54W-99312-79582

1 vaccination 6 coded responses 7 check-ins 6 free-text entries 6 call cases

Sex: Female
Age at first dose: 41-45
ZIP prefix: 980 / WA
Registered: 2021-05-16

Relationship: Self
Race: White
Ethnicity: Not Hispanic or Latino

Timeline

Registration Vaccinations Survey responses Call reports Cases without a report Call attempts Call successful Pregnancy survey

2021-04-23
Dose 1 — Moderna
2021-05-16
Registered in v-safe
2021-05-16
Survey response — day 21, dose 1
MedDRA: Anaphylactic shock, Anaphylaxis treatment, Emergency care, Immune-mediated adverse reaction, Office visit — Feeling: Fair · Be unable to work, Be unable to do your normal daily activities, Get care from a doctor or other healthcare professional · Outpatient clinic or urgent care clinic visit, Emergency room or emergency department visit

Free text: Symptoms: I went into anaphylactic shock at the vaccine site, received epi pen and went to ER. I have been dealing w severe and continued issues or 3.5 weeks and on medication to suppress my immune response. . . · Healthcare visit (other): Allergist

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-05-16
Report sent to call center — day 21, dose 1
Be unable to work · Be unable to do your normal daily activities · Get care from a doctor or other healthcare professional

1 call case(s)
2021-05-21
Survey response — day 28, dose 1
MedDRA: Flushing, Ocular hyperaemia, Pruritus, Rash, Visual impairment — Feeling: Fair · Be unable to do your normal daily activities, Get care from a doctor or other healthcare professional · Outpatient clinic or urgent care clinic visit

Free text: with reduction of allergy medicine dosage I broke out in a rash across my chest amd neck, my face/neck/chesr flushed, I experienced bloodshot eyes and vision is fuzzy and started itching all over. Allergist increased medicine dosage to 4x daily.

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-05-21
Report sent to call center — day 28, dose 1
Be unable to do your normal daily activities · Get care from a doctor or other healthcare professional

1 call case(s)
2021-06-01
Survey response — day 35, dose 1
MedDRA: Hypersensitivity — Feeling: Fair · Get care from a doctor or other healthcare professional · Outpatient clinic or urgent care clinic visit

Free text: I am not a candidate to get a 2nd covid vaccine per my doctor. I am still dealing w significant allergic reaxtion from my first vaccine. My allergist did blood work last week and my kidney levels are off.

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-06-01
Report sent to call center — day 35, dose 1
Get care from a doctor or other healthcare professional

1 call case(s)
2021-06-06
Health check-in — day 42, dose 1
Feeling: Fair

Adult check-in
2021-07-09
Call 1 — Could Not Reach Participant
2021-07-14
Call 2 — Could Not Reach Participant
2021-07-25
Survey response — 3 months, dose 1
MedDRA: Condition aggravated, Pre-existing disease — Feeling: Fair · Be unable to work or attend school, Be unable to do your normal daily activities, Get care from a doctor or other healthcare professional · Telehealth, virtual health, or email health consultation

Free text: I tried to come off the medication I have been on since my reaction to the vacci on Aril 23. mid July. Within a few days, I was having severe auto immune issues. I went back on the medication and my system stabilized.

MedDRA releases: 2021-09,2024-11 · check-in free text available
2021-07-25
Report sent to call center — 3 months, dose 1
Be unable to work or attend school · Be unable to do your normal daily activities · Get care from a doctor or other healthcare pr

1 call case(s)
2021-07-29
Call 1 — Could Not Reach Participant
2021-08-03
Call 2 — Could Not Reach Participant
2021-10-24
Survey response — 6 months, dose 1
MedDRA: Adverse reaction, Emergency care, Inflammation — Feeling: Fair · Be unable to work or attend school, Be unable to do your normal daily activities, Get care from a doctor or other healthcare professional · Telehealth, virtual health, or email health consultation, Outpatient clinic or urgent care clinic visit, Emergency room or emergency department visit

Free text: Continued inflammation symtoms. Since my covid vaccine, I have had to take 10-40 mg of certrizine daily to mitigate my bodys reaction. I got my flu shot, and had a reaction and had to go to ER. I have never had an issue w the flu shot before.

MedDRA releases: 2024-11 · check-in free text available
2021-10-24
Report sent to call center — 6 months, dose 1
Be unable to work or attend school · Be unable to do your normal daily activities · Get care from a doctor or other healthcare pr

Telehealth, virtual health, or email health consultation · Outpatient clinic or urgent care clinic visit · Emergency room or emergency department visit · 1 call case(s)
2021-10-26
Call 1 — Could Not Reach Participant
2021-10-29
Call 2 — Could Not Reach Participant
2022-04-23
Survey response — 12 months, dose 1
MedDRA: Immunisation reaction, Mast cell activation syndrome — Feeling: Fair · Get care from a doctor or other healthcare professional · Telehealth, virtual health, or email health consultation

Free text: I have finally been diagnosed. The covid vaccine incident caused mast cell activation syndrome. To manage my symptoms, I have to tale 40 mg of certrizine each day....and I still have episodic flareups at times. I was healthy before the vaccine.

MedDRA releases: 2024-11 · check-in free text available
2022-04-23
Report sent to call center — 12 months, dose 1
Get care from a doctor or other healthcare professional

Telehealth, virtual health, or email health consultation · 1 call case(s)
2022-04-25
Call successful
Reported to VAERS voluntarily prior to GDIT contact

Vaccinations

Dose	Date	Manufacturer	Co-administered
1	2021-04-23	Moderna

Call center

6 call center cases

6 successful

VAERS report filed, before or during a call: 4

See the call center timeline

Free text

Release 8 — day 21, dose 1

2021-05-16

Symptoms: I went into anaphylactic shock at the vaccine site, received epi pen and went to ER. I have been dealing w severe and continued issues or 3.5 weeks and on medication to suppress my immune response. . .

Healthcare visit (other): Allergist

Release 8 — day 28, dose 1

2021-05-21

Symptoms: with reduction of allergy medicine dosage I broke out in a rash across my chest amd neck, my face/neck/chesr flushed, I experienced bloodshot eyes and vision is fuzzy and started itching all over. Allergist increased medicine dosage to 4x daily.

Release 8 — day 35, dose 1

2021-06-01

Symptoms: I am not a candidate to get a 2nd covid vaccine per my doctor. I am still dealing w significant allergic reaxtion from my first vaccine. My allergist did blood work last week and my kidney levels are off.

Release 9 — 3 months, dose 1

2021-07-25

Symptoms: I tried to come off the medication I have been on since my reaction to the vacci on Aril 23. mid July. Within a few days, I was having severe auto immune issues. I went back on the medication and my system stabilized.

Release 10 — 6 months, dose 1

2021-10-24

Symptoms: Continued inflammation symtoms. Since my covid vaccine, I have had to take 10-40 mg of certrizine daily to mitigate my bodys reaction. I got my flu shot, and had a reaction and had to go to ER. I have never had an issue w the flu shot before.

Release 11 — 12 months, dose 1

2022-04-23

Symptoms: I have finally been diagnosed. The covid vaccine incident caused mast cell activation syndrome. To manage my symptoms, I have to tale 40 mg of certrizine each day....and I still have episodic flareups at times. I was healthy before the vaccine. cut off by CDC

Each entry is dated by the survey it was written in (the CDC re-sent the releases with survey dates in 2025); click a date to see that survey response. The CDC cut some text off at about 250 characters: symptoms in every release, and the other two fields in releases 9-12. Those entries are marked "cut off by CDC".

MedDRA terms by release

Field	Preferred term	2021-09	2023-04	2024-11
HCVO	Office visit	✓	✓	✓
SD	Adverse reaction	·	·	✓
SD	Anaphylactic shock	✓	✓	✓
SD	Anaphylaxis treatment	✓	✓	✓
SD	Condition aggravated	✓	·	✓
SD	Emergency care	✓	✓	✓
SD	Flushing	✓	✓	✓
SD	Hypersensitivity	✓	✓	✓
SD	Immune-mediated adverse reaction	✓	✓	✓
SD	Immunisation reaction	·	·	✓
SD	Inflammation	·	·	✓
SD	Mast cell activation syndrome	·	·	✓
SD	Ocular hyperaemia	✓	✓	✓
SD	Pre-existing disease	✓	·	✓
SD	Pruritus	✓	✓	✓
SD	Rash	✓	✓	✓
SD	Visual impairment	✓	✓	✓

✓ active code · ○ coded but marked inactive · blank = not in that release