COVID After Vaccine: Anecdotal Reporting


One of the issues that emergency physicians are interested in is how effective the vaccines are, especially with several variants that are emerging. 

If you have evaluated patients who have been fully vaccinated and now have presumed or confirmed COVID-19, please complete this form (it should take less than 2 minutes). A case is considered a vaccine breakthrough case when the patient is presumed or tested positive for COVID-19 more than two weeks after the completed vaccine series.

The data from your feedback will be used in aggregate to help inform additional resources and studies. 

In addition to filling out this short form, please culture the patient (RT-PCR) and have the lab send the specimen to your local health department marked "suspected vaccine breakthrough." 

This should help track geographic distribution of vaccine breakthroughs to discover trends in certain areas. It can take 3 to 6 weeks for samples to have genomic analysis, so the information you provide on this form can serve as an early alert system. 
 
 
 
 
 
 
 
Patient's age?
 
 
 
 
 
Patient's sex
 
Female
Male
Other
Transgender
 
 
 
 
State where patient was seen?
Or country if outside the United States
 
 
 
 
 
Which vaccine?
 
Pfizer (BNT162b2)
Moderna (MRNA-1273)
Janssen / Johnson & Johnson
AstraZeneca
Novavax
 
 
 
 
Number of shots?
 
Single Dose
First Dose
Second Dose
Third Dose
 
 
 
 
Approximate date of patient's last shot - MM/DD/YYYY
 
 
 
 
 
Date of COVID-19 symptom onset - MM/DD/YYYY
 
 
 
 
 
How was COVID diagnosed?
 
Confirmed by testing
Suspected from symptoms
 
 
 
 
What were the patient's primary symptoms? (check all that apply)
 
Fever
Cough
Fatigue
Body aches
Shortness of breath
None
Other
 
If "other" symptoms, please describe them.
 
 
 
 
 
What was the patient's disposition?
 
Discharged
Admitted
ICU
Still in ED
Deceased
Other - please describe
 
 
 
 
Is the patient a healthcare worker?
 
Yes
No
 
 
 
 
Does the patient have comorbidities or other risk factors?
 
Yes
No
 
 
 
 
Any other information that may be important to note: