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Associations Between Blood Type and COVID-19 Infection, Intubation, and Death ✉ Michael Zietz 1, Jason Zucker2 & Nicholas P

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Associations Between Blood Type and COVID-19 Infection, Intubation, and Death ✉ Michael Zietz 1, Jason Zucker2 & Nicholas P ARTICLE https://doi.org/10.1038/s41467-020-19623-x OPEN Associations between blood type and COVID-19 infection, intubation, and death ✉ Michael Zietz 1, Jason Zucker2 & Nicholas P. Tatonetti 1,2,3,4 The rapid global spread of the novel coronavirus SARS-CoV-2 has strained healthcare and testing resources, making the identification and prioritization of individuals most at-risk a critical challenge. Recent evidence suggests blood type may affect risk of severe COVID-19. 1234567890():,; Here, we use observational healthcare data on 14,112 individuals tested for SARS-CoV-2 with known blood type in the New York Presbyterian (NYP) hospital system to assess the association between ABO and Rh blood types and infection, intubation, and death. We find slightly increased infection prevalence among non-O types. Risk of intubation was decreased among A and increased among AB and B types, compared with type O, while risk of death was increased for type AB and decreased for types A and B. We estimate Rh-negative blood type to have a protective effect for all three outcomes. Our results add to the growing body of evidence suggesting blood type may play a role in COVID-19. 1 Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, NY, USA. 2 Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA. 3 Department of Systems Biology, Columbia University Irving Medical Center, New York, NY, USA. 4 Institute for ✉ Genomic Medicine, Columbia University Irving Medical Center, New York, NY, USA. email: [email protected] NATURE COMMUNICATIONS | (2020) 11:5761 | https://doi.org/10.1038/s41467-020-19623-x | www.nature.com/naturecommunications 1 ARTICLE NATURE COMMUNICATIONS | https://doi.org/10.1038/s41467-020-19623-x he novel Coronavirus disease (COVID-19, caused by the Rh(D) phenotypes (positive and negative Rh blood types) are SARS-CoV-2 virus) has spread rapidly across the globe and associated with very few diseases compared to ABO49. Like ABO, T fi has caused over 21.1 million con rmed infections and over Rh type is important for type compatibility and immune 761,000 deaths worldwide as of August 17, 20201. Within the response. For example, hemolytic disease of the newborn is a United States, New York suffered among the worst outbreaks concern when Rh(D) is mismatched between mother and off- during the early phases of the pandemic. As of August 22, New spring50. Other studies have found evidence that Rh-positive York City has recorded 228,144 confirmed infections and 19,014 individuals are protected against the effects of latent tox- deaths2. A number of risk factors for COVID-19 morbidity and oplasmosis51, though Toxoplasma gondii is a eukaryotic para- mortality are known, including age, sex, smoking, hypertension, site52, not a virus like SARS-CoV-2. diabetes, and chronic cardiovascular and respiratory diseases3,4. In this study, we sought to understand the association between Recent work has demonstrated an association between ABO SARS-CoV-2 infection/COVID-19 and blood type using elec- blood types and COVID-19 risk. Using data from Wuhan and tronic health record (EHR) data from NewYork-Presbyterian/ Shenzhen, Zhao et al. found a greater proportion of A and a lower Columbia University Irving Medical Center (NYP/CUIMC) proportion of O blood types among COVID-19 patients, relative hospital in New York City, USA. We compared both ABO and Rh to the general populations of Wuhan and Shenzhen5. Similarly, (D) blood types, and we investigated initial infection status and using a meta-analysis of data from Italy and Spain, Ellinghaus two severe COVID-19 outcomes: intubation and death. We et al. found6 a higher risk of COVID-19 among A and a lower risk evaluated potential confounding due to population stratification among O blood types. Conversely, however, they estimated lower using a multivariate analysis, and we report clinically meaningful odds of mechanical ventilation for all non-O types, though the measures of effect. estimated odds ratios were not statistically significant at the 5% level for this outcome. Results The ABO blood type trait reflects polymorphisms within the Data collection and cohort selection. We determined blood ABO gene. This gene is associated with a number of other traits, types using laboratory measurements recorded in the NYP/ including risk factors for COVID-19 morbidity and mortality. For CUIMC EHR system. After removing likely errors, such as example, genome-wide association studies have associated var- individuals with contradictory blood-type results, we identified iants within ABO to activity of the angiotensin converting 14,112 adult individuals with known blood types who received at enzyme7, red blood cell count, hemoglobin concentration, – – least one SARS-CoV-2 swab test (Table 1 and Supplementary hematocrit8 11, von Willebrand factor12 15, myocardial – Fig. 1). We performed chi-squared tests of independence and infarction16,17, coronary artery disease17 21, ischemic – found insufficient evidence to conclude that the blood-group stroke13,19,22, type 2 diabetes23 25, and venous thromboembo- – frequencies differ between SARS-CoV-2-tested and non-tested lism26 33. A 2012 meta-analysis found that, in addition to indi- groups (Supplementary Table 1). Individuals were considered vidual variants, a non-O blood type is among the most important initially SARS-CoV-2-positive (COV+) if they tested positive on genetic risk factors for venous thromboembolism34. These con- their first recorded test or within the following 96 h. We evaluated ditions are also relevant for COVID-19. For example, coagulo- – associations between blood types and outcomes using three pathy is a common issue for COVID-19 patients35 41, and risk of comparisons: infection prevalence among initial tests and survival venous thromboembolism must be carefully managed42. analysis for intubation and death among individuals with infec- The numerous associations between conditions and both blood tions confirmed by the swab test. We report on clinical data as of type and COVID-19 provide reason to believe that true associa- August 1, 2020. tions may exist between blood type and morbidity and mortality due to COVID-19. In addition, previous work has identified associations between ABO blood groups and a number of dif- Infection prevalence. The unadjusted prevalence of initial ferent infections or disease severity following infections, including infection was higher among A and B blood types and lower SARS-CoV-143, P. falciparum44, H. pylori45, Norwalk virus46, among AB types, compared with type O (Table 2 and Fig. 1). To hepatitis B virus47, and N. gonorrhoeae48. avoid bias with respect to healthcare utilization, length of hospital Table 1 Summary demographics for SARS-CoV-2-tested individuals at NYP/CUIMC, stratified by blood type. A AB B O Rh neg Rh pos N 4298 (32.9) 559 (4.3) 2033 (15.6) 6161 (47.2) 1195 (9.2) 11,856 (90.8) Age (IQR) 58 (37–72) 57 (37–71) 57 (37–72) 55 (36–71) 56 (37–70) 56 (37–71) Male (%) 1676 (39.0) 231 (41.3) 778 (38.3) 2339 (38.0) 430 (36.0) 4594 (38.7) Hispanic (%) 1572 (36.6) 173 (30.9) 666 (32.8) 2583 (41.9) 389 (32.6) 4605 (38.8) Race Asian (%) 71 (1.7) 21 (3.8) 89 (4.4) 123 (2.0) 16 (1.3) 288 (2.4) Black (%) 629 (14.6) 95 (17.0) 493 (24.2) 1179 (19.1) 151 (12.6) 2245 (18.9) Missing (%) 728 (16.9) 79 (14.1) 370 (18.2) 1093 (17.7) 192 (16.1) 2078 (17.5) Other (%) 1085 (25.2) 132 (23.6) 464 (22.8) 1715 (27.8) 263 (22.0) 3133 (26.4) White (%) 1785 (41.5) 232 (41.5) 617 (30.3) 2051 (33.3) 573 (47.9) 4112 (34.7) Outcomes Initially COV+ (%) 754 (17.5) 88 (15.7) 363 (17.9) 1060 (17.2) 164 (13.7) 2101 (17.7) COV+ (%) 786 (18.3) 94 (16.8) 392 (19.3) 1122 (18.2) 175 (14.6) 2219 (18.7) COV+ Intubated (%) 111 (2.6) 17 (3.0) 78 (3.8) 193 (3.1) 24 (2.0) 375 (3.2) COV+ Died (%) 104 (2.4) 15 (2.7) 46 (2.3) 166 (2.7) 11 (0.9) 320 (2.7) N is the number of individuals having the given blood type who had at least one recorded test for SARS-CoV-2. Age is reported as the median and interquartile range (25–75). Percents are reported relative to individuals having the blood type, except the N row, where percents are by blood-group type (ABO or Rh) and are relative to all individuals in the study. 2 NATURE COMMUNICATIONS | (2020) 11:5761 | https://doi.org/10.1038/s41467-020-19623-x | www.nature.com/naturecommunications NATURE COMMUNICATIONS | https://doi.org/10.1038/s41467-020-19623-x ARTICLE Table 2 Effect size estimates for blood types with and without correction for race and ethnicity. Unadjusted Race and ethnicity adjusted Outcome Blood type Risk Risk difference Risk ratio Risk Risk difference Risk ratio Prevalence A 17.5 (16.3–18.8) 0.3 (−1.2–1.9) 1.02 (0.93–1.12) 18.0 (16.8–19.2) 1.3 (−0.3–3.0) 1.08 (0.98–1.19) AB 15.7 (12.8–18.7) −1.5 (−4.5–1.7) 0.91 (0.74–1.10) 16.8 (13.9–19.8) 0.1 (−2.8–3.2) 1.01 (0.83–1.20) B 17.9 (16.1–19.5) 0.7 (−1.4–2.6) 1.04 (0.92–1.16) 18.0 (16.3–19.7) 1.3 (−0.7–3.3) 1.08 (0.96–1.20) O 17.2 (16.2–18.1) Reference Reference 16.7 (15.7–17.6) Reference Reference Rh pos 17.7 (17.0–18.4) Reference Reference 17.6 (16.9–18.3) Reference Reference Rh neg 13.7 (11.8–15.5) −4.0 (−6.1 to −2.0) 0.77 (0.66–0.88) 14.9 (13.0–16.8) −2.7 (−4.7 to −0.8) 0.85 (0.73–0.96) Intubation A 17.2 (14.2–20.1) −3.2 (−7.5–0.3) 0.84 (0.66–1.02) 17.3 (14.3–20.4) −2.9 (−7.2–0.6) 0.85 (0.68–1.03) AB 21.8 (12.3–31.7) 1.4 (−8.5–11.6) 1.07 (0.59–1.57) 22.1 (12.8–32.1) 1.8 (−8.3–12.2) 1.09 (0.60–1.59) B 22.9 (18.6–27.6) 2.5 (−2.5–7.6) 1.12 (0.89–1.40) 22.8 (18.6–27.5) 2.5 (−2.7–7.5) 1.12 (0.88–1.40) O 20.4
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