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VAERS Report 2095851

Case Report Section

Vaer Report Details

Age: 64 years old

Gender: Female

State: Unknown

Patient Died?
No
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: 037a21b


Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: 033c21a


Date report was received
2022-02-08
Date form completed
Date Vaccinated
2021-05-08
Date of Onset
261
Number of days (onset date – vaccination date)
261
Adverse Event Description

event occurred after 2nd vaccine; breakthrough case

Lab Data
1/24/2022 covid +
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