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VAERS Report 2115866

Case Report Section

Vaer Report Details

Age: NA

Gender: Male

State: Outside US

Patient Died?
No
Vaccine information

Name: COVID19 (COVID19 (JANSSEN))

Type: Coronavirus 2019 vaccine

Manufacturer: JANSSEN

Lot: unknown


Date report was received
2022-02-16
Date form completed
Date Vaccinated
2021-05-19
Date of Onset
170
Number of days (onset date – vaccination date)
170
Adverse Event Description

vaccination failure; sars-cov-2 infection; this spontaneous report received from a physician by a regulatory authority (ra, at-basgages-2022-002925) on 14-feb-2022 concerned a 51 year old male of unspecified race and ethnicity. the patient's height, and weight were not reported. no past medical history or concurrent conditions were reported. the patient received covid-19 vaccine ad26.cov2.s (suspension for injection, intramuscular, batch number was not reported) dose was not reported, 1 total administered on 19-may-2021 for an unspecified indication. the batch number was not reported. per procedure, no follow-up will be requested for this case. no concomitant medications were reported. on 05-nov-2021, the patient experienced vaccination failure, and sars-cov-2 infection (severe acute respiratory syndrome coronavirus 2). laboratory data included: covid-19 pcr (polymerase chain reaction) test (nr: not provided) positive. the action taken with covid-19 vaccine ad26.cov2.s was not applicable. the outcome of the vaccination failure and sars-cov-2 infection was not reported. this report was serious (other medically important condition). this case was associated with product quality complaint, and reference number requested

Lab Data
test date: 20211105; test name: covid-19 pcr test; result unstructured data: positive
List of symptoms
covid-19 sars-cov-2 test vaccination failure
Patient Died?
No
Date Died
NA
Birth defect
false
Vaccine Administered By:
Other
Vaccine Purchased By:
Unknown
Patient visit ER?
No
Patient Hospitalized?
No
Stay in hospital
No
Days in hospital
Unspecified
Permanent disability?
No
Allergies:
na
Current Illness
na