Adverse Event Reporting

VAERS ID 917117
Gender Male
Age 82
StateCode AR
Pharmaceutical Company MODERNA
Lot Number
Number of vaccinations 1
Vaccinated 2020-12-22
Onset 2020-12-28
Condition Died
  • SARS-CoV-2 test positive
  • COVID-19
  • Death

Current Illness


Preexisting Conditions


Other Medications

Quietapine, Mertazipine, Hydrocodone, Fentanyl

Previous Vaccinations



Laboratory Data

COVID-19 positive test approximately one week after vaccination.
There is no evidence to support that the vaccine caused his death in any way.


After vaccination, patient tested positive for COVID-19.
Patient was very ill and had numerous chronic health issues prior to vaccination.
Facility had a number of patients who had already tested positive for COVID-19.
Vaccination continued in an effort to prevent this patient from contracting the virus or to mitigate his risk.
This was unsuccessful and patient died.