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