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: positive covid-19 PCR on 8/30/21

Allergies: NKA

Symptom List: Anxiety, Dyspnoea

Symptoms: patient developed covid-19 infection on 8/28/21

Other Meds: ARIPiprazole (ABILIFY) 10 mg tablet Take 1 tablet (10 mg) by mouth 1 time per day VYVANSE 50 MG capsule Take 1 capsule (50 mg) by mouth 1 time per day loratadine (CLARITIN) 10 mg tablet Take 1 tablet (10 mg) by mouth 1 time a day as needed

Current Illness: none

ID: 1656515
Sex: F
Age: 69
State: CA

Vax Date: 08/28/2021
Onset Date: 08/29/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot: EL1284
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: Zithromycin

Symptom List: Chest discomfort, Dysphagia, Pain in extremity, Visual impairment

Symptoms: Fever 102 Weakness Body aches Nauseous

Other Meds: Symbicort inhaler Prilosec Daily multivitamin Xanax Vitamin d

Current Illness:

ID: 1656516
Sex: F
Age: 64
State: MN

Vax Date: 04/03/2021
Onset Date: 08/25/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: unknown
Dose Series: UNK
Vax Route:
Vax Site:

Lab Data: SARS-CoV2-RNA, TMA SWAB, NASOPHARYNX Detected

Allergies: None

Symptom List: Dizziness, Fatigue, Mobility decreased

Symptoms: Positive test for COVID-19. Symptoms: scratchy throat, fever, headache, body aches

Other Meds: *sertraline 100 mg tablet * fluticasone propion-salmeteroL 250-50 mcg/dose diskus 1 puff 2 (two) times a day * albuterol 90 mcg/actuation inhaler * olmesartan-hydroCHLOROthiazide 20-12.5 mg per tablet * glimepiride 4 mg tablet 2x daily *

Current Illness: None

ID: 1656517
Sex: F
Age: 33
State: GA

Vax Date: 04/09/2021
Onset Date: 08/24/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Checked urine for blood 8/25 stated treatment with cipro 8/25. Pain got worse 8/29 went for a 2nd urine check, still blood in urine starting treatment Sulfamethoxazole-TMP DS

Allergies: None

Symptom List: Injection site erythema, Injection site pruritus, Injection site swelling, Injection site warmth

Symptoms: 8/25 flank pain and cramps, went to Dr, blood in urine, diagnosed with kidney infection

Other Meds: Wellbutrin Lexapro Ambien Xanax Losartan potassium

Current Illness: None

ID: 1656518
Sex: M
Age: 43
State: NY

Vax Date: 08/18/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: FLUC4
Manufacturer: SEQIRUS, INC.
Vax Name: INFLUENZA (SEASONAL) (FLUCELVAX QUADRIVALENT)
Lot: 276563
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: ultrasound

Allergies: shrimp / shellfish

Symptom List: Chills, Confusional state, Eye inflammation, Headache, Laboratory test

Symptoms: blood clot left leg - thrombosis left gastronomies' vein

Other Meds: none

Current Illness: none

ID: 1656519
Sex: M
Age: 40
State: CA

Vax Date: 03/14/2021
Onset Date: 08/12/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Pyrexia, White blood cell count decreased

Symptoms: Breakthrough Covid Infection, respiratory failure

Other Meds:

Current Illness:

ID: 1656520
Sex: M
Age: 62
State: OR

Vax Date: 02/25/2021
Onset Date: 03/15/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: UNK
Vax Route: IM
Vax Site: LA

Lab Data: Having CT scan done on maxillofacial area soon

Allergies:

Symptom List: Pharyngeal swelling

Symptoms: the constant feeling of full ears. Constantly having to try to clear them. Has now progressed into my jaws and teeth. (specifically my molars both top and bottom)

Other Meds:

Current Illness:

ID: 1656521
Sex: M
Age: 68
State: FL

Vax Date: 08/28/2021
Onset Date: 08/29/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: none

Allergies: none

Symptom List: Abdominal pain, Chills, Sleep disorder

Symptoms: got strong chills and sweats, alternating about every 20 minutes, for the next 14 hours, along with a headache

Other Meds: none

Current Illness: none

ID: 1656522
Sex: F
Age: 65
State: WA

Vax Date: 08/20/2021
Onset Date: 08/20/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J201A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: Optical

Symptom List: Diarrhoea, Nasal congestion

Symptoms: I start feeling body ache. So, I went to bed. As the night went on and, on the pain, got worst. I have a serve headache. My skin hurt; I could not put a blanket on. I had to the bathroom I could not walk, I felt like I was going to faint. I felt nausea. Went back to bed and started shaking. I was confused and did not know where I was. My skin also felt hot to the touch.

Other Meds: Hydrocortisone; fluprazine; Methimazole; Escitalopram; Fosamax; vitamin C; vitamin D; vitamin B12; propionic

Current Illness:

ID: 1656523
Sex: M
Age: 17
State: HI

Vax Date: 08/25/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: None

Allergies: None

Symptom List: Vaccination site erythema, Vaccination site pruritus, Vaccination site swelling

Symptoms: Morning after vaccine had pain and swelling to axilla of the same side he received the vaccine. that swelling subsided but over the next few days developed swelling to his right chest wall and flank area. No redness or pruritis, does have some pain with movement. Swelling is improving but not completely gone.

Other Meds: Motrin

Current Illness: None

ID: 1656524
Sex: F
Age: 64
State: KS

Vax Date: 08/02/2021
Onset Date: 08/02/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039k20a
Dose Series: 1
Vax Route: SYR
Vax Site: RA

Lab Data: none

Allergies: none

Symptom List: Rash, Urticaria

Symptoms: About 8:00 pm on the day I received the vaccine, my upper arm was sore and hurt to use it so I took Naproxen Sodium 12-hour overnight for 2 nights. That relieved pain. On day 2, after the shot, my left calf muscle began to feel very sore. Sore to touch it, sore to use it, then the soreness progressed in intensity and spread to the entire calf (gastrocnemius and soleus-the outside calf muscle). On Day 3 after the shot (8-5-21), my right calf muscle also began to be sore and had same symptoms (gastrocnemius and soleus pain and soremess) the soreness was so bad, I applied ice a few times, and I withheld some of my normal walking & swimming exercises. On day 4 and 5 and 6 after the shot, I couldn't walk normally! I had to shuffle, or shuffle backwards (!) so as not to use my calves! I sat around with my feet propped up, massaging my calves , even though that didn't feel great. I finally took some ibuprofen and/or Tylenol and that relieved a lot of the pain and discomfort, but still couldn't walk normally. On Day 7 I eventually regained some walking ability, only if I took Tylenol. Day 8 was much better and only took Tylenol in the night. Day 9 regular walking. I also experienced fatigue, I slept an hour or 2 longer than usual for 2 weeks. I have had low energy levels for 4 weeks. I got vertigo again (same as after 1st shot) and lasted 3 weeks. Brain zaps occasionally too. Sensations of visual interruptions.

Other Meds: Levothyroxine sodium, 75mcg/daily, One-aDay women's over 50 vitamin, Vit D 3,000/day

Current Illness: none

ID: 1656525
Sex: F
Age: 15
State: IL

Vax Date: 08/27/2021
Onset Date: 08/27/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Blood pressure decreased, Chest pain, Chills, Confusional state, Decreased appetite

Symptoms: PATIENT'S EYES CLOSED AND THE PATIENT PROGRESS TO FALL OUT OF THE CHAIR IMMEDIATELY AFTER THE IMMUNIZATIONS. PHARMACIST AND A PARENT HELD THE PATIENT TO PREVENT FROM FALLING TO THE GROUND

Other Meds:

Current Illness:

ID: 1656526
Sex: M
Age: 55
State: FL

Vax Date: 05/06/2021
Onset Date: 08/22/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20-2A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Dyspnoea, Fatigue, Feeling abnormal, Head discomfort, Headache

Symptoms: Pt states severe pain and neck pain. He ran a fever. was hospitalized.

Other Meds:

Current Illness:

ID: 1656527
Sex: F
Age: 19
State: OH

Vax Date: 08/26/2021
Onset Date: 08/28/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: 8/30/21 saw dr and he confirmed her spleen was enlarged and felt it was a reaction to the vaccine. Wants a follow up appointment in a week.

Allergies: Keflex

Symptom List: Heart rate decreased, Heart rate increased, Hypertension, Injection site pain, Musculoskeletal chest pain

Symptoms: Enlarged spleen, pain and discomfort in rib and upper left abdomen area

Other Meds: None

Current Illness: None

ID: 1656528
Sex: F
Age: 21
State: CA

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: None.

Allergies: None listed

Symptom List: Nausea, Pain, Pain in extremity, Paraesthesia oral, Pyrexia

Symptoms: Patient complained of vertigo, bilateral asthenia of the legs, with tingling in the toes after COVID vaccination. Although patient was able to ambulate to post-vaccination waiting area without assistance, she complained of some more vertigo, and general weakness in the ensuing minutes. Patient admitted to feeling anxious. Patient was placed in a reclined position with feet above her head and heart. Patient was also given Gatorade, water, and Tylenol. Patient was able to leave the clinic under her own power without ambulatory assistance.

Other Meds: Tylenol, migraine medication, albuterol inhaler

Current Illness: none

ID: 1656529
Sex: F
Age: 14
State: FL

Vax Date: 08/22/2021
Onset Date: 08/22/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: DTAPHEPBIP
Manufacturer: GLAXOSMITHKLINE BIOLOGICALS
Vax Name: DTAP + HEPB + IPV (PEDIARIX)
Lot:
Dose Series: UNK
Vax Route:
Vax Site: LG

Lab Data:

Allergies:

Symptom List: SARS-CoV-2 antibody test, SARS-CoV-2 test negative

Symptoms: Patient was given the moderna vaccine at our pharmacy location although he was 14 years of age

Other Meds:

Current Illness:

ID: 1656530
Sex: F
Age: 74
State: IL

Vax Date: 04/28/2021
Onset Date: 05/02/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: HIBV
Manufacturer: MERCK & CO. INC.
Vax Name: HIB (PEDVAXHIB)
Lot:
Dose Series: UNK
Vax Route:
Vax Site: LG

Lab Data: see dermatology , considering biologics

Allergies:

Symptom List: Ear pain, Hypoaesthesia

Symptoms: severe psoriatic plaques covering 60% of skin, no hx of skin lesions prior to vaccine

Other Meds:

Current Illness:

Date Died: 08/16/2021

ID: 1656531
Sex: M
Age: 66
State: CA

Vax Date: 03/08/2021
Onset Date: 08/11/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: PNC13
Manufacturer: PFIZER\WYETH
Vax Name: PNEUMO (PREVNAR13)
Lot:
Dose Series: UNK
Vax Route:
Vax Site: LG

Lab Data:

Allergies:

Symptom List: Abdominal pain upper, Dizziness, Dysgeusia

Symptoms: breakthrough Covid infection, acute resp failure, patient died

Other Meds:

Current Illness:

ID: 1656532
Sex: M
Age: 14
State: WA

Vax Date: 08/22/2021
Onset Date: 08/22/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: RV1
Manufacturer: GLAXOSMITHKLINE BIOLOGICALS
Vax Name: ROTAVIRUS (ROTARIX)
Lot:
Dose Series: 1
Vax Route: PO
Vax Site: MO

Lab Data:

Allergies:

Symptom List: Blood pressure increased, Chest discomfort, Heart rate increased

Symptoms: Within about 2 minutes of vaccine, pt lost consciousness, for btwn 30-60sec. Became rigid for 1-2 seconds. Regained consciousness, but had become very pale, and was a bit groggy. Was a little nautious, but did not vomit. Had pt fully reclined, and about 25min later, pt was able to sit up, and just around 30min afterward was able to walk again. Pt was expecting this, as this has occured post vaccination before.

Other Meds:

Current Illness:

ID: 1656533
Sex: F
Age: 59
State: MN

Vax Date: 01/29/2021
Onset Date: 08/27/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot: Eh9899
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: SARS COVID-19 MOLECULAR (PMC): POSITIVE 8/30/2021

Allergies: NONE

Symptom List: Injection site erythema, Injection site pruritus, Injection site swelling, Lymph node pain, Lymphadenopathy

Symptoms: SYMPTOMS STARTED 8/28/2021: FEVER 103.2; SCRATCHY THROAT, NAUSEA, TIRED, ACHY

Other Meds: NONE

Current Illness: NONE

ID: 1656534
Sex: M
Age: 76
State: CA

Vax Date: 02/22/2021
Onset Date: 06/01/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: MRI 7/20/21 Epidural 8/6/21

Allergies:

Symptom List: Unevaluable event

Symptoms: Sciatica

Other Meds: Simvastatin 5 mg Lisopril 20 mg

Current Illness:

ID: 1656535
Sex: F
Age: 30
State: CA

Vax Date: 02/20/2021
Onset Date: 02/27/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: No

Allergies: Antibiotics - vancomycin; septra; Rocephin; doxycycline

Symptom List: Chills, Dizziness, Injection site pain, Myalgia, Pyrexia

Symptoms: On 02/27/2021, that was my breaking point I did an emergency appointment with my doctor and therapist. I was basically having a mental break down. Dr.'s colleague put me up on different medication, a higher anti-depression medication, and anti-anxiety medication, and therapy sessions. I have not recovered 100 percent from my AEs I would say I am recovered 60 percent.

Other Meds: Prozac; Crestor

Current Illness: Side effects from the 1st vaccine, Moderna Dose 1 fever arm soreness; joint pain; nausea; fatigue

ID: 1656536
Sex: F
Age: 44
State: OR

Vax Date: 07/20/2021
Onset Date: 07/20/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011L20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: Codeine; morphine; Tetanus vaccine

Symptom List: Injection site pain, Pain

Symptoms: Tight painful lungs at 2:30AM on the 20th, along with feeling I had the flu. I tracked my vitals all night. I remember struggling to get full breath into the night and next day I went to Urgent care. On the 26th after all the flu like symptoms had gone away I had horrific arm pain around my injection sight, it pulled into lump and spread up to my shoulder and shoulder blade, the pain was level 10. I had a fever of 100.5. I treated it with ibuprofen, CBD lotion. Wednesday 28 went to level 8 pain and then it disappeared. I'm now using an albuterol inhaler 4 times a day.

Other Meds: Estradiol; Trazodone; Lamictal; propranolol; Valium; Prebiotic and probiotic

Current Illness:

ID: 1656537
Sex: F
Age: 17
State: NE

Vax Date: 08/26/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: None

Allergies: Unknown No reported allergy to a component of a COVID-19 vaccine

Symptom List: Injection site pain, Menorrhagia

Symptoms: There is no adverse event to report. This is an administration error. Moderna was given to this 17 year old.

Other Meds: Unknown

Current Illness: Unknown

ID: 1656538
Sex: F
Age: 25
State: VA

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data:

Allergies: NKA

Symptom List: Arthralgia, Chills, Headache, Mobility decreased, Myalgia

Symptoms: GAVE PT PFIZER VACCINE WHEN SHE WAS SUPPOSED TO RECEIVE SECOND DOSE OF MODERNA VACCINE, PT HAD NO SYMPTOMS OR REACTION WHEN IN PHARMACY SETTING

Other Meds: NONE LISTED

Current Illness: NONE LISTED

ID: 1656539
Sex: F
Age: 23
State: VA

Vax Date: 08/08/2021
Onset Date: 08/16/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: 8/30/21 hospital visit at 4am for extreme body pain and neck ,back and head pain

Allergies: Tumeric tamerin

Symptom List: Nausea, Pain in extremity, Pyrexia

Symptoms: Extreme pain in head and neck area body hot sometimes and head cold and vise versa dizziness inability to perform everyday tasks such as care for children bin to hospital at least 4 or 5 times since second dose

Other Meds: None

Current Illness: Irregular heartbeat anxiety panic attacks

ID: 1656540
Sex: M
Age: 72
State: FL

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: UNK
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies: No known allergies

Symptom List: Chills, Fatigue, Headache, Myalgia

Symptoms: Patient came to the pharmacy this morning and asked if we had the covid-19 vaccine. We told him we had the 3 available vaccines and patient stated he wanted to get the Pfizer vaccine. Patient came back at 4pm for the vaccine. He filled out the consent form, and was reading the VIS dated 08/12/2021 that I gave him all while I prepared the vaccine. He is a patient of ours and I have on file that he has no known allergies, but I asked him before administering the vaccine to reassured. I also verified he never had a reaction to a previous vaccine. I also asked, Patient you did not get any prior dose of the covid vaccine? He said no, I have not. He waited the 15 minutes, we talked about the 2nd dose timeframe and I gave him the card. Patient left. I opened SHOTS to report it and found out patient had both doses of Pfizer covid vaccine on April 7 and April 22, 2021. I called the patient twice and left a voice message. He has not returned the call. I also contacted his PCP and let her know. I called SHOTS for guidance on how to report this erroneous dose but it is after hours already.

Other Meds: Lisinopril 20mg Atorvastatin 20mg

Current Illness:

ID: 1656541
Sex: F
Age: 72
State: AL

Vax Date: 08/26/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies:

Symptom List: Headache, Heart rate increased, Injection site erythema, Injection site pain, Injection site swelling

Symptoms: PFIZER-BIONTECH COVID-19 VACCINE EUA. ADMINISTRATION ERROR- MIXED DOSE SERIES. It is unclear what patient received for 1st dose of Covid-19 vaccine. Immunization database shows patient received 1st dose of Moderna on 4/21/21. Provider of 1st immunization is saying patient received Johnson & Johnson. Nursing facility doctor states patient is immunocompromised and needs an additional dose. Due to exceptional circumstances, patient cannot leave nursing facility and having trouble determining what they actually received for 1st dose. Patient vaccinated with Pfizer on 8/26/21 for 2nd dose to complete series or provide additional dose.

Other Meds:

Current Illness:

ID: 1656542
Sex: M
Age: 62
State: CA

Vax Date: 04/30/2021
Onset Date: 08/09/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies:

Symptom List: Nausea

Symptoms: breakthrough covid infection,

Other Meds:

Current Illness:

ID: 1656543
Sex: F
Age: 38
State: IL

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: UNK
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: None

Symptom List: Injection site pain

Symptoms: PATIENT PASSED OUT WITHIN 10 SECONDS AFTER SHOT GIVEN. PT WAS SWEATING PROFUSELY AND LOOKING PALE. PT BECAME UNRESPONSIVE FOR ABOUT 7 SECONDS. SHE HAD PULSE AND WAS BREATHING NORMALLY. SHE WAS GIVEN ICE PACK AND SHE HELD IT NEAR HER CHEST. SHE BECAME UNRESPONSE AGAIN. 911 WAS CALLED. PT BECAME RESPONSIVE AGAIN AFTER A FEW SECONDS. SHE WAS GIVEN COLD WATER TO DRINK. SHE DRANK A FEW SIPS AND CLAIMED SHE WAS OK. SHE WAS SWEATING PROFUSELY BY THEN AND WAS STILL VISIBLY PALE. PARAMEDICS CAME AND TOOK OVER.

Other Meds: None

Current Illness: None

ID: 1656544
Sex: F
Age: 31
State: MI

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: n/a

Symptom List: Injection site induration, Injection site pruritus, Injection site swelling, Injection site warmth

Symptoms: no adverse effects of the vaccination are documented, however 6 full doses of the vaccine were administered to the patient without knowledge of the administrator 1.8 ml of dillutent was injected into the vaccine vial, entire vial was drawn up and injected instead of 0.3ml. the vial was then found empty and assumed that the entire vial was used on one patient. patient, cdc, health department, poison control, and health care provider were all informed and asked for more information

Other Meds: n/a

Current Illness: n/a

ID: 1656545
Sex: M
Age: 64
State: WA

Vax Date: 06/04/2021
Onset Date: 06/07/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011j20a
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: None - I reported the initial adverse event and then the subsequent increase in the problem after the second dose. No tests have been done.

Allergies: None

Symptom List: Chills, Dizziness, Nausea, Pain, Tachycardia

Symptoms: Significant ringing in my head (Tinnitus) began within a couple of days of receiving the vaccine. I delayed getting the second dose by a month hoping that it would subside and out of fear that the second dose would make it worse. I decided to get the second dose on 8-4-21. Within 2-3 days, the ringing intensified by a factor of approximately 3X. Big mistake but stopping short of being fully vaccinated would not permit me to enjoy unhindered travel and avoid other restrictions.

Other Meds: Lipitor

Current Illness: None

ID: 1656546
Sex: M
Age: 60
State: CA

Vax Date: 05/10/2021
Onset Date: 05/10/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Sclerosis of the liver

Allergies:

Symptom List: Tremor

Symptoms: Fever, chills, body aches and felt like flu.

Other Meds: Blood pressure med; anti anxiety med

Current Illness: High blood; hepatitis C

ID: 1656547
Sex: F
Age: 66
State: SC

Vax Date: 02/18/2021
Onset Date: 07/16/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: CBC and other blood work, Covid test, CAT scan of abdomen, EKG

Allergies: none

Symptom List: Erythema, Pruritus

Symptoms: Fever, dizziness, pain in chest, shortness of breath, muscle and joint aches, chills

Other Meds: calcium, vitamin D, multi-vitamin

Current Illness: none

ID: 1656548
Sex: F
Age: 18
State: VA

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: UNK
Manufacturer: UNKNOWN MANUFACTURER
Vax Name: VACCINE NOT SPECIFIED (NO BRAND NAME)
Lot:
Dose Series: UNK
Vax Route: SYR
Vax Site: UN

Lab Data:

Allergies: OMNICEF

Symptom List: Injection site erythema, Injection site induration, Injection site pruritus, Injection site swelling, Myalgia

Symptoms: GAVE PT PFIZER VACCINE FOR 2ND DOSE , WAS SUPPOSE TO RECEIVE MODERNA VACCINE

Other Meds: BIRTH CONTROL

Current Illness: NONE LISTED

ID: 1656549
Sex: F
Age: 33
State: TX

Vax Date: 03/26/2021
Onset Date: 03/28/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: A battery of blood tests, TTT, EKG, blood pressure monitoring, etc?

Allergies: Kiwi, banana, avocado

Symptom List: Cough, Limb discomfort, Pain, SARS-CoV-2 test positive

Symptoms: Neurological side effects (dizziness, double vision, extreme brain fog, confusion, low blood pressure). Eventually diagnosed with dysautonomia and POTS. Vaccine discussed as very possible trigger by multiple doctors.

Other Meds: Metronidazole, doxycycline, insulin

Current Illness: Diabetes type 1

ID: 1656550
Sex: F
Age: 58
State: OH

Vax Date: 08/30/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Asthenia, Chills, Headache, Myalgia

Symptoms: Acute bronchospsasm

Other Meds:

Current Illness:

ID: 1656551
Sex: F
Age: 17
State: NE

Vax Date: 08/26/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: None

Allergies: Unknown Denies allergy to a component of a COVID-19 vaccine

Symptom List: Injection site erythema, Injection site pain, Injection site swelling

Symptoms: No adverse event. This is a medication administration error. She is 17 and received Moderna.

Other Meds: Unknown

Current Illness: Unknown

Date Died: 08/21/2021

ID: 1656552
Sex: M
Age: 83
State: TX

Vax Date: 04/02/2021
Onset Date: 08/04/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot: EK9231
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: COVID positive (8/4/21)

Allergies: Hydralazine, Clonidine, Diltiazem, Metoprolol Succinate, Floxin in D5W

Symptom List: Chills, Feeling cold, Feeling hot, Myalgia, Pain

Symptoms: Pfizer BionCOVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Pfizer BionNTech Vaccine on 03/05/2021 and 04/02/2021. Patient presented to ED on 8/4/21 for shortness of breath. Patient reported progressive worsening of shortness of breath which started 3 days prior. EMS found pt to have O2 sats at 70% RA and temp of 104F. Patient tested positive for COVID-19 infection in the emergency room. Patient had a chest x-ray done in the emergency room which revealed bilateral infiltrates consistent with COVID pneumonia versus pulmonary edema. Patient's requirement for oxygen started to increase. He was on high-flow oxygen. He also has thrombocytopenia. Required pressor support. Treated with Rocephin for UTI for Klebsiella. Pt also recieved decadron and remdesivir during stay. Patient had severe bradycardia and had a external pacemaker placed on 8/11/2021. Patient was then intubated for airway support. He also developed some acute kidney injury with the history of CKD. Patient condition slowly worsened requiring pressors. His leukocytosis increased. Patient went on to need dialysis and additional measures and family opted for comfort care. Patient expired on 8/21/21

Other Meds: albuterol 2 puffs q4; alfuzosin 10mg daily, amlodipine 5mg BID, Vitamin C 500mg daily, aspirin 81 daily, atorvastatin 10mg 1/2 tab nightly, combigan 1 drop left eye q12h, vitamin b-12 1000mcg daily, dutasteride 0.5mg daily, ergocalciferol 1

Current Illness: UTI (8/14/21)

ID: 1656553
Sex: M
Age: 53
State: NJ

Vax Date: 04/01/2021
Onset Date: 08/30/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: None

Allergies: None

Symptom List: Pain in extremity

Symptoms: Shingles Diagnosed 08/30/2021

Other Meds: Warfarin; Metformin; Daily multiple vitamin; zinc; Lysiene

Current Illness: None

ID: 1656554
Sex: M
Age: 53
State: MI

Vax Date: 08/27/2021
Onset Date: 08/28/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 2
Vax Route:
Vax Site:

Lab Data: I contacted my primary doctor, that's all so far.

Allergies: None

Symptom List: Abdominal pain upper, Abnormal behaviour, Adverse reaction, Anger, Asthma

Symptoms: Later that night I felt strange and the next day I woke up with dizziness. It has gotten worse, feels like the room is spinning.

Other Meds: Lyrica, Norco, Amitriptyline

Current Illness: None

ID: 1656555
Sex: F
Age: 79
State: MT

Vax Date: 03/29/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: SARS-CoV-2 RNA Resp Ql NAA+probe POSITIVE Ordered Test: SARS-CoV-2 RNA Resp Ql NAA+probe Ordered Test Codes: 94500-6 (LN LOINC)/ Status: Final Accession Number: 822485241 Specimen Source: SOFT TISSUE SAMPLE Specimen Site: Nasopharynx(Nasopharynx) Specimen Collection Date/Time: 2021-08-26 11:06:00.0

Allergies: NKDA

Symptom List: Consciousness fluctuating, Crying, Dry skin, Epistaxis, Headache

Symptoms: Case completed 2 dose Covid vaccine series on 3/29/21, and ws subsequently hospitalized for Covid pneumonia on 8/26/21.

Other Meds: acetaminophen (TYLENOL) 500 mg tablet Take 1,000 mg by mouth every 6 hours as needed for Pain. alendronate (FOSAMAX) 70 mg tablet Take 1 tablet by mouth every 7 days. Patient taking differently: Take 70 mg by mouth every 7 days Wednes

Current Illness: ? Arthritis ? Atrial fibrillation ? Collar bone fracture 02/2019 ? Colon polyp ? Edema ? High cholesterol ? History of colonoscopy ? Hyperlipidemia ? Malignant neoplasm of upper-outer quadrant of left female breast (HCC) 8/17/2017 ? Motion sickness ? Rheumatoid arthritis(714.0)

Date Died:

ID: 1656556
Sex: M
Age: 84
State: TX

Vax Date: 02/26/2021
Onset Date: 03/07/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Laboratory tests; Metabolic Panel; CT Head; MRI Brain; Us carotid duplex; Transthoracic Echocardiogram Complete; ECG; XR chest; XR abdomen; CT Abdomen; CT Head; IR Lumbar Puncture; Modified Barium Swallow; XR hip.

Allergies: Sulfa MSG

Symptom List: Hypotonia, Lethargy, Respiratory rate decreased, Screaming, Skin warm

Symptoms: *** SEVERE NEUROLOGICAL IMPACT*** *** MASSIVE BRAIN INFLAMMATION*** *** DEATH *** 3/07/2021: Intractable stabbing pain in head at ears every 3-4 seconds. Pain level 10. 3/10/2021: Intractable stabbing pain in head at ears every 3-4 seconds. Pain level 10. ER visit Urgent Care ER Treatment: morphine IV ER Tests: CT brain w/o IV contrast; CTA carotid; Basic Metabolic Panel; CBC w platelet count Diagnosis: Neck muscle spasm Rx: tramadol (not helpful after morphine wore off) 3/12/2021: Intractable stabbing pain in head at ears every 3-4 seconds continues. Pain level 10. ER visit Urgent Care: ER Treatment: morphine pills - twice; Tylenol; Colace; Lidocaine ER Tests: XR 2 views; Basic Metabolic Panel; CBC w platelet count; Lactic acid, venous Diagnosis: Left ear pain; pneumonia due to infectious organism, unspecified laterality, unspecified part of lung Rx: amoxicillin-clavulanate; neomycin-polymyxin-hydrocortisone (did not fill these prescriptions) 3/14/2021: Intractable stabbing pain in head at ears every 3-4 seconds continues. Pain level 10. ER visit Hospital: admitted to hospital; treatment for 14 days; Discharge diagnosis: ACUTE METABOLIC ENCEPHALOPATHY and HEPATITIS 3/28/2021: Transferred to Hospice. 3/31/2021: Transferred to Home Hospice. 4/10/2021: Death occurred Death Certificate: PRESUMED MENINGITIS

Other Meds: Seroquel; Viibryd; Gabapentin; Aricept; Namenda; Trazadone; Cardura; Proscar; Lipitor; Plavix: Latanoprost; Fluticasone Propionate; Ipratopium Bromide

Current Illness:

ID: 1656557
Sex: F
Age: 77
State: WA

Vax Date: 08/12/2021
Onset Date: 08/12/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 026LZOA
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies:

Symptom List: Vomiting

Symptoms: patient wanted to get second Shingrix but she got Moderna ( counseled and offered Moderna card too)

Other Meds:

Current Illness:

ID: 1656558
Sex: F
Age: 77
State: FL

Vax Date: 08/16/2021
Onset Date: 08/25/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 037K20A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Headache, Limb discomfort, Nasal congestion

Symptoms: Patient stated that she received bumps around the injection site. The second shot cause a red marks on legs and the booster gave her a red itich rash all over.

Other Meds: Losartan 100 mg

Current Illness:

ID: 1656559
Sex: F
Age: 32
State: TX

Vax Date: 08/12/2021
Onset Date: 08/16/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies: None

Symptom List: Back pain, Cold sweat, Headache, Nausea, Vomiting

Symptoms: The hours following my vaccination, I had random heart fluttering/palpitations which subsided after the first day. 72 hours after vaccination I had a sudden and rapid onset of chills, sweatiness, achey muscles, and extreme nausea. I proceeded to vomit and was ill/fatigued the entire day. The days following I had extreme fatigue and spells of dizziness. I have also had intermittent diarrhea, bloating, nausea, and another episode of vomiting. I had additional episodes of achey muscles, sweating and feeling chills which disrupted my ability to sleep., menstrual cramps when I am not on my period, swollen lymph nodes in the neck, numbness in my arms and hands, brain fog. Symptoms seem to be persistent and becoming worse as time goes on.

Other Meds: Vyvanse 50mg 3 times a day Loryna Drospirenone & Ethinyl Estradiol tablets (3mg/0.02mg) Vitamin D3 Zinc Magnesium-calcium-zinc Vitamin B6 Super Lysine + immune support (vitamin c, calcium, L-Lysine, garlic, echinacea, propolis, licorice r

Current Illness:

Date Died: 08/18/2021

ID: 1656560
Sex: F
Age: 54
State: TX

Vax Date: 07/10/2021
Onset Date: 07/31/2021
Rec V Date: 08/30/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025j20-2A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: COVID positive 8/2/2021; CTA revealed bilateral pulmonary embolisms and extensive bilateral pulmonary infiltrates; Troponin 1.33 on 8/6/2021

Allergies: No known allergies

Symptom List: Injection site swelling, Limb discomfort

Symptoms: Janssen (J&J) COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Janssen Vaccine on 07/10/2021. Patient started having symptoms on 7/31/2021 and presented to ED on 8/2/2021. Patient received dexamethasone and enoxaparin at outside hospital. Patient rapidly declined eventually requiring mechanical ventilation and was then transfered to ED on 8/5/2021. Patient was diagnosed with bilateral pulmonary embolisms. Patient received dexamethasone, enoxaparin, remdesivir, & ceftriaxone. Hospital course progressed without meaningful recovery of lung function ad patient expired on 8/18/2021.

Other Meds:

Current Illness:

ID: 1656561
Sex: F
Age: 17
State: NE

Vax Date: 08/26/2021
Onset Date: 08/26/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: none

Allergies: unknown no allergy reported to COVID-19 vaccine components

Symptom List: Chills, Diarrhoea, Fatigue, Feeling abnormal, Headache

Symptoms: No adverse event occurred. This is a report of a vaccine administration error as she received Moderna at age 17.

Other Meds: unknown

Current Illness: unknown

ID: 1656562
Sex: F
Age: 42
State: MA

Vax Date: 06/11/2021
Onset Date: 06/12/2021
Rec V Date: 08/30/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 037K20A
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: None

Allergies: None

Symptom List: Hot flush, Myalgia, Nausea, Tension headache

Symptoms: 1.) Fever, 2.) Loss of Appetite / Nausea 3.) Headache 4.) Body Aches 5.) Unable to standup

Other Meds: Birth Control: Syeda Multivitamin (Women's One-A-Day)

Current Illness: None

Total 2021 VAERS Injuries: 654,986

Page last modified: 13 November 2021 9:17am