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: 1804491
Sex: M
Age: 83
State: MN

Vax Date: 09/12/2021
Onset Date: 10/19/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: Lab Tests Completed C-REACTIVE PROTEIN (INFLAMMATION) COMPREHENSIVE METABOLIC PANEL D-DIMER QUANTITATIVE GLUCOSE BY METER, POCT LAB ONLY-COMPLETE BLOOD COUNT WITH DIFFERENTIAL LAB ONLY-URINE MICROSCOPIC REFLEX MAGNESIUM PROTIME/INR PTT SARS-COV-2, INFLUENZA A+B, AND/OR RSV NUCLEIC ACID TESTING PANEL TROPONIN I URINE DIP, REFLEX TO MICROSCOPIC, REFLEX TO CULTURE Icon Imaging Orders Placed Today Imaging Tests CT HEAD WITHOUT CONTRAST CTA CHEST EKG XRAY CHEST 1V - AP/PA Inspiration

Allergies:

Symptom List: Dysphagia, Epiglottitis

Symptoms: 83yr old male presented to ED from the clinic via cart. Patient was sitting in room and just passed out. Upon arrival to the clinic the patient was not responding to voice or touch. Patient was lifted from wheelchair onto cot and wheeled to the ED. Enroute to the ED the patient became more responsive and was able to open his eyes. After a couple of minutes of being in the ED the patient was able to speak and answer questions. Wife states that she did not notice any unusual weakness or changes prior to this incident. He walked by himself into the clinic. She states that he is active for a day and then needs a day of rest, but that has become his normal. Per report from spouse patient has been rubbing his abdomen lately, he did have a mass that she is wondering if it is bothering. Patient was coming into the clinic ajoining the hospital for a rountine flu shot when he collapsed. He was driven by his wife, who noted that he seemed fine on the ride over and that he got out of the car and walked normally on his own into the clinic while she parked the car. The patient was joined inside the clinic by his wife after she parked her car, he was sitting with her for her appointment and planned to get his flu shot, his wife noted that he kinda 'made a noise' and she looked over at him to note that he seemed unconscious and was drooling, he was held up in the chair until help arrived and he was placed on a gurney and taken to the ER. During the initial departure of the gurney, he woke up. Reason for Visit Neurological Changes Diagnoses Syncope, unspecified syncope type Loss of consciousness Leukocytosis, unspecified type Positive D dimer Dehydration

Other Meds:

Current Illness:

ID: 1804492
Sex: F
Age: 31
State:

Vax Date: 10/18/2021
Onset Date: 10/18/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: Na

Allergies: Na

Symptom List: Anxiety, Dyspnoea

Symptoms: Puffy Tongue Facial Numbness and neck numbness Metallic taste in mouth Pins and needles/gradual boiling sensation throughout whole body Aggressive vomiting Hard time walking Nausea Dizziness Chills and high fever Inability to keep anything down Hypersensitivity to light, sound and touch Aches and pains all over

Other Meds: Na

Current Illness: Na

ID: 1804493
Sex: M
Age: 9
State: CA

Vax Date: 10/21/2021
Onset Date: 10/21/2021
Rec V Date: 10/21/2021
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: NONE

Allergies: Lactose, dust, cedar

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

Symptoms: little raised bumps around both elbows, and four finger distant from the injection site. On the injections site there was no sign of redness, warmth, or irritation. Also patient had a slight raised streak on the left upper quadrant on his chest, just above the nipple region. Sx onset within 15 minutes. Patient c/o itchiness. Treatment: 10 ml of Benadryl. Outcome: Decrease bumps & itchiness.

Other Meds: Kirkland Children's Complete Multi-Vitamin Gummies (last took 2 days ago)

Current Illness: constipation, 1 episode of bloody stool

ID: 1804494
Sex: F
Age: 34
State: WI

Vax Date: 10/15/2021
Onset Date: 10/16/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: 10/20/21: Neg POCT Sars-COV, CBC, BMET, ESR, CRP wnl. D-Dimer abnormal 4,043 10/20/21: US venous duplex lower ext bilateral. No sonographic evidence of deep venous thrombosis in either lower extremity. 10/20/21 CT PE Chest Angio: Subsegmental pulmonary embolus along the posterior branch of the right upper lobe segmental artery. No heart right strain. 10/21/21: CT abd pelvis and labs ordered without results at time of this form.

Allergies: Penicillins

Symptom List: Dizziness, Fatigue, Mobility decreased

Symptoms: 10/19/21 call to clinic stating tingling, numbness all over body, body aches, fatigue, fever, chest tightness and intermittent palpitations. 10/20/21 Office Visit Note below Friday got first dose of covid vaccine, states she is feeling off since then. Was fine for the first couple of hours but then 3 hours later started feeling drained, tired, arm was throbbing. As the days went on she has noticed more and more symptoms. Got chills, felt as though face was on fire. 101.5F, alternating tylenol and ibuprofen. This morning when she woke up this morning had a fever and took ibuprofen. Bilateral groin tenderness started Saturday/sunday. Gets weird numbness and tingling throughout body. Palpitations started Friday night. Every 2 hours, lasts 5-10 minutes. Slightly some shortness of breath and "slightly" some chest pain with it. Currently legs are sore, hard to walk because of the pain, elevates her legs because of the swelling. No noted redness. Swelling is new to her legs. No prior history of this. Notices sock line. This does improve once she elevates her legs but then as soon as she gets up again notices the swelling. Legs are bothering her the most with the leg swelling. Face feels hot but fingers and hands are freezing. Neck is also sore. Has been off of work due to her fevers and symptoms. No prior history of PEs. Has Mirena IUD in place. 10/21/21: Presents to ED, see notes below, still in ED at time of this form HPI The patient is a 35 year old female with a history of asthma who presents to the Emergency Department with a chief complaint of left leg pain. The patient received the first dose of the Pfizer COVID-19 vaccine on 10/15/2021 and states that she has been feeling "off" since. She was evaluated at the Respiratory Clinic yesterday for fatigue, fevers, chills, shortness of breath, chest tightness, and leg swelling and pain. A bilateral lower extremity ultrasound, CT angio of the chest, and labs were obtained. Findings were significant for a single subsegmental PE. Patient was contacted today with CT scan findings and was recommended to come into the Emergency Department for further evaluation of symptoms. The patient states that she woke up this morning with increased left anterior thigh pain and an acute onset of left sided abdominal pain. Notes that the pain work her up from her sleep this morning. Her left thigh pain is currently rated as a 7/10 in severity and described as aching with no radiation. No other associated symptoms noted. Symptoms are aggravated with palpation and movement of the left lower extremity and there are no alleviating factors. The patient denies nausea, vomiting, chest pain, back pain, head pain, dizziness, or lightheadedness. She denies taking any medications prior to arrival. No other reported symptoms at this time.

Other Meds: Albuterol HFA 90mcg inhaler, inhale 2 puffs q 6 hrs as needed -Mirena IUD -Multivitamin, 2 tablets daily -Maxalt-MLT, 1 tablet as needed may repeat second pill in 2 hours. -Topamax 50mg started 9/10/21 Sig: Take 0.5 tablets (25 mg total) by

Current Illness: 10/5/21 started with VIRAL URI symptoms, father COVID positive. Seen for OV 10/7/21, negative POCT COVID, negative Rapid Strep Test, negative Respiratory PCR panel

ID: 1804495
Sex: M
Age: 73
State: MI

Vax Date: 05/22/2021
Onset Date: 10/11/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: Chest CT: Hyperinflation which can be seen in COPD

Allergies: n/a

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

Symptoms: Came to ER on 10/19 after 10/11 COVID Diagnosis. Visit was for worsening congestion. Upon talking with patient it became apparent that pt was very confused and not oriented. Was admitted to hospital and remains hospitalized.

Other Meds: atorvastatin, clopidogrel, docusate sodium, donepezil, ferrous sulfate, hydrocodone-acetaminophen, montelukast, nitroGLYCerin, sennosides

Current Illness: n/a

ID: 1804496
Sex: M
Age: 87
State:

Vax Date: 02/13/2021
Onset Date: 02/13/2021
Rec V Date: 10/21/2021
Hospital: Y

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:

Allergies:

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

Symptoms: Admitted to Hospital on Date of Adverse Event [recorded in VAERS] for treatment of Covid-19 Positive following completion of Covid Vaccine Series.

Other Meds:

Current Illness:

ID: 1804497
Sex: M
Age: 86
State: FL

Vax Date: 04/03/2021
Onset Date: 09/04/2021
Rec V Date: 10/21/2021
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: POSITIVE COVID TEST 09/04/2021

Allergies: NKA

Symptom List: Pyrexia, White blood cell count decreased

Symptoms: PT C/O SOB AND COUGH FOR 5 DAYS

Other Meds: amiodarone 200 mg oral tablet, 200 mg= 1 TAB, PO, Daily atorvastatin 40 mg oral tablet, 80 mg= 2 TAB, PO, Daily Eliquis 2.5 mg oral tablet, 2.5 mg= 1 TAB, PO, BID (2 times a day) Flonase 50 mcg/inh nasal spray, 1 Spray, Both Nares, Daily, P

Current Illness:

ID: 1804499
Sex: F
Age: 34
State: MN

Vax Date: 01/09/2021
Onset Date: 10/20/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies:

Symptom List: Pharyngeal swelling

Symptoms: Tested positive for COVID 10/20/21 after being fully vaccinated.

Other Meds:

Current Illness:

ID: 1804500
Sex: M
Age: 23
State: OH

Vax Date: 10/14/2021
Onset Date: 10/16/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data:

Allergies: NKA

Symptom List: Abdominal pain, Chills, Sleep disorder

Symptoms: Patient presented with expressive aphasia 2 days after infection and was found to have a L M2 occlusion requiring tPA and emergent mechanical thrombectomy

Other Meds: mesalamine

Current Illness: ulcerative colitis

ID: 1804501
Sex: F
Age: 27
State: TN

Vax Date: 10/14/2021
Onset Date: 10/14/2021
Rec V Date: 10/21/2021
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: UNKNOWN

Symptom List: Diarrhoea, Nasal congestion

Symptoms: Per the patient: "Approximately 5-10 minutes after injection, I began to experience soreness at injection site, a sore arm (left side), neck pain/ache (left), and a headache on the back side of my head. About 30 minutes after injection, my upper arm (left) became slightly numb and my hand (left) began to tingle. I also experienced a sharp shooting pain in my lower arm (left), down to my hand and below my thumb (left). The neck pain and sore arm increased at this time. That night (10/14/2021), at 7:00 pm, I began to experience numbness and tingling in both hands and both feet. When I got up to walk, I experienced numbness predominantly on my left side, my entire and and entire leg. I felt significantly weaker on that side. Today, 10/16/2021 @ 7:07 pm, all symptoms remain and numbness in my left knee is significantly worse. " I have tried reaching out to patient to follow-up but have not received a response.

Other Meds: UNKNOWN

Current Illness: UNKNOWN

ID: 1804502
Sex: F
Age: 22
State: LA

Vax Date: 08/17/2021
Onset Date: 09/29/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: Ultrasound OB transvaginal - Impression: Failed pregnancy with retained products of conception. Single intrauterine gestational sac with embryo crown-rump length measurement of 1.87cm, but no detectable cardiac flutter of cardiac activity.

Allergies: NKDA

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

Symptoms: Patient was pregnant. LMP 7/26/21 EDD- 5/2/22, patient went for dating sonogram on 9/29/21 , no detectable cardiac flutter or cardiac activity.

Other Meds: prenatal vitamins, vitamin D

Current Illness: none

ID: 1804503
Sex: M
Age: 74
State: SC

Vax Date: 09/28/2021
Onset Date: 10/14/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: Covid-19 test

Allergies: codeine, Percocet

Symptom List: Rash, Urticaria

Symptoms: I had a really bad cough. Worst then a cold. I had a difficulty breathing. Everything tasted salty. I had chills that I began to shake. I was really cold. I have a fever of a 103. I went to the ER. They did a Covid-19 test, which came back positive. I am very fatigue.

Other Meds: N/A

Current Illness: N/A

ID: 1804504
Sex: F
Age: 44
State: VA

Vax Date: 10/11/2021
Onset Date: 10/19/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies: diary

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

Symptoms: My arm started itching 2 days ago and a hot, inflamed rash has formed around the injection site.

Other Meds: zinc, vitamin c, magnesium, elderberry, vitamin a, b-complex, and d

Current Illness: none

ID: 1804505
Sex: F
Age: 30
State:

Vax Date: 10/14/2021
Onset Date: 10/15/2021
Rec V Date: 10/21/2021
Hospital:

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: Heart palpations, sharp pain in chest when inhaling, intermittent chest pain over the heart

Other Meds:

Current Illness:

Date Died: 09/11/2021

ID: 1804506
Sex: F
Age: 68
State:

Vax Date: 04/06/2021
Onset Date: 09/09/2021
Rec V Date: 10/21/2021
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: Heart rate decreased, Heart rate increased, Hypertension, Injection site pain, Musculoskeletal chest pain

Symptoms: pt to ER via EMS with SOB; diagnosed with AHRF with COVID pneumonia; placed on nonrebreather mask; comfort measures and meds requested as pt's condition worsened; pt expired in the hospital

Other Meds:

Current Illness:

Date Died: 10/08/2021

ID: 1804507
Sex: M
Age: 88
State: KY

Vax Date: 03/23/2021
Onset Date: 09/25/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: Patient contracted COVID 19 and subsequently passed away.

Other Meds:

Current Illness:

ID: 1804508
Sex: M
Age: 39
State: MN

Vax Date: 05/12/2021
Onset Date: 05/15/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: 5/15/21 Echocardiogram * Normal LV systolic function estimated at 55-60%. No obvious regional wall motion abnormalities visualized. * Normal atrial size. * No significant valvular abnormalities visualized. * No pericardial effusion present. * IVC is dilated with minimal respiratory variation. * No prior study available for comparison. CBC, Metabolic panel, Lipase, LFTs, Troponin, D-dimer, TSH, CRP, Sed rate done on 5/15/21

Allergies: No known allergies

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

Symptoms: 39-year-old male who was admitted with a 1 day history of chest pain on 5/15/21. Initial labs showed elevated troponin with diffuse ST changes consistent for myopericarditis. Patient had his second dose of the Pfizer Covid vaccination on May 12. Patient was initiated on colchicine with improvement in his symptoms. Echocardiogram performed showing normal LV function with no significant valvular abnormalities. Patient was seen by cardiology, plan for 3-month treatment with colchicine and high-dose ibuprofen for at least 2 weeks until CRP has normalized. Patient will be on PPI while continuing his medications. Outpatient cardiac MRI will be completed. Patient discharged home in stable condition.

Other Meds: NONE

Current Illness: None

ID: 1804509
Sex: F
Age: 72
State: MA

Vax Date: 02/20/2021
Onset Date: 09/07/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: 9/28/21 and 9/25/21 - COVID PCR positive.

Allergies: oxycodone, ACE-inhibitors, sulfa, adhesive,

Symptom List: Ear pain, Hypoaesthesia

Symptoms: Client is a 73 yo F with PMH of HTN, HLD, ESRD/CKD s/p renal transplant x2 (1994 and 1995, on immunosuppression) s/p bilateral AV fistulas, DVT on Coumadin, hypothyroidism, who tested positive for COVID on 9/7/2021 who then presented to Hospital with AMS and hypoxia to high 80s. She was vaccinated with Pfizer and got a booster dose given her transplant history. She was treated with dexamethasone x10 days and ceftriaxone and azithromycin for COVID PNA. She was weaned from 6L to 1L NC. She was ready for discharge 9/24 but labs showed elevated d-dimer 4739 from initially 388 from admission. CTA chest showed aneurysmal enlargement of the ascending thoracic aorta to 5.0cm c/f Stanford type A ascending aortic dissection without significant luminal compromise, extends into the aortic arch but is not extending into the brachiocephalic arteries. She was subsequently started on esmolol gtt transferred to hospital for further management. Upon reviewing images it was determined she was a poor surgical candidate and that the dissection was chronic. She has remained on Lopressor for adequate impulse management of the dissection, and has been followed by the Renal Transplant team during her admission for continued immunosuppression therapy and monitoring. She has been medically managed and is stable and ready for discharge to rehab on 9/29/2021.

Other Meds: acetaminophen, aspirin, vitamin D, Cyclosporine, famotidine, iron, lasix, symthroid, ativan, melatonin, lopressor, pravachol, prednisone 5mg daily, tramadol, warfarin

Current Illness: unknown.

ID: 1804511
Sex: F
Age: 75
State: MI

Vax Date: 04/21/2021
Onset Date: 10/11/2021
Rec V Date: 10/21/2021
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: admitted for increasing cough and shortness of breath after COVID positive test

Other Meds:

Current Illness:

ID: 1804512
Sex: M
Age: 39
State: WA

Vax Date: 08/01/2021
Onset Date: 08/10/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: I just got a new job so I'm between insurance plans. I can't see the doc for maybe 1 more month until my employers new insurance gets activated.

Allergies: Augmentin, my body violently rejected

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

Symptoms: Ever since my first shot I get recurring BAD postules/cysts all over my hands but mainly palms and now my feet. Skin gets so dry it's scales and so thick that my own dead skin cuts through the other hand. Open sores all over hands, very painful to be at work, and now it's on my feet too. Soon I won't be able to work if this gets bad. This ONLY started after my first dose of the Vax. I've never ever had raised bumps like this that explode when I squeeze my hand into a fist. Who do I seek for help with this? The Vax triggered an autoimmune response! Palmoplantar pustulosis explains my experience to the T, every thing.

Other Meds: Ibuprofen and kratom for pain. Eucerin for major skin irritations. Neosporin for cracks on hands.

Current Illness:

ID: 1804513
Sex: F
Age: 58
State: OH

Vax Date: 05/14/2021
Onset Date: 05/16/2021
Rec V Date: 10/21/2021
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:

Allergies: NKA

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

Symptoms: Vaccines not given at our facitlity. Advised client to contact vaccinating pharmacy to submit report.--Pharmacy; Client states beginning 2 days following 2nd dose Moderna vaccine- weakness, progressing to immobility of right thumb and index finger. 6/2/21 - Dx of Extensor tendon rupture and surgery done on 6/8/2021.

Other Meds: Novalog Ozempic Synthroid "antacid"

Current Illness: none

ID: 1804514
Sex: M
Age: 70
State: CA

Vax Date: 02/13/2021
Onset Date: 03/02/2021
Rec V Date: 10/21/2021
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: Unevaluable event

Symptoms: body aches, pain in shoulders and legs only lasted 15 seconds

Other Meds:

Current Illness:

ID: 1804515
Sex: M
Age: 53
State: IN

Vax Date: 10/21/2021
Onset Date: 10/21/2021
Rec V Date: 10/21/2021
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:

Allergies: none

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

Symptoms: Numbness, tingling and weakness in right hand and right leg. Pain and tightness in neck and shoulders. Severe headache.

Other Meds: none

Current Illness: none

ID: 1804516
Sex: M
Age: 67
State: FL

Vax Date: 10/01/2021
Onset Date: 10/07/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: N/A

Allergies: N/A

Symptom List: Injection site pain, Pain

Symptoms: Pt. states that after receiving the 1st dose of Influenza Fluarix 10/01/2021, started experiencing symptoms 10/07/2021 of right leg cramps. Chiropractor visit 10/11/2021 recommended reporting/ Primary communications recommendation of Hot/Cold pack for pain. Still continuing to experience symptoms.

Other Meds: Metoprolol, Tamsalosin, Anipromaliace, Amodipine, 81mg Aspirin

Current Illness: N/A

ID: 1804517
Sex: M
Age: 80
State: WI

Vax Date: 10/14/2021
Onset Date: 10/14/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: N/A

Allergies: NKDA

Symptom List: Injection site pain, Menorrhagia

Symptoms: Patient received booster injection from a vial that was out overnight- past the 6 hour time frame.

Other Meds: Eliquis, Gabapentin, Lopressor, Zoloft, Zocor, Hytrin, Cordarone, D3, Iron, Loratadine, magnesium,

Current Illness: Unknown

Date Died: 10/12/2021

ID: 1804518
Sex: F
Age: 54
State: TN

Vax Date: 04/22/2021
Onset Date: 09/16/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: 9/16 Chest x ray with worsening interstitial and airspace lung infiltrates concerning for pneumonia.

Allergies: Penicillin, Aspirin, Amoxicillin

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

Symptoms: Prolonged hospitalization with eventual patient death. Acute respiratory failure with hypoxia secondary to COVID pneumonia. BiPAP, hasd previous hospitalization requiring ICU placemtn on Vapotherm and BiPAP, discharged home then hospitalized again with acute hypoxi respiratory failure, IV antibiotic therapy, IV solumendrol, SVT

Other Meds: Unknown

Current Illness: Unknown

ID: 1804519
Sex: F
Age: 51
State: WA

Vax Date: 09/10/2021
Onset Date: 09/16/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: Listed above ECG ECHOCARDIOGRAM ANGIOGRAM BLOOD LABS CT SCAN ZIO PATCH

Allergies: Sulfa antibiotics, Hydrocodone, Grass, Dust

Symptom List: Nausea, Pain in extremity, Pyrexia

Symptoms: For 4 days after vaccine I had trouble breathing with what felt like muscle spasms in my right side, rib cage, back side. On day 6 I had strange pains again but extended up my chest and neck tightening. Heaviness on my chest. Confusion, couldn?t get comfortable or catch my breath. Overwhelming feeling something was wrong. After 911 responders started monitoring heart I collapsed, heart stopped, they shocked me 3 times, took me to Hosp where cardiologist did angiogram and believes he saw 2 arterial dissections. Other cardiologist said he disagreed and it was Tokotsubo syndrome, broken heart syndrome, did Echo cardio grams and ECG?s. Put me on aspirin, Plavix, metropolol succinate, lisinopril. Gave me heparin shots to abdomen multiple times throughout the day. Stayed for 3 days. ECG?s all showed prolonged Q-T interval, Echo showed 40% heart function. My usual BP is 100-110/60-70. It was continuously very low, 60-80/25-45. Angiogram showed zero blockages, no plaque, later CT showed 0 Calcium score, no calcification in all the areas checked. I?ve always had great cholesterol levels (lol LDL, high HDL) low triglycerides, low healthy heart rate (in Hosp approx 45-55.) Two weeks after first Hosp Stay I went back in for another 3 days because of abnormal heart rhythms.

Other Meds: Fluoxetine, vit D-2, Multivitamin, Phentermine, Contrave (previous week taking Wellbutrin then stopped for 2 days and started Contrave)

Current Illness: None

ID: 1804520
Sex: F
Age: 36
State: MI

Vax Date: 10/19/2021
Onset Date: 10/20/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: None.

Allergies: Penicillin

Symptom List: Chills, Fatigue, Headache, Myalgia

Symptoms: Large, tense, painful blisters at site of injection of the flu vaccine. Photos available upon request.

Other Meds: 1. Dextroamphetamine 30mg. 2x/day 2. Pepcid AC 20mg 1x/day

Current Illness: None

ID: 1804521
Sex: F
Age: 26
State: NC

Vax Date: 09/18/2021
Onset Date: 09/01/2021
Rec V Date: 10/21/2021
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: Physical exam on 11-Oct-2021 to confirm sinus infection at urgent care. Nasal scope on 19-Oct-2021 at ENT showed no sign of sinus infection.

Allergies: tetracycline

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

Symptoms: build up of sinus pressure, ear pain, headache in both ears starting around 23-Sep-2021. switched taking sudafed and Dayquil and zyrtec to manage symptoms. Symptoms were not resolving . Went to urgent care doctor on 11-Oct-2021 to be treated with antibiotics and steroids for sinus infection and fluid buildup behind ear. After completion of antibiotics and steroids, infection resolved, however headache and ear pain was not resolved. Went to ENT on 19-Oct-2021 to have a sinus scope which showed clear of sinus infection. However, sinus pressure, ear pain and headache still persist.

Other Meds: Mirena, zyrtec, b12 supplement

Current Illness: N/a

ID: 1804522
Sex: F
Age: 85
State: FL

Vax Date: 03/30/2021
Onset Date: 09/05/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: POSITIVE COVID TEST 09/05/2021

Allergies: NKA

Symptom List: Nausea

Symptoms: HOSPITAL STAY FOR WEAKNESS AND SOB, O2 SAT 95% ON 4L N/C

Other Meds: albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, NEB, Q6H (Every 6 hours) ascorbic acid 500 mg oral tablet 500 mg = 1 TAB, PO, Daily Coreg 3.125 mg oral tablet 3.125 mg = 1 TAB, PO, BID (2 times a day) dexamethasone

Current Illness:

ID: 1804523
Sex: F
Age: 52
State:

Vax Date: 09/21/2021
Onset Date: 10/22/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies: No.

Symptom List: Injection site pain

Symptoms: Nothing heart till the next morning . Arm felt absolutely sore like I fell down stairs. Bruised injection site formed and kind of went blackish stayed for 3 weeks. Left hand gets cold . Heart has been feeling tight and races and it feels like I have something in the back of my throat that I can't swallow, makes me cough sometimes.

Other Meds: None.

Current Illness: No.

ID: 1804524
Sex: M
Age: 28
State: CA

Vax Date: 10/21/2021
Onset Date: 10/21/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: N/A

Allergies: NKA

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

Symptoms: At 1015AM Client arrived at Vaccination Center requesting Janssen Covid Vaccine. Ancillary staff registered walk-in client. Ancillary staff was not notified History of Moderna Trial. Client notified Vaccinator that he had participated in the Moderna Trial. He states he received his 1st dose 4-7-2021 and 2nd dose 5-5-2021. Client states his employer is requesting vaccination status and due to blind trial is unable to provide proof. At 1022AM PHN notified and sent text to Vaccine Operations Leads and were directed to send a request for medical consult. Client was interviewed for information. At 1053 Medical Consult was sent via text. At 1101 PHN received confirmation of approval for Janssen dose 1 with 30minute observation and at 1104 received approval for Flu vaccine from the Medical Consult team. At 1110 Vaccinator administered Janssen dose 1. Client was observed for 30 minutes. At 1140 Client completed observation without complaints and left vaccination center with steady gait.

Other Meds: N/A

Current Illness: N/A

ID: 1804525
Sex: F
Age: 60
State: NC

Vax Date: 10/21/2021
Onset Date: 10/21/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: Patient reported swelling of lips and tongue "feeling thick". Patient given diphenhydramine 25mg oral solution. Symptoms resolved after 15 minutes

Other Meds:

Current Illness:

ID: 1804526
Sex: F
Age: 91
State: PA

Vax Date: 10/23/2020
Onset Date: 10/24/2020
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: 10/24- ZPAK, 10/26 -Xray right shoulder (inferior acromial spur, moderate glenohumeral joint arthropathy), US, Synovial fluid collection 10/28, 10/28 appt with orthopedics (leukocytes 1,774 (abnormal)

Allergies: Exforge, Cipro, Oxycodone-ace, codeine, lactose

Symptom List: Tremor

Symptoms: Patient with complaints of shoulder pain almost immediately after immunization. Swelling, pain,

Other Meds: Tramadol, Proair, Amlodipine-Benazepril, Famotidine, Hydralazine, Ferrous sulfate, Atorvastatin, Carvedilol,

Current Illness: Cervicalgia, , lumbar radiculopathy, migraine, SNHL, Atherosclerosis, HTN, Left atrial enlargement, PVD, Mitral regurgitation, TIA, CAD, GERD, Osteoarthritis, Hyperlipidemia, Anemia, Anxiety, Ischemic colitis

ID: 1804527
Sex: F
Age: 47
State: PA

Vax Date: 10/20/2021
Onset Date: 10/20/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: Vital signs and continuous pulse oximetry.

Allergies: Shellfish, latex, seasonal

Symptom List: Erythema, Pruritus

Symptoms: Hives, itching on chest, neck and face. Throat irritation followed by difficulty breathing, shortness of breath, persistent coughing about 35 minutes after vaccine. Self administered Benadryl and took rescue inhaler then went to local Emergency Room. Placed on pulse oximetry, received prednisone and famotidine. Evaluated and observed for a few hours.

Other Meds: Vitamin D, Allegra, Spiriva, Breo

Current Illness: None

ID: 1804528
Sex: M
Age: 78
State: MI

Vax Date: 03/23/2021
Onset Date: 10/11/2021
Rec V Date: 10/21/2021
Hospital: Y

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:

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

Symptoms: Pt on chemotherapy...admitted with increasing cough and worsening shortness of breath.

Other Meds:

Current Illness:

ID: 1804529
Sex: M
Age: 43
State: MI

Vax Date: 10/21/2021
Onset Date: 10/21/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies: none

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

Symptoms: Patient felt light headed and dizzy after receiving his second dose of Pfizer. His blood pressure was 174/110 and his glucose was 46. After he was given glucose tablets, his glucose was 85. He was picked up by his coworkers and he refused EMS.

Other Meds:

Current Illness:

Date Died: 10/15/2021

ID: 1804530
Sex: M
Age: 69
State: TX

Vax Date: 02/05/2021
Onset Date: 10/09/2021
Rec V Date: 10/21/2021
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: COVID-19 Positive Test on 10/9/2021 using the Roche LIAT SARS assay platform using PCR or equivalent Nucleic Acid Amplification(NAA)technology. Patient also reports positive 10/3/21

Allergies: Bactrim (Anaphylaxis), Zolpidem

Symptom List: Asthenia, Chills, Headache, Myalgia

Symptoms: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Moderna Vaccines on 1/8/2021 and 2/5/2021. On 10/9/2021 presented to ED with complaints of dyspnea, back pain, chest pain and nausea. Patient was noted to require high O2 requirements and ultimately required intubation. Echo with findings of acute drop in EF compounded with significant elevation in biomarker's. Patient given DAPT + Heparin infusion for maximal medical management. Pt pancultured and negative but developed worsening cardiogenic shock. Patient maxed out on vasopressors and later developed worsening leukocytosis and fever. Abx broadened but further progressed into multiple organ failure. Family elected to transition to full comfort measures. Patient passed away on 10/15/2021.

Other Meds: Aspirin, enalapril, pepcid, lasix, folic acid, fentanyl patch, gabapentin, gemfibrozil, prevacid, multivitamin, spiriva, tazodone, phenergan, warfarin

Current Illness:

ID: 1804531
Sex: F
Age: 41
State: NC

Vax Date: 04/23/2021
Onset Date: 05/04/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: Blood work from primary care physician, more blood work, nerve & muscle testing from a neurologist..

Allergies: Sulfa

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

Symptoms: 11 days after the 2nd vaccine, I started having tremors, anxiety and insomnia.

Other Meds: Juice Plus multi vitamin

Current Illness: None

ID: 1804532
Sex: M
Age: 57
State: IN

Vax Date: 10/19/2021
Onset Date: 10/19/2021
Rec V Date: 10/21/2021
Hospital:

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:

Allergies: sulfa, penicillin, keflex, dairy

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

Symptoms: Was not required to wait 15 minutes, left facility, then just about passed out while driving. Sweating, dizziness, confusion, tingling hands & feet, not able to stand up. Additionally, approximately 6 hrs post shot fever, headache, body aches for 24 hours

Other Meds: none

Current Illness: none

ID: 1804533
Sex: F
Age: 84
State: FL

Vax Date: 10/18/2021
Onset Date: 10/18/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies: None

Symptom List: Pain in extremity

Symptoms: No adverse event has occurred. Patient was administered 2 flu shots on 9/24/21 and 10/18/21

Other Meds:

Current Illness:

ID: 1804534
Sex: M
Age: 72
State: NY

Vax Date: 03/16/2021
Onset Date: 03/16/2021
Rec V Date: 10/21/2021
Hospital: Y

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

Lab Data: I had blood drawn, chest x-rays and multiple other tests. I was in and out of it from medications so I cannot remember everything.

Allergies: I do not have any allergies.

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

Symptoms: Immediately after receiving my vaccine, I felt a burning in my lungs. I have had asthma my entire life, so I figured that was why. Within two weeks, I developed a severe outbreak of shingles on my face and my head. At the same time I developed pneumonia. I ended up hospitalized Winter Haven Hospital in Winter Haven As of today, I still have shingles, but the pneumonia has cleared.

Other Meds: I was taking Livalo, Montelukast, Benecar, Chondroitin Sulfate and Glucosamine Sulfate.

Current Illness: I was not experiencing any illness.

ID: 1804535
Sex: M
Age: 48
State: KY

Vax Date: 10/21/2021
Onset Date: 10/21/2021
Rec V Date: 10/21/2021
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: none to shot

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

Symptoms: The patient made an appointment for the 3rd moderna shot booster online and filled out a vaccine consent form. On that form, he attested to that he had previously had this shot before but we had no record of his previous vaccination status. He also attested to being immunosuppressed which made him eligible for the 3rd dose (0.5 ml) of Moderna. The patient reported not having his vaccine card and was unsure of its location so I went ahead and proceeded with vaccination administration. After a few hours had passed, the patient came back with his card and it revealed he had J&J. The patient misled his vaccination status resulting in the wrong vaccine administered. I went ahead and put the moderna shot on his vaccine card.

Other Meds: Unknown but attested to immunocompromised therapy and status

Current Illness: not recorded due to not being live virus

ID: 1804536
Sex: F
Age: 59
State: CA

Vax Date: 09/10/2021
Onset Date: 09/12/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: X-ray provided on knee, leg- states arthritic pain. Unsure if it is now rheumatoid arthritis. physical therapy

Allergies: Yes

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

Symptoms: Sunday morning started to have a rash on left arm on direct spot of injection site. Over a week rash was in Left Knee, leg, hip began to swell with excruciating pain in joints. Rash cleared up over 2 weeks time except for both knees. Rash has settled in knees by 10/15/20201. Pain was in left knee, hip , leg. Unable to walk. X-ray provided on knee, leg- states arthritic pain. Unsure if it is now rheumatoid arthritis.

Other Meds: None

Current Illness: None

ID: 1804537
Sex: F
Age: 50
State: CA

Vax Date: 10/15/2021
Onset Date: 10/17/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: none

Allergies: NKA

Symptom List: Vomiting

Symptoms: I received my COVID19 booster on 10/15/21 in my right arm. On Sunday 10/17/21 I had pain in my armpit (lymph node), also a severe headache. I started taking 500 mg Acetaminophen on Sunday, however it wasn't really giving my any relief. This lasted until 10/20/21 around 4:30 pm. I was told by our nurse at the COVID19 command center to report these events.

Other Meds: N/A

Current Illness: NONE

ID: 1804538
Sex: F
Age: 38
State: CA

Vax Date: 08/27/2021
Onset Date: 09/06/2021
Rec V Date: 10/21/2021
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: gluten, dairy, shell fish

Symptom List: Headache, Limb discomfort, Nasal congestion

Symptoms: Since receiving the 2nd dose of COVID vax, I developed generalized itching all over my body. I will itch more around 10 pm every night, however, the itching persists throughout the day. There are no rashes, but there are hives. My skin welts up as I scratch. Some days I itch throughout the entire day. While other days, I only itch in the AM and then again at 10 PM. The itching occurs all over my body with the exception of my face. My scalp also itches as well. I take antihistamines and the itchiness goes away, however, when the medication wears off, I continue to itch repeatedly.

Other Meds: Compounded thyroid medication

Current Illness:

Date Died: 10/18/2021

ID: 1804539
Sex: M
Age: 93
State: WI

Vax Date: 03/04/2021
Onset Date: 10/18/2021
Rec V Date: 10/21/2021
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: Back pain, Cold sweat, Headache, Nausea, Vomiting

Symptoms: COVID-19 death of fully immunized individual

Other Meds:

Current Illness:

ID: 1804540
Sex: F
Age: 37
State: TN

Vax Date: 10/18/2021
Onset Date: 10/19/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data: N/A

Allergies: NKA

Symptom List: Injection site swelling, Limb discomfort

Symptoms: Pt reports she got her 2nd covid vaccine Monday and developed a rash over both arms, chest , abd, and back on Tuesday. rash noted on left arm further exam deferred until provider in room. Pt has no c/o pain, itching, shortness of breath and reports no concerns other than rash. Pt reports she is her to have the rash documented but is feeling fine otherwise and has no other concerns. Denies previous medication allergies or reactions to vaccines.

Other Meds: Folic Acid 1mg qD Prenatal Vitamin qD.

Current Illness: NONE

Date Died: 10/19/2021

ID: 1804541
Sex: F
Age: 80
State: MI

Vax Date: 01/24/2021
Onset Date: 10/14/2021
Rec V Date: 10/21/2021
Hospital:

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: Chills, Diarrhoea, Fatigue, Feeling abnormal, Headache

Symptoms: Pt had a GI bleed and increasing respiratory symptoms. Pt tested positive for COVID. Pt ultimately passed.

Other Meds:

Current Illness:

ID: 1804542
Sex: F
Age: 29
State:

Vax Date: 09/29/2021
Onset Date: 09/29/2021
Rec V Date: 10/21/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: Numbness and tingling on 4th and 5th digit of left hand (received dose in left arm), left arm burning, and lost of sensation in 5th digit

Other Meds:

Current Illness:

Total 2021 VAERS Injuries: 654,986

Page last modified: 13 November 2021 9:17am