Keywords
COVID-19; vaccination status; blood groups; case fatality; risk factors.
This article is included in the Emerging Diseases and Outbreaks gateway.
This article is included in the Coronavirus (COVID-19) collection.
In response to the global cumulative reported case fatality ratio of COVID-19 following the detection of the severe acute respiratory syndrome coronavirus-2, governments and healthcare authorities worldwide have developed and distributed an impressive number of new COVID-19 vaccines. This study aimed to investigate the relationship between vaccination status and the outcomes of hospitalized COVID-19 patients. This study aimed to explore the association between vaccination status and the outcome of hospitalized COVID-19 patients.
A retrospective study was carried in Aseer Central Hospital, Abha City, Saudi Arabia. The study included all hospitalized COVID-19 patients (N = 606) admitted to the intensive care unit of Aseer Central Hospital with confirmed COVID-19 infection, who had their detailed personal characteristics, vaccination status, and confirmed outcome (i.e., survival or death) recorded.
On admission, 62.5% of the patients did not receive any vaccine doses against COVID-19, while 8.1% received one dose, 14.5% received two doses, and 14.9% received three doses. The condition of 51.3% of the patients was critical. Case fatality rates of included patients differed significantly according to their blood groups, received vaccine doses, gender, age groups, nationality, and among those who received intubation or BiPAP/CPAP masks (p<0.001 for all). There were significant odds ratios for patients’ vaccination status, health status on admission, and nationality (p<0.001 for all).
Vaccination against COVID-19 has a significant preventive impact on patients’ case fatality. Risk factors related to higher case fatalities among hospitalized COVID-19 patients including older age, non-Saudi, and being critically ill, should be considered in any future outbreaks or epidemics.
COVID-19; vaccination status; blood groups; case fatality; risk factors.
This revised version presents an improved and clarified analysis of the risk factors associated with COVID-19 fatality among hospitalized patients in Abha City, Saudi Arabia. Following peer review, substantial revisions were made to enhance the manuscript’s clarity, organization, and scientific quality. The English language and syntax were comprehensively edited by a field expert to ensure clear communication of the study’s findings.
The research design is now clearly identified as a retrospective observational analytic study. The Methods section was restructured into three components—sample description, variable measurements, and analytical models—to improve transparency and reproducibility. The data analysis was revised to clearly state the use of multivariate logistic regression, ensuring methodological consistency.
A new summary table of key results has been added to make the findings easier to interpret. The Introduction and Discussion were expanded to include up-to-date literature from 2023–2025, providing deeper theoretical context and connecting this study to global research on COVID-19 outcomes, vaccination, and public health preparedness.
The title and Abstract have been refined to specify the study location and highlight the main results and implications. The Discussion section now provides a critical comparison with previous studies, while the new Conclusion section is divided into theoretical, policy, and future research implications.
These revisions collectively improve the study’s readability, methodological rigor, and relevance for healthcare practitioners and policymakers. The authors appreciate the reviewers’ insightful feedback, which helped strengthen the contribution of this work to the understanding of COVID-19 fatality determinants and future pandemic preparedness in Saudi Arabia and similar settings.
To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table.
The coronavirus disease 2019 (COVID-19) marked the first time most of the world’s population experienced a pandemic (Dasgupta and Crunkhorn 2020). It has triggered an unprecedented wave of illness and death worldwide, impacting millions of lives and overwhelming healthcare systems (Liu and Lou 2022).
The overall reported case fatality rate of COVID-19 rose to 7.2% by the 17th epidemiological week after the detection of severe acute respiratory syndrome coronavirus-2 (Hasan et al. 2021). In response, governments and healthcare authorities worldwide have developed and distributed COVID-19 vaccines. Vaccination programs have been implemented as a key strategy to reduce virus transmission and lessen the disease’s impact (Stefanelli and Rezza 2022). Through various production platforms, many vaccine candidates have been in preclinical and clinical development. By early September 2022, more than two-thirds of the global population had received at least one dose of a COVID-19 vaccine (Briciu et al. 2023).
Several risk factors for developing COVID-19 in adults have been identified, ranging from demographic factors (e.g., older age, male sex) to the presence of underlying health conditions (e.g., diabetes) (Zhang et al. 2023). Sayli (2020) argued that understanding an association between blood group types and COVID-19 may assist in its management and treatment. Zhao et al. (2020) reported that blood type [A] is linked to a higher risk of COVID-19 infection and death, while blood type [O] is linked to a lower risk of infection and death. Similarly, Zietz, Zucker, and Tatonetti (2020) found that blood type [A] is associated with increased odds of testing positive for the disease.
Aruffo et al. (2022) noted that exploring the risk factors and the impact of vaccination on the overall case fatality rates is an important area of research. However, little research has examined vaccination effects in hospitalized populations, patients who typically have the most severe COVID-19 disease (Baker et al. 2023). However, there is still a paucity of data regarding the relationship between several risk factors, such as vaccination status, ABO blood typing, and the outcome of COVID-19 disease.
Relevant literature indicates that, while some strong predictors of higher case-fatality among hospitalized COVID-19 patients are well known (e.g., cardiorespiratory/renal disease, obesity, immunosuppression, and hospital strain), studies consistently find residual, unexplained variation in in-hospital death rates. That means there are likely unknown or unmeasured factors contributing to higher case-fatality rates (Chou et al. 2021; Bottle et al. 2022).
Therefore, the present study needs to answer the questions related to which factors are associated with higher case fatality rates among hospitalized COVID-19 cases, and if their vaccination status against COVID-19 is associated with their outcomes.
This is a single-center, retrospective study conducted at a tertiary care hospital in Abha City, Aseer Region, Saudi Arabia.
All adult COVID-19 cases (aged above 18 years) constituted the study population. The study sample included all hospitalized COVID-19 patients admitted to the intensive care unit of Aseer Central Hospital (ACH) during the period from January 2021 to October 2021 with COVID-19 infection for breathing/ventilation support, with recorded detailed vaccination status, and a confirmed outcome (i.e., survival or death) (N=606), while patients with missing data or those admitted to ACH before January 2021 were excluded (n=89).
All relevant data, e.g., personal characteristics, health status on admission to the intensive care unit (ICU), either stable or critical, vaccination status, and in-hospital mortality, were extracted from the study hospital’s electronic health records.
A data collection Excel sheet was developed by the researcher. It included the following variables:
• Independent variables: Patient’s age, gender, nationality, blood group, COVID-19 vaccination status, health status on admission (stable or critical), associated chronic comorbidity (e.g., diabetes or hypertension), and type of respiration support.
• Dependent variables: Patients’ outcomes on discharge.
All the necessary official permissions were fully secured before data collection. The Ethical Administrative Approval (#07 – ACH – 24) was obtained from the Institutional Review Board (IRB) at the Directorate of Health Affairs, Aseer Region, Ministry of Health, Kingdom of Saudi Arabia, on February 13th, 2024. The study did not include any identification data (e.g., patients’ names, hospital patient numbers, or ID), and the collected data were used only for research purposes.
The Statistical Package for Social Sciences (IBM, SPSS, Version 25) was used for the statistical analyses. Descriptive statistics (e.g., frequency and percentage) were applied. A univariate screen between vaccination status, blood group type, demographics, comorbidities, and the outcomes of interest was performed using the Chi-square (χ2) test. The multivariate logistic regression was performed for the intubation and death composite variable to study the odds of vaccination status, ABO blood groups, and other variables with 95% confidence intervals. P-values less than 0.05 were considered statistically significant.
The present study included 606 patients, of whom 352 (58.1%) were males. About one-third of patients (34.2%) were 41-50 years old, 44.9% were 51-60 years old, and only 6.3% were less than 40 years old. The majority of patients were Saudi (545, 89.9%). Almost one-fourth of the patients (24.6%) were smokers, while 27.7% were diabetic. Blood group [O] was the most prevalent type (48.5%), followed by blood group [A] (38.8%), and [B] (10.4%), while [AB] was the least prevalent (2.3%). On admission, 62.5% of the patients did not receive any vaccine doses against COVID-19, while 8.1% received one dose, 14.5% received two doses, and 14.9% received three doses. The condition of 51.3% of the patients was critical. Provided respiration assistance was mainly through intubation (45.2%), or oxygen mask (49.8%). On discharge, patients’ COVID-19-related case fatality was 53.1% ( Table 1).
Figure 1 shows that 53.1% of hospitalized COVID-19 patients died.
Patients’ case fatality was significantly higher among male patients (p<0.001). Patients’ case fatality differed according to their age groups (p<0.001), being significantly higher among older patients aged above 60 years. In addition, case fatality differed according to patients’ nationality (p<0.001), being significantly higher among non-Saudi patients. COVID-19 case fatality differed significantly according to patients’ ABO blood group types (p<0.001), being highest among blood group [O] patients (60.5%) and lowest among blood group B patients (33.3%). However, case fatality did not differ significantly according to patients’ Rh-factors. Patients’ case fatality differed according to their anti-COVID-19 vaccination status (p<0.001), being highest among unvaccinated patients. Case fatality was significantly higher among patients who were critically ill on admission (p<0.001), smokers (p=0.001), and those with associated chronic comorbidity (p=0.021). Moreover, patients’ case fatality was highest among those who received intubation or BiPAP/CPAP masks (96.7% and 83.3%, respectively, p<0.001) ( Table 2).
| Death | Survival | P | |
|---|---|---|---|
| Variables | No. (%) | No. (%) | Value |
| Gender | <0.001*** | ||
| • Male | 210 (59.7%) | 142 (40.3%) | |
| • Female | 112 (44.1%) | 142 (55.9%) | |
| Age groups | <0.001*** | ||
| • <40 years | 1 (2.6%) | 37 (97.4%) | |
| • 41-50 years | 44 (21.3%) | 163 (78.7%) | |
| • 51-60 years | 191 (70.2%) | 81 (29.8%) | |
| • >60 years | 86 (96.6%) | 3 (3.4%) | |
| Nationality | <0.001*** | ||
| • Saudi | 275 (50.6%) | 270 (49.5%) | |
| • Non-Saudi | 47 (77.0%) | 14 (23.0%) | |
| ABO blood types | <0.001*** | ||
| • O | 178 (60.5%) | 116 (39.5%) | |
| • A | 115 (48.9%) | 120 (51.1%) | |
| • B | 21 (33.3%) | 42 (66.7%) | |
| • AB | 8 (57.1%) | 6 (42.9%) | |
| Rh-factors | 0.449 | ||
| • Negative | 44 (49.4%) | 45 (50.6%) | |
| • Positive | 278 (53.8%) | 239 (46.2%) | |
| Vaccination status on admission | <0.001*** | ||
| • Not vaccinated | 305 (82.0%) | 67 (18.0%) | |
| • One dose | 9 (16.1%) | 47 (83.9%) | |
| • Two doses | 6 (6.8%) | 82 (93.2%) | |
| • Three doses | 2 (2.2%) | 88 (97.8%) | |
| Health status on admission | <0.001*** | ||
| • Critical | 287 (92.3%) | 24 (7.7%) | |
| • Stable | 35 (11.9%) | 260 (88.1%) | |
| Smoking status | <0.001*** | ||
| • Non-smoker | 226 (49.5%) | 231 (50.5%) | |
| • Smoker | 96 (64.4%) | 53 (35.6%) | |
| Associated chronic comorbidity | 0.021† | ||
| • No | 220 (50.2%) | 218 (49.8%) | |
| • Yes | 102 (60.7%) | 66 (39.3%) | |
| Type of respiration support | |||
| • Oxygen mask | 39 (12.9%) | 263 (87.1%) | <0.001*** |
| • Intubation | 265 (96.7%) | 9 (3.3%) | |
| • BiPAP/CPAP mask | 15 (83.3%) | 3 (16.7%) | |
| • High-flow nasal cannula | 3 (25.0%) | 9 (75.0%) |
Significant odds ratios for patients’ outcomes were associated with patients’ vaccination status (129.733, p<0.001), their health status on admission, i.e., stable or critical (103.213, p<0.001), their age groups (0.067, p<0.001), and nationality (0.080, p<0.001). However, the odds ratios for patients’ gender, blood group, Rh-factor, and associated comorbidity (diabetes) were not statistically significant ( Table 3).
| Standard | P | Adjusted | 95% CI | |||
|---|---|---|---|---|---|---|
| Variables | β | Error | Value | OR | Lower | Upper |
| Gender | 0.533 | 0.518 | 0.303 | 1.704 | 0.618 | 4.698 |
| Age group | -2.697 | 0.466 | <0.001*** | 0.067 | 0.027 | 0.168 |
| Nationality | -2.524 | 1.337 | 0.059 | 0.080 | 0.006 | 1.101 |
| Vaccination | 4.865 | 1.045 | <0.001*** | 129.733 | 16.735 | 1005.727 |
| ABO blood group | 0.420 | 0.306 | 0.170 | 1.522 | 0.836 | 2.772 |
| Rh group | 0.038 | 0.639 | 0.952 | 1.039 | 0.297 | 3.635 |
| Comorbidity | 0.299 | 0.585 | 0.609 | 1.349 | 0.429 | 4.244 |
| Health status | 4.637 | 0.611 | <0.001*** | 103.213 | 31.138 | 342.124 |
| Smoking | -0.068 | 0.709 | 0.923 | 0.934 | 0.233 | 3.749 |
| Constant | 4.617 | 2.233 | 0.039† | |||
The findings of this study showed that more than half of our hospitalized COVID-19 patients were males, and almost two-thirds were above 50 years old. Almost one-fourth were smokers, while more than one-quarter of the patients were diabetic. On admission, the condition of about half of our patients was critical, and most patients received respiratory assistance through intubation or an oxygen mask. On discharge, patients’ COVID-19-related case fatality was quite high (53.1%). The case fatality of our patients was significantly higher among males, older, non-Saudi patients, those with associated chronic comorbidity, and those who received intubation or BiPAP/CPAP masks. Multivariate logistic regression confirmed several risk factors for COVID-19 patients’ mortality, including their older age and being non-Saudi.
These results are in agreement with those reported by several studies in Saudi Arabia (Al-Omari et al. 2020; Alhumaid et al. 2021; Aljuaid et al. 2022). The higher incidence of COVID-19 among males and older patients is possibly due to more prevalent associated comorbidities and lower immunity states. Therefore, the identification of these risk factors is important for preventive and tailored healthcare and to minimize complications among these vulnerable groups (Alghamdi 2021; Al-Otaiby et al. 2022).
It is to be noted that the significantly higher case fatality among non-Saudi hospitalized COVID-19 patients may be explained by the relatively more delayed presentation for receiving health care among non-Saudi patients. Moreover, it has been reported that associated chronic comorbidities among COVID-19 patients (e.g., diabetes mellitus) are common (Zhang et al. 2023).
It is worth mentioning that the observed higher case fatality rate among non-Saudi patients may reflect disparities in healthcare access or delayed presentation rather than biological differences. Therefore, further studies are needed to consider the social determinants of health.
The high prevalence of diabetes among our hospitalized COVID-19 patients is in line with that reported by other studies in Saudi Arabia, where almost half of COVID-19 patients were diabetic (Hindawi et al. 2023; Jarrar et al. 2023). Dondorp et al. (2020) added that ventilatory support is vital for the survival of COVID-19 patients, with oxygen saturation <93%, respiratory rates >30/min, or those with respiratory failure.
While the study confirms a high prevalence of diabetes among hospitalized patients, consistent with other reports from Saudi Arabia, the detailed impact of glycemic control or other comorbidities could not be explored in this study since its obtained data are limited to patients’ registered data.
Our study showed that blood group [O] was the most prevalent type among our hospitalized COVID-19 patients, followed by blood groups [A and B], while group [AB] was the least prevalent (2.3%). Moreover, most of our patients were Rh-positive.
These findings are in accordance with those reported by a study conducted in the northern area of the Aseer region, with 45.9% of the population having a blood group [O] (Belali 2022). In addition, the study of Al-Bshabshe et al. (2023) reported similar findings, with 51% of COVID-19 patients possessing blood group [O].
Case fatality among our patients differed according to patients’ ABO blood group types, being highest among patients with blood group [O], and lowest among those with blood group [B]. However, multivariate logistic regression analysis indicated an insignificant adjusted odds ratio (1.522, p=0.170). Moreover, case fatality did not differ significantly according to patients’ Rh factors.
Previous studies have identified associations between ABO blood groups and several different infections or disease severity following infections, including SARS-CoV-1, P. falciparum, H. pylori, Norwalk virus, hepatitis B, and N. gonorrhoeae (Degarege et al. 2012; Chen et al. 2016; Batool, Durrani & Tariq 2017; Murugananthan et al. 2018).
Zhao et al. (2020) reported that individuals with blood group [A] showed a significantly higher risk of COVID-19 infection compared with those with other blood groups, while individuals with blood group [O] showed a significantly lower risk for COVID-19 infection compared with those with other blood groups. Moreover, some other studies have suggested that those with blood type [A] were at a higher risk of contracting the disease, while those with blood type [O] were less prone to it (Solhpour et al. 2020; Al-Ansari et al. 2021; Franchini et al. 2021; Liu et al. 2021; Zhang et al. 2021).
However, several local (Jawdat et al. 2022; Nasif et al. 2022), and international studies (Latz et al. 2020; Levi et al. 2021; Niles et al. 2021) failed to establish significant associations between blood type and COVID-19 susceptibility or case fatality. Also, studies in several countries failed to establish a correlation between Rh-type and ICU admission, mechanical ventilation support, or case fatality rates among COVID-19 patients in Sudan (Taha et al. 2020), Iran (Dal et al. 2021), or Turkey (Abdollahi et al. 2020).
It is to be noted that, although this study reported differences in case fatality rates across ABO blood groups, the adjusted odds ratios were not statistically significant. Although previous studies have suggested associations between blood group and susceptibility to several infectious diseases (Batool et al. 2017; Zhao et al. 2020), this evidence remains to be supported and warrants further investigation in larger, multi-center cohorts.
Our study showed that almost two-thirds of our patients did not receive any vaccine against COVID-19, 8.1% received only one dose, while 14.5% received two doses, and 14.9% received three doses. Patients’ case fatality differed significantly according to their anti-COVID-19 vaccination status, being highest among unvaccinated and incompletely vaccinated patients.
Briciu et al. (2023) noted that by the end of 2020, several vaccines against COVID-19, utilizing different production platforms, had already received emergency use approval. They emphasized that vaccination against COVID-19 is the most reliable method to avoid severe disease and reduce mortality. Haider et al. (2023) reported that following the second booster dose of the COVID-19 vaccine, both incidence and case fatality are significantly reduced. Additionally, De Gier et al. (2023) and Mendoza-Cano et al. (2023) confirmed the considerable public health benefits of primary and booster COVID-19 vaccinations and found high effectiveness against COVID-19 mortality.
Finally, after the end of the COVID-19 pandemic, several lessons should be learned. These lessons include the following:
1. Undue delays in diagnosing cases and timely access to health care not only will allow infectious diseases’ widespread transmission but also will increase their case fatality. Therefore, it is important to build real-time surveillance systems, deploy rapid diagnostic testing and point-of-care tools early in outbreaks, and integrate digital reporting systems for timely case identification and follow-up.
2. It is important to minimize overwhelmed hospitals and ICU shortages, since this will directly increase case fatalities. Therefore, it is important to establish a reserve health workforce and cross-trained staff for crisis deployment.
3. It is crucial to protect vulnerable populations, whereelderly individuals, people with comorbidities, and marginalized communities may face the highest case fatalities. Therefore, it is important to prioritize vaccination and early management for high-risk groups.
The present study provided a significant understanding of the favorable impact of vaccination against COVID-19, in addition to the weight of several risk factors associated with hospitalized COVID-19 patients’ case fatality. However, the researchers admit the presence of certain limitations. This is a single-center study at a tertiary hospital, which limits the generalizability of its findings. Regional differences in healthcare infrastructure, patient demographics, and treatment protocols could influence outcomes in other settings.
Moreover, due to the retrospective nature of the present study, a few other inherent limitations should be considered, including potential biases related to data completeness and accuracy. Also, since the data were extracted from existing medical records, there may have been inconsistencies or missing information that could not be controlled. For example, this study could not stratify patients based on the specific viral variants that they were infected with. This could have influenced disease severity and mortality.
Another important limitation is the lack of detailed information regarding the type of COVID-19 vaccines administered and the time elapsed since vaccination. In addition, our study population included patients admitted to the ICU, i.e., inherently selecting for severe cases only. Hence, the observed case fatality rate in this study may not reflect the broader population of COVID-19 patients, particularly those with milder disease severity. Furthermore, this study could not include long-term follow-up data, which limits understanding of post-discharge outcomes and potential long COVID complications. Therefore, the risk of bias (e.g., selection and information bias) cannot be fully overcome, and only associations should be regarded since causality cannot be established.
The present study provided a significant understanding of the favorable impact of vaccination against COVID-19, in addition to the weight of several risk factors associated with hospitalized COVID-19 patients’ case fatality. However, the researchers admit the presence of certain limitations. First, this is a single-center study, which limits the generalizability of its findings. Moreover, due to the retrospective nature of the present study, a few limitations should be considered. The risk of bias (e.g., selection and information bias) cannot be fully overcome, and only associations should be regarded since causality cannot be established.
In conclusion, vaccination against COVID-19 has a significant preventive impact on patients’ case fatality. Several risk factors related to higher case fatalities among hospitalized COVID-19 patients have been identified, such as older age, being non-Saudi, or being critically ill. Moreover, patients with blood group [B] may have a lower case-fatality than those with blood group [O], but this finding remains to be explained. Identified risk factors for higher case fatalities among COVID-19 patients should be considered in any future outbreaks or epidemics.
Unfortunately, our dataset related to this article cannot be shared publicly due to the institutional and legal restrictions enforced by the Ministry of Health in the Kingdom of Saudi Arabia regarding the COVID-19 pandemic. The dataset includes sensitive health-related information that were provided to the researchers under strict confidentiality conditions, and its public release is not permitted under current national data protection regulations. Data access is restricted to authorized research personnel only. For formal inquiries related to data governance, please contact the Research Ethics Committee via Email (Rec-aseer@moh.gov.sa), The relevant section from our IRB approval reflects that the research team are not allowed to disclose personally identification data of the participant in the study to any other party.
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Is the work clearly and accurately presented and does it cite the current literature?
No
Is the study design appropriate and is the work technically sound?
No
Are sufficient details of methods and analysis provided to allow replication by others?
No
If applicable, is the statistical analysis and its interpretation appropriate?
No
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Public health (Epidemiology, communicable diseases, environmental/occupational medicine, noncommunicable diseases, international health).
Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Public Health, Vaccination Policies, Pandemic Crises
Alongside their report, reviewers assign a status to the article:
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