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VAERS Report 2157417

Case Report Section

Vaer Report Details

Age: NA

Gender: Female

State: Outside US

Patient Died?
Yes
Vaccine information

Name: COVID19 (COVID19 (JANSSEN))

Type: Coronavirus 2019 vaccine

Manufacturer: JANSSEN

Lot: unknown


Date report was received
2022-03-04
Date form completed
Date Vaccinated
2021-07-26
Date of Onset
7
Number of days (onset date – vaccination date)
7
Adverse Event Description

diffuse pain; this spontaneous report received from a consumer by a regulatory authority (it-minisal02-847097) on 01-mar-2022 and concerned a 79 year old female of unknown race and ethnic origin. the patient's weight was 55 kilograms, and height was 160 centimeters. 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, expiry: unknown) 1 dosage forms, 1 total, administered on 26-jul-2021 for covid-19 immunisation. the batch number was not reported. the company is unable to perform follow-up request batch/lot numbers. no concomitant medications were reported. on 02-aug-2021, the patient experienced diffuse pain. on an unspecified date, the patient died due to unknown cause. it was unknown if autopsy was performed or not. the action taken with covid-19 vaccine ad26.cov2.s was not applicable. this report was serious (death).; reported cause(s) of death: unknown cause of death

Lab Data
na
List of symptoms
pain
Patient Died?
Yes
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