Prospective postmortem evaluation of 735 consecutive SARS-CoV-2-associated death cases

Abstract

Coronavirus disease 19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic with significant mortality. Accurate information on the specific circumstances of death and whether patients died from or with SARS-CoV-2 is scarce. To distinguish COVID-19 from non-COVID-19 deaths, we performed a systematic review of 735 SARS-CoV-2-associated deaths in Hamburg, Germany, from March to December 2020, using conventional autopsy, ultrasound-guided minimally invasive autopsy, postmortem computed tomography and medical records. Statistical analyses including multiple logistic regression were used to compare both cohorts. 84.1% (n = 618) were classified as COVID-19 deaths, 6.4% (n = 47) as non-COVID-19 deaths, 9.5% (n = 70) remained unclear. Median age of COVID-19 deaths was 83.0 years, 54.4% were male. In the autopsy group (n = 283), the majority died of pneumonia and/or diffuse alveolar damage (73.6%; n = 187). Thromboses were found in 39.2% (n = 62/158 cases), pulmonary embolism in 22.1% (n = 56/253 cases). In 2020, annual mortality in Hamburg was about 5.5% higher than in the previous 20 years, of which 3.4% (n = 618) represented COVID-19 deaths. Our study highlights the need for mortality surveillance and postmortem examinations. The vast majority of individuals who died directly from SARS-CoV-2 infection were of advanced age and had multiple comorbidities.

Figure 1

Reported SARS-CoV-2 associated deaths per day by the Robert Koch Institute (RKI) in grey scales versus the reported COVID-19 deaths per day by the Institute of Legal Medicine (ILM) Hamburg in blue scales.

Figure 2

Number of deaths in general in Hamburg. Top: comparison of the monthly number of deaths in 2020 with the monthly average of 2016–2019, displayed with 95% confidence interval (CI) of the mean, blue dots for 2020 numbers within and red dots outside this CI. Bottom: comparison of the annual number of deaths between 2000 and 2019 with 99% CI of the mean as greyish dotted lines and the total number for 2020 with 18,417 fatalities in dotted blue line. Underlying data was available at the Federal Statistical Office Germany (DESTATIS).

Figure 3

Flow chart of SARS-CoV-2 associated death evaluation at the ILM. This flow chart depicts processes and steps for the evaluation of 735 SARS-CoV-2 associated deaths in cooperation with the Hamburg public health authority. After the evaluation process based on medical report, postmortem computed tomography (PMCT), ultrasound-guided minimally invasive autopsy (usMIA) and conventional autopsy, 618 deaths were classified as COVID-19 deaths, 47 deaths were non-COVID-19 deaths and 70 deaths remained unclear. am antemortem, pm postmortem, ILM Institute of Legal Medicine, RKI Robert Koch Institute; a multiple inclusion of one patient in the various categories possible.