The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology.

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Fear-related associations in children of parents with an anxiety disorder.

BACKGROUND AND OBJECTIVES: Children of parents with an anxiety disorder are at elevated risk for developing an anxiety disorder themselves. According to cognitive theories, a possible risk factor is the development of schema-related associations. This study is the first to investigate whether children of anxious parents display fear-related associations and whether these associations relate to parental anxiety. METHODS: 44 children of parents with panic disorder, 27 children of parents with social anxiety disorder, and 84 children of parents without an anxiety disorder filled out the SCARED-71, and the children performed an Affective Priming Task. RESULTS: We found partial evidence for disorder-specificity: When the primes were related to their parent's disorder and the targets were negative, the children of parents with panic disorder and children of parents with social anxiety disorder showed the lowest error rates related to their parents' disorder, but they did not have faster responses. We did not find any evidence for the expected specificity in the relationship between the parents' or the children's self-reported anxiety and the children's fear-related associations, as measured with the APT. LIMITATIONS: Reliability of the Affective Priming Task was moderate, and power was low for finding small interaction effects. CONCLUSIONS: Whereas clearly more research is needed, our results suggest that negative associations may qualify as a possible vulnerability factor for children of parents with an anxiety disorder.

Interpretation biases in childhood spider fear: Content-specificity, priming, and avoidance.

BACKGROUND AND OBJECTIVES: The relation between fear and interpretation bias has been widely studied in children. However, much less is known about its content-specificity and how interpretation biases predict variance in avoidance. The current study examined different interpretation bias tasks, the role of priming and the ability of the interpretation bias tasks to predict spider fear-related avoidance behaviour. METHODS: 169 children with varying levels of spider fear performed a behavioural avoidance task, two versions of the Ambiguous Scenarios Task (AST; with and without priming), and a size and distance estimation task. RESULTS: Both versions of the AST and the size-estimation were significantly related to self-reported spider fear and avoidance. These relations were content-specific: children with higher levels of spider fear had a more negative interpretation bias related to spider-related materials than to other materials, and a more negative bias than children with lower levels of spider fear. Furthermore, self-reported spider fear, the AST with priming, and the size-estimation predicted unique variance in avoidance behaviour. LIMITATIONS: Children varied in their level of spider fear, but clinical diagnoses of spider phobia were not assessed. The participants of this study were not randomly selected, they were children of parents with panic disorder or social anxiety disorder or no anxiety disorder and could therefore partly be seen as children at risk. CONCLUSIONS: The results support cognitive models of childhood anxiety and indicate that both controlled and automatic processes play an important role in fear-related behaviour.

Intergenerational relations in childhood anxiety: A network approach.

OBJECTIVE: Family factors are assumed to play a central role in the development of childhood anxiety disorders. How child and parental anxiety symptoms are intertwined on a symptom and family level has not yet been examined. Such knowledge may lead to a more detailed understanding of the intergenerational relation in anxiety problems. The current study investigated the relation between anxiety in children and their parents at a symptom level using a network approach. METHOD: Parents of 1,452 clinically referred children in the Netherlands completed questionnaires on anxiety about their children and themselves. We examined relations on a symptom level both within persons and between parents and children. In addition, we also compared the relations between parental and child anxiety symptoms in families with children with an anxiety disorder (n = 350) versus families with children who displayed other psychiatric diagnoses (n = 1,102). RESULTS: Anxiety symptom relations within persons were more intertwined than the symptom relations between family members. Between-person relations were found among similar anxiety symptoms, suggesting specific intergenerational relations. The feeling of being fearful was found to be a central and connecting symptom in all family members (fathers, mothers, and children). The relations between parental and child anxiety symptoms were more specific (i.e., among similar symptoms) in families with children with an anxiety disorder than in families with children with other types of psychopathologies. CONCLUSIONS: This study found that anxiety symptom associations are present within the family on a detailed (symptom) level. This stresses the importance of future studies to examine factors responsible for this family-anxiety transmission.

Sources of stress among domestic and international students: a cross-sectional study of university students in Amsterdam, The Netherlands.

High perceived stress is associated with psychological and academic difficulties among college students. In this study, we aimed to investigate associations of student status (international vs domestic student in the Netherlands) with eight common sources of stress (i.e., financial, health, love life, relationship with family, relationship with people at work/ school, the health of loved ones, other problems of loved ones, and life in general). Participants were 2,196 college students (domestic: n = 1,642, international: n = 554) from two universities in Amsterdam, the Netherlands. Hierarchical linear regression analyses were used to estimate associations of student status with all eight sources of stress. Student status was significantly associated with higher levels of perceived stress in almost all life domains. International student status was significantly associated with higher perceived stress in the domains of financial situation and health of loved ones after adjusting for sociodemographic characteristics, depressive and anxiety symptoms, and other sources of stress. Findings highlight that several differences exist in the magnitude of perceived stress in certain areas between international and domestic students in the Netherlands. Consequently, it is essential to uncover the different needs of college students and develop specific strategies to deliver the most suitable services.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students.

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

Emotional and social loneliness and their unique links with social isolation, depression and anxiety.

BACKGROUND: Loneliness and social isolation are known to be associated with depression, general anxiety, and social anxiety. However, knowledge on the overlapping and unique features of these relationships, while differentiating between social loneliness (perceived absence of an acceptable social network) and emotional loneliness (perceived absence of close connections), is lacking. METHODS: We constructed a network analysis to examine the relationships between self-reported social loneliness, emotional loneliness, social isolation, depression, general anxiety and social anxiety in a large sample of university students (N = 7314, 67.4 % female, range 16.3-75.8 years, Mage = 23.9, SDage = 5.7). Hierarchical regression analyses were used to examine whether depression, general anxiety and social anxiety moderated the relationship between social isolation and loneliness types. As comorbidity between anxiety and depression is high, the role of anxiety as a moderator in the relationship between depression and loneliness types was also examined. RESULTS: The network analysis showed that social loneliness was most strongly explained by social isolation, whereas emotional loneliness was most strongly explained by social anxiety and depression. General anxiety was solely related to loneliness through depression. The regression analyses showed that general and social anxiety and depression did not moderate the relationship between social isolation and loneliness types. LIMITATIONS: Differences found between loneliness types may be influenced by a methodological artifact of the DJGLS. CONCLUSIONS: These findings highlight the importance of social anxiety over general anxiety in relation to loneliness. Also, it showed unique relationships for social- and emotional loneliness with psycho-social variables, which has important implications for research- and clinical settings.

The Role of Distorted Cognitions in Mediating Treatment Outcome in Children with Social Anxiety Disorder: A Preliminary Study.

This study examined whether distorted cognition changes during cognitive behavioural therapy (CBT) in children (N = 61; aged 7-12) with social anxiety disorder (SAD) and whether changes in distorted cognition from pre- to post-treatment predict SAD at 6-month follow-up. Baseline distorted cognition was also examined as a predictor of post-treatment outcome. Multiple informant SAD-measures were obtained pre-treatment, post-treatment and at 6-month follow-up. Children reported on interpretation bias and dysfunctional beliefs. A decrease in interpretation bias and dysfunctional beliefs was prospectively related to greater SAD change between post-treatment and 6-month follow-up. Child-reported SAD-change at post-treatment predicted greater change in dysfunctional beliefs at 6-month follow-up. Higher baseline interpretation bias predicted greater change in SAD-severity at post-treatment. Children with greater distorted cognition reductions during treatment, showed greater treatment gains at 6-month follow-up. Children who do not show this reduction may require additional efforts focused on distorted cognition to maximally benefit from treatment.

Facing Uncertainty: Interpretation of Ambiguous Emotional Faces in Childhood Social Anxiety Disorder.

OBJECTIVE: The current study examined whether children with a social anxiety disorder (SAD) demonstrate divergent facial emotion processing and a disorder-specific negative interpretation bias in the processing of facial emotional expressions. This study aimed to overcome previous study limitations by including both a nonsocially anxious control group and a healthy control group to examine whether childhood SAD is characterized by a general emotion labeling deficit, and/or by a negative interpretation bias, indicated by systematic misclassifications, or a lower threshold for recognizing threatening emotions. METHOD: Participants were 132 children aged 7-12 years (Mage = 9.15; 45.5% female). Children with SAD (n = 42) were compared to children with other, nonsocial, anxiety disorders (n = 40) and healthy control children (n = 50) on a novel facial emotion recognition task. Children judged ambiguous happy/neutral, angry/neutral and fear/neutral faces that were morphed at different intensities (10%, 30%, 50%, 70%). RESULTS: Children with SAD did not differ from other groups in their accuracy of identifying emotions. They did not show systematic misclassifications or a heightened sensitivity to negative, threatening faces either. Rather, children with nonsocial anxiety disorders showed a generally heightened sensitivity to emotional faces. CONCLUSIONS: The current study does not provide evidence for a general deficit in labeling of emotional faces in childhood SAD. Childhood SAD was not characterized by an interpretation bias in processing emotional faces. Children with nonsocial anxiety disorders may benefit from assistance in accurately interpreting the degree of emotionality in interpersonal situations.

Guided internet-based transdiagnostic individually tailored Cognitive Behavioral Therapy for symptoms of depression and/or anxiety in college students: A randomized controlled trial.

Common mental disorders, such as depression and anxiety, often emerge in college students during the transition into early adulthood. Mental health problems can seriously impact students' functioning, interpersonal relationships, and academic achievement. Actively reaching out to college students with mental health problems and offering them internet-based interventions may be a promising way of providing low-threshold access to evidence-based treatment in colleges. This randomized controlled trial aimed to assess the effectiveness of a guided web-based transdiagnostic individually tailored Cognitive Behavioral Therapy (iCBT) in treating college students with depression and/or anxiety symptoms. Through an online survey that screened college students' mental health, we recruited 100 college students aged ≥18 years who reported mild to moderate depression and/or anxiety symptoms and were attending colleges in the Netherlands. Participants were randomly allocated to guided iCBT (n = 48) or treatment as usual (TAU) control (n = 52). Primary outcomes were symptoms of depression and anxiety measured at post-treatment (7 weeks post-randomization). We also measured all outcomes at 6- and 12-months post-randomization. All analyses were based on the intention-to-treat principle and were repeated using the complete-case sample. We found no evidence of a difference between the effects of guided iCBT and TAU in any of the examined outcomes (i.e., symptoms of depression and anxiety, quality of life, educational achievement, and college dropout) across all time points (p > .05). There was no evidence that effects of iCBT were associated with treatment satisfaction and adherence. More research into transdiagnostic individually tailored iCBT is necessary. Further, future studies should recruit larger samples to investigate possible smaller but clinically relevant effects of internet-based interventions for college students with depression and/or anxiety.

Specificity of Dysfunctional Beliefs in Children with Social Anxiety Disorder: Effects of Comorbidity.

Objective: This study examined the content-specificity of dysfunctional social beliefs to Social Anxiety Disorder (SoAD) in a large, clinically referred sample of children with a variety of anxiety, mood and externalizing disorders. The effects of comorbidity on the content-specificity of dysfunctional social beliefs were examined.Method: Participants included 912 children aged 7-12 years (Mage = 9.15; 45.5% female) who presented at a specialized clinic for assessment and treatment of anxiety disorders. Children with SoAD were compared to children with nonsocial anxiety disorders, children with SoAD and mood disorders, and children with SoAD and externalizing disorders, on self-reported dysfunctional social threat beliefs, physical threat, hostility, and personal failure beliefs.Results: Children with SoAD endorsed significantly higher levels of dysfunctional social threat beliefs when compared to children with nonsocial anxiety disorders. However, children with SoAD and mood comorbidity scored significantly higher on dysfunctional social beliefs than all other groups.Conclusions: Results suggest that within childhood anxiety disorders, dysfunctional social beliefs are content-specific for SoAD. Externalizing comorbidity does not seem to change the level of dysfunctional social beliefs in this group. However, mood comorbidity leads to endorsement of higher levels of dysfunctional social beliefs. These results provide support for, and refine, the content-specificity hypothesis and highlight the importance of taking comorbidity into account when examining and treating dysfunctional beliefs in youth.

COVID-19 and mental health among at-risk university students: A prospective study into risk and protective factors.

OBJECTIVE: The COVID-19 pandemic has confronted young adults with an unprecedented mental health challenge. Yet, prospective studies examining protective factors are limited. METHODS: In the present study, we focused on changes in mental health in a large sample (N = 685) of at-risk university students, which were measured before and during the pandemic. Network modeling was applied to 20 measured variables to explore intercorrelations between mental health factors, and to identify risk and protective factors. Latent change score modeling was used on a subset of variables. RESULTS: The main findings indicate that (1) mental health problems increased at group level, especially depression-anxiety and loneliness; (2) emotional support during the COVID pandemic was associated with smaller increases in loneliness and depression-anxiety; (3) COVID-related stress predicted increases in depression-anxiety; (4) loneliness acted as a bridge construct between emotional support and changes in mental health. CONCLUSION: To mitigate the impact of the COVID-19 pandemic on the mental health of young adults, is it recommended to focus on interventions that strengthen internal resources (stress-regulating abilities) and reduce loneliness.

Online computer or therapist-guided cognitive behavioral therapy in university students with anxiety and/or depression: study protocol of a randomised controlled trial.

INTRODUCTION: Emerging adulthood is a phase in life that is associated with an increased risk to develop a variety of mental health disorders including anxiety and depression. However, less than 25% of university students receive professional help for their mental health reports. Internet-based cognitive behavioural therapy (iCBT) may entail useful interventions in a format that is attractive for university students. The aim of this study protocol is to test the effectiveness of a therapist-guided versus a computer-guided transdiagnostic iCBT programme with a main focus on anxiety and depression. METHODS AND ANALYSIS: University students with anxiety and/or depressive symptoms will be randomised to a (1) 7-week iCBT programme (excluding booster session) with therapist feedback, (2) the identical iCBT programme with computer feedback only or (3) care as usual. Participants in the care as usual condition are informed and referred to conventional care services and encouraged to seek the help they need. Primary outcome variables are self-reported levels of anxiety as measured with the General Anxiety Disorder-7 and self-reported levels of depression as measured with the Patient Health Questionnaire-9. Secondary outcomes include treatment adherence, client satisfaction, medical service use, substance use, quality of life and academic achievement. Assessments will take place at baseline (t1), midtreatment (t2), post-treatment (t3), at 6 months (t4) and 12 months (t5) postbaseline. Social anxiety and perfectionism are included as potentially important predictors of treatment outcome. Power calculations are based on a 3 (group) × 3 (measurement: pretreatment, midtreatment and post-treatment) interaction, resulting in an aimed sample of 276 participants. Data will be analysed based on intention-to-treat and per protocol samples using mixed linear models. ETHICS AND DISSEMINATION: The current study was approved by the Medical Ethics Review Committee (METC) of the Academic Medical Centre, Amsterdam, The Netherlands (number: NL64929.018.18). Results of this trial will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NL7328.

The Associations of Common Psychological Problems With Mental Disorders Among College Students.

Psychological problems like procrastination, perfectionism, low self-esteem, test anxiety and stress are common among college students. There are evidence-based interventions available for these problems that not only have direct effects on these problems, but also indirect effects on mental disorders such as depression and anxiety disorders. Targeting these psychological problems may offer new opportunities to prevent and treat mental disorders in a way that is less stigmatizing to students. In this study we examined the association of five psychological problems with five common mental disorders (panic, generalized anxiety, bipolar, major depressive, and substance use disorder) in a sample of 2,449 students from two Dutch universities. Psychological problems were measured with one item for each problem and mental disorders were measured with the Composite International Diagnostic Interview Screening Scales. Associations were examined with Poisson regression models as relative risks (RR) of the disorders as a function of the psychological problems. The population attributable fraction (PAF) indicates by what percentage the prevalence of the mental disorder would be reduced if the psychological problem was addressed successfully by an intervention. Especially generalized anxiety disorder was strongly associated with psychological problems (strong associations with stress and low self-esteem and moderately with test anxiety). The group with three or more psychological problems had a strongly increased risk for generalized anxiety (RR = 11.25; 95% CI: 7.51-16.85), and a moderately increase risk for major depression (RR = 3.22; 95% CI: 2.63-3.95), panic disorder (RR = 3.19; 95% CI: 1.96-5.20) and bipolar disorder (RR = 3.66; 95% CI: 2.40-5.58). The PAFs for having any of the psychological problems (one or more) were considerable, especially for generalized anxiety (60.8%), but also for panic disorder (35.1%), bipolar disorder (30.6%) and major depression (34.0%). We conclude that common psychological problems are associated with mental disorders and with each other. After adjustment, psychological problems are associated with different patterns of mental disorders. If the impact of the psychological problems could be taken away, the prevalence of several mental disorders would be reduced considerably. The psychological problems may provide a promising target to indirectly prevent and intervene in psychopathology in hard to reach college students with mental disorders.

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

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.

The Role of Social Skills in Predicting Treatment-Recovery in Children with a Social Anxiety Disorder.

The current study investigated the role of social skills and its interaction with social anxiety as predictors of treatment outcome in children with an anxiety disorder either with or without a social anxiety disorder (SoAD). In total, 133 children (aged 8 to 13) with an anxiety disorder received a 10-session cognitive behavioral treatment (FRIENDS program). Pre- to post treatment Reliable Change (RC) and Treatment-Recovery (TR) were assessed from a multi-informant perspective, by including diagnostic information (ADIS C/P), child-reported anxiety symptoms (MASC) and parent-reported internalizing symptoms (CBCL-Int). Social skills were assessed with the parent-rated Social Skills Rating System (assertion, self-control, responsibility). Results showed that 1) parents of children with a SoAD reported significantly less favorable use of assertive and responsible social behavior in their children pre-treatment than parents of children without SoAD, 2) children with higher social skills had a better treatment recovery, and 3) children with anxiety and higher responsible behavior pre-treatment and without a SoAD had a better treatment recovery, but this effect did not show for children with SoAD. In conclusion, better use of social behavior increased the likelihood of treatment recovery but not of reliable change. Further studies on the role of social skills in the treatment of childhood (social) anxiety are needed to investigate the mechanisms by which social skills impact treatment outcome.

Prospective associations between social status and social anxiety in early adolescence.

This study examined the transactional longitudinal association between social status (likeability and popularity) and social anxiety symptoms (fear of negative evaluation and social avoidance and distress), and explored gender differences in this association. Participants included 274 adolescents (136 boys, Mage  = 12.55). Data were collected at two waves with a 6-month interval. Likeability and popularity were measured with peer nominations and social anxiety symptoms with self-reports. Autoregressive cross-lagged path models showed relative stability of social status and social anxiety. Girls who were seen as less popular by their classmates avoided social situations more frequently and experienced more distress during such situations over time. These results highlight the importance of distinguishing between different social status components and social anxiety symptoms and to take gender into account. Early support for less popular girls seems important to prevent more severe consequences of avoidance and distress, such as social exclusion and victimization.

[SARS-CoV­2 incidental findings among Hamburg deaths: an epidemiological monitoring during the dynamic infection event in spring 2020]. / SARS-CoV­2-Zufallsentdeckungen bei Hamburger Todesfällen: ein epidemiologisches Monitoring während des dynamischen Infektionsgeschehens im Frühjahr 2020.

Background: In the context of the COVID-19-pandemic, mortality and incidence are key determinants to assess the transmission dynamics and the resulting potential threat. Systematic microbiological monitoring of deaths provides a fundamental basis to particularly assess underrecording of community-acquired mortality. It should be further elucidated whether a death cohort of previously unreported cases may be structurally different from the cohort of officially registered cases. Methods: A systematic reverse transcription (RT) qPCR testing for SARS-CoV­2 infections from nasopharyngeal swab samples was carried out. A representative sample of corpses from crematoria and the Institute of Legal Medicine of the Federal State of Hamburg were included. A comparative analysis of primarily reported and unreported fatalities in an 8­week period after occurrence of the first pandemic-related deaths in Hamburg was performed. Results: A total of 1231 deaths were included, all of which were previously unsuspicious for SARS-CoV­2 infection. Thereof 29 cases of previously unknown infections were recorded. In the first phase of the pandemic, incidental findings predominantly occurred among younger people from domestic environments with unclear or unnatural manner of death at the Institute of Legal Medicine. Over time, incidental findings investigated at the crematoria increased, mostly related to nursing home residents. The overall cohort showed no significant sociodemographic differences to a comparative collective of known SARS-CoV­2-associated deaths. Primarily unreported cases showed a significantly lower proportion of COVID-19 as the underlying cause of death. Conclusion: A systematic PCR-based monitoring of deaths allows a more targeted detection and classification of SARS-CoV­2 positive cases. A preventive contribution can be made by disclosing unreported pandemic-related cases of death.

Deaths associated with newly launched SARS-CoV-2 vaccination (Comirnaty®).

Since 27th December 2020, a mRNA vaccine from BioNTech / Pfizer (Comirnaty®) has been used across Germany. As of 12th March 2021, 286 fatalities of vaccinated German individuals were registered at the Paul-Ehrlich-Institute with time intervals after vaccination between one hour to 40 days. From our catchment area in northern Germany, we have so far become aware of 22 deaths in connection with vaccination in a 5 week period (range: 0-28 days after vaccination). Three death cases after vaccination with Comirnaty®, which were autopsied at the Institute of Legal Medicine Hamburg, are presented in more detail. All three deceased had severe cardiovascular diseases, among other comorbidities, and died in the context of these pre-existing conditions, while one case developed a COVID-19 pneumonia as cause of death. Taking into account the results of the postmortem examination a causal relation between the vaccination and the death was not established in any case. If there are indications of an allergic reaction, histological and postmortem laboratory examinations should be performed subsequent to the autopsy (tryptase, total IgE, CRP, interleukin-6, complement activity C3/C5).