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VAERS Report 2095671

Case Report Section

Vaer Report Details

Age: 63 years old

Gender: Male

State: Unknown

Patient Died?
No
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: fj1611


Date report was received
2022-02-08
Date form completed
Date Vaccinated
Date of Onset
0
Number of days (onset date – vaccination date)
0
Adverse Event Description

event occurred after 3rd vaccine; breakthrough case

Lab Data
1/20/2022 covid-19 positive
List of symptoms
covid-19 sars-cov-2 test positive vaccine breakthrough infection
Patient Died?
No
Date Died
NA
Birth defect
false
Vaccine Administered By:
Private
Vaccine Purchased By:
Unknown
Patient visit ER?
No
Patient Hospitalized?
Yes
Stay in hospital
No
Days in hospital
Unspecified
Permanent disability?
No
Allergies:
na
Current Illness
na