Adverse Event Reporting

VAERS ID 917793
Gender Female
Age 78
StateCode AR
Pharmaceutical Company MODERNA
Lot Number
Number of vaccinations 1
Vaccinated 2020-12-22
Onset 2020-12-29
Condition Died
  • SARS-CoV-2 test positive
  • COVID-19
  • Death

Current Illness

Diabetes, Thyroid disease

Preexisting Conditions

Diabetes, Thyroid Disease

Other Medications

Metoprolol-Tartrate, Latanoprost, Glipizide, Pravastatin, Metformin, Benaprezil, Potassium-Chloride, Levothyroxine

Previous Vaccinations



Laboratory Data



Prior to the administration of the COVID 19 vaccine, the nursing home had an outbreak of COVID-19.
Patient was vaccinated and about a week later she tested positive for COVID-19.
She had underlying thyroid and diabetes disease.
She died as a result of COVID-19 and her underlying health conditions and not as a result of the vaccine.