Covid-19 vaccine and death: Causality algorithm according to the who eligibility diagnosis

Cristoforo Pomara, Francesco Sessa, Marcello Ciaccio, Francesco Dieli, Massimiliano Esposito, Giovanni Maurizio Giammanco, Sebastiano Fabio Garozzo, Antonino Giarratano, Daniele Prati, Francesca Rappa, Monica Salerno, Claudio Tripodo, Pier Mannuccio Mannucci, Paolo Zamboni

Research output: Contribution to journalArticlepeer-review


The current challenge worldwide is the administration of anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. Even if rarely, severe vascular adverse reactions temporally related to vaccine administration have induced diffidence in the population at large. In particular, researchers worldwide are focusing on the so-called “thrombosis and thrombocytopenia after COVID-19 vaccination”. This study aims to establish a practical workflow to define the relationship between adverse events following immunization (AEFI) and COVID-19 vaccination, following the basic framework of the World Health Organization (WHO). Post-mortem investigation plays a pivotal role to support this causality relationship when death occurs. To demonstrate the usefulness and feasibility of the proposed workflow, we applied it to two exemplificative cases of suspected AEFI following COVID-19 vaccination. Based on the proposed model, we took into consideration any possible causality relationship between COVID-19 vaccine administration and AEFI. This led us to conclude that vaccination with ChAdOx1 nCov-19 may cause the rare development of immune thrombocytopenia mediated by platelet-activating antibodies against platelet factor 4 (PF4), which clinically mimics heparin-induced autoimmune thrombocytopenia. We suggest the adoption of the proposed methodology in order to confirm or rule out a causal relationship between vaccination and the occurrence of AEFI.

Original languageEnglish
Article number955
Issue number6
Publication statusPublished - Jun 2021


  • Autopsy
  • COVID-19
  • Deep vein thrombosis
  • Disseminated intravascular coagulation
  • Immune thrombocytopenia
  • Post-mortem investigation
  • SARS-CoV-2
  • Standard protocol
  • Vaccination campaign
  • Vaccine

ASJC Scopus subject areas

  • Clinical Biochemistry


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