Impact of the COVID-19 pandemic on admissions of deceased to an institute of legal medicine in Germany

Abstract

All over the world, the COVID-19 pandemic has impacted mortality beyond deaths that can be directly attributed to the viral disease. This study investigates the effects of the pandemic on admissions of deceased to a large institute of legal medicine and metropolitan morgue in Germany. Employing statistical models, the general time trend was separated from the effect of the pandemic in terms of place of death, autopsy category, age and sex. In addition, the pandemic's impact on one of the structurally most important public health determinants, poverty, on numbers of admissions in different place of death categories was analyzed. We find that the pandemic has caused a significant increase in admissions of those who died at residential addresses, which appears to be primarily driven by SARS-CoV-2 negative cases, and those who died in retirement and care facilities, with a significant overrepresentation of SARS-CoV-2 positive cases. A high degree of poverty in a neighborhood does not impact the likelihood to be admitted to the institute in those two categories before or during the pandemic. For dead bodies found in public spaces, however, a poverty variable causes a significant increase in the number of admissions during the pre-pandemic phase. Interestingly, this effect is reversed during the pandemic period. The number of admissions without an autopsy being ordered or requested increased significantly during the pandemic. Further, the COVID-19 pandemic caused a significant increase in admissions in the senile population. Our results indicate that the reluctance of treating physicians to conduct house calls to certify a death has persisted throughout the pandemic and has caused a surge of admissions of deceased to the institute of legal medicine without any criminological indications or subsequent rise in forensic autopsy orders.

Keywords: Autopsies; COVID-19 deaths; Germany; Legal medicine; Pandemic; Post mortem examination; Public health determinants.

Fig. 1

Admissions of deceased categorized by places of death from 2018 to mid-2023. (a) The monthly admissions to the Institute of Legal Medicine in Hamburg (left axis) are divided into 9 categories for places of death (see Data Collection). The mortality rate in the city-state of Hamburg (dashed line) is shown on the right axis. The pandemic phase according to the WHO definition (March 11, 2020 to May 5, 2023) is highlighted in a light-orange shade. (b) Percentages for each place of death category for admissions to the Institute of Legal Medicine are shown for the pre-pandemic phase (blue) and the pandemic phase (red). Missing values are marked as NA (not available).

Fig. 2

Admissions by place of death: How did the pandemic impact the trend? Predicted number of monthly admissions to the Institute of Legal Medicine categorized by place of death if the pandemic had never occurred (blue) or if the pandemic had already existed prior to the actual onset (red), analyzed in a Poisson regression using the number of monthly admissions in each category as the dependent variable and the respective month, the pandemic dummy variable and the multiplicative interaction term of both as independent variables. (a) Significant impact on category “residential address”: Increasing the value of the time variable by one standard deviation from its mean increases the number of predicted monthly admissions by 18.6% under the pandemic scenario, while we would have expected a decrease by 5.8% under a non-pandemic scenario. (b) Significant impact on category „retirement/care facility”: Increasing the value of the time variable by one standard deviation from its mean increases the number of predicted monthly admissions by 13.2% under the pandemic scenario, while we would have expected an increase by only 4.0% under a non-pandemic scenario. (c) Significant impact on category “public”: Increasing the value of the time variable by one standard deviation from its mean increases the number of predicted monthly admissions by 15.1% under the pandemic scenario, while we would have expected a decrease by 8.6% under a non-pandemic scenario. (d) For the category “University Medical Center”, a slightly significant positive impact of the pandemic on admissions can only be detected in the early phase of the pandemic, with trends converging over the course of the observation period.

Fig. 3

Admissions by place of death: What impact do structural variables such as poverty have? Predicted number of monthly admissions to the Institute of Legal Medicine categorized by place of death if the pandemic had never occurred (blue) or if the pandemic had already existed prior to the actual onset (red), analyzed in a multivariate Poisson regression using the number of monthly admissions in each category as the dependent variable and a poverty variable for the respective neighborhood, the pandemic dummy variable and the multiplicative interaction term of both as well as further structural variables (see Methods) as independent variables. We don’t see any effect of the poverty variable on the number of admissions in the categories “residential address” (a) and “retirement/care facility” (b). In the category “public” (c) a higher degree of poverty in a neighborhood leads to an increase in the expected number of admissions in a pre-pandemic situation, but not in a pandemic situation.

Fig. 4

Admissions of deceased by autopsy category from 2018 to mid-2023. (a) The monthly admissions to the Institute of Legal Medicine in Hamburg are divided into 6 autopsy categories as well as those admissions for which no autopsy is ordered and performed. The red line shows the number of monthly admissions with a confirmed post mortem SARS-CoV-2 infection. The pandemic phase according to the WHO definition (March 11, 2020 to May 5, 2023) is highlighted in a light-orange shade. (b) Percentages for each autopsy category are shown for the pre-pandemic phase (blue) and the pandemic phase (red).

Fig. 5

Percentages of admissions to the Institute of Legal Medicine divided into age categories prior to the pandemic (left column) as well as during the COVID-19 pandemic period (right column). Admissions in the 85 + age category were significantly overrepresented in the pandemic phase.

Fig. 6

Admissions by age category: How did the pandemic impact the trend? Predicted number of monthly admissions to the Institute of Legal Medicine categorized by age if the pandemic had never occurred (blue) and if the pandemic had already existed prior to the actual onset (red), analyzed in a Poisson regression using the number of monthly admissions in each category as the dependent variable and the respective month, the pandemic dummy variable and the multiplicative interaction term of both as independent variables. For admissions in the age categories 36 to 59 years (a) and 60 to 74 years (b), a significant impact of the pandemic cannot be distinguished from a general time trend. However, the pandemic had a significant impact on admissions in the age category 85 years and older (c). Increasing the value of the time variable by one standard deviation from its mean increases the number of predicted monthly admissions by 17.6% under the pandemic scenario, while we would have expected a decrease by 8.0% under a non-pandemic scenario.