Autopsy findings after SARS-CoV-2 vaccination: a German national registry study

Autopsies are the foundation of evidence-based medicine and gold standard for determining causes of death. A potential causal relationship between COVID-19 vaccination and death remains a subject of debate, however multidisciplinary, multicentric national autopsy studies are missing. N = 486 eligible SARS-CoV-2 vaccinated autopsy cases from 14 German pathology, neuropathology and legal medicine university centres between 2021 and 2024 were available via the German National Autopsy Registry. For comparison COVID-19 autopsies were included ( n = 385 cases, all performed before the vaccination campaign in Germany started). A previously established causality algorithm was applied in a consensus assessment of potential causality between vaccine administration and an adverse event following immunization (AEFI). N = 176 cases with a post vaccination interval ≤ 28d were included into analyses. In a single case of allergic reaction, in 5/8 cases of either myocarditis ( n = 4 cases) or perimyocarditis ( n = 1 case), and 9/26 cases of thromboembolism, the consensus process resulted in a potential AEFI in these cases, but no definite causality. In n = 3 cases in which the cause of death remained unclear after autopsy, no potential AEFI could be established. In SARS-CoV-2 positive autopsy cases without vaccination, thromboembolism was documented as cause of death in 18/385 cases and myocarditis in 2/385 cases. In conclusion, autopsies are a valuable tool to assess adverse effects. Currently, post vaccination autopsy numbers are too low to draw conclusions on the general population or to identify rare AEFI signals. As part of pandemic preparedness, international guidelines for post vaccination autopsy procedures, diagnostics and interpretation are necessary. Autopsy registries can support this collective effort.