Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia

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Abdullah" }, { "@type": "Person", "name": "Faris Saeed Alsulayyim" }, { "@type": "Person", "name": "Abdullah Mohammed Alshehri" }, { "@type": "Person", "name": "Saja Saeed Hussain" }, { "@type": "Person", "name": "Ibrahim S. Al-Jabbar" }, { "@type": "Person", "name": "Ibrahim Muhayya" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": "Abstract Background 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. Methods 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. Results 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). Conclusions 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. 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F1000Research 2025, 14 :795 ( https://doi.org/10.12688/f1000research.167889.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] Previously titled: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 Mohammed Aldail https://orcid.org/0009-0000-7045-4727 1 , Khalid Almosa 2 , Naif S. Abdullah 2 , [...] Faris Saeed Alsulayyim 1 , Abdullah Mohammed Alshehri 3 , Saja Saeed Hussain 4 , Ibrahim S. Al-Jabbar 5 , Ibrahim Muhayya 6 Mohammed Aldail https://orcid.org/0009-0000-7045-4727 1 , Khalid Almosa 2 , [...] Naif S. Abdullah 2 , Faris Saeed Alsulayyim 1 , Abdullah Mohammed Alshehri 3 , Saja Saeed Hussain 4 , Ibrahim S. Al-Jabbar 5 , Ibrahim Muhayya 6 PUBLISHED 28 Oct 2025 Author details Author details 1 Resident, Saudi Board of Preventive Medicine, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia 2 Consultant, Preventive Medicine and Public Health Program, Saudi Board of Preventive Medicine, Aseer Branch of the Ministry of Health, Abha, Aseer Province, Saudi Arabia 3 Preventive Medicine Consultant, Communicable Diseases Control Department, Aseer Branch of the Ministry of Health, Abha, Aseer Province, Saudi Arabia 4 Public Health Specialist, Vaccination Unit, Communicable Diseases Control Department, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia 5 Lab Technician, Health Programs Administration Department, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia 6 Lab Specialist, Aseer Central Hospital, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia Mohammed Aldail Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation Khalid Almosa Roles: Conceptualization, Supervision, Writing – Review & Editing Naif S. Abdullah Roles: Methodology, Supervision, Validation Faris Saeed Alsulayyim Roles: Data Curation, Formal Analysis, Writing – Original Draft Preparation Abdullah Mohammed Alshehri Roles: Data Curation, Project Administration, Resources Saja Saeed Hussain Roles: Data Curation, Resources, Validation Ibrahim S. Al-Jabbar Roles: Data Curation, Resources, Visualization Ibrahim Muhayya Roles: Project Administration, Resources, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Emerging Diseases and Outbreaks gateway. This article is included in the Coronavirus (COVID-19) collection. Abstract Abstract Background 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. Methods 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. Results 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). Conclusions 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. READ ALL READ LESS Keywords COVID-19; vaccination status; blood groups; case fatality; risk factors. Corresponding Author(s) Mohammed Aldail ( [email protected] ) Close Corresponding author: Mohammed Aldail Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Aldail M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Aldail M, Almosa K, Abdullah NS et al. Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.12688/f1000research.167889.2 ) First published: 18 Aug 2025, 14 :795 ( https://doi.org/10.12688/f1000research.167889.1 ) Latest published: 28 Oct 2025, 14 :795 ( https://doi.org/10.12688/f1000research.167889.2 ) Revised Amendments from Version 1 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. 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. See the authors' detailed response to the review by Mario Coccia READ REVIEWER RESPONSES Introduction 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. Aim of study The present study aimed to identify risk factors associated with overall case fatality rates among hospitalized COVID-19 cases and to explore the association between vaccination status and the outcomes of hospitalized COVID-19 patients. Patients and methods Study design and setting This is a single-center, retrospective study conducted at a tertiary care hospital in Abha City, Aseer Region, Saudi Arabia. Study population and sample 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). Study data and variables 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 13 th , 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. Models and data analysis procedure 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 ( χ 2 ) 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. Results 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 ). Table 1. COVID-19 patients' characteristics. Characteristics No. % Gender • Male 352 58.1 • Female 254 41.9 Age groups • 60 years 89 14.7 Nationality • Saudi 545 89.9 • Non-Saudi 61 10.1 ABO blood types • O 294 48.5 • A 235 38.8 • B 63 10.4 • AB 14 2.3 Rh-factors • Negative 89 14.7 • Positive 517 85.3 Vaccination status on admission • Not vaccinated 372 61.4 • One dose 56 9.2 • Two doses 88 14.5 • Three doses 90 14.9 Health status on admission • Critical 311 51.3 • Stable 295 48.7 Smoking status • Non-smoker 457 75.4 • Smoker 149 24.6 Associated chronic comorbidity • No 438 72.3 • Yes 168 27.7 Type of respiration support • Oxygen mask 302 49.8 • Intubation 274 45.2 • BiPAP/CPAP mask 18 3.0 • High-flow nasal cannula 12 2.0 Figure 1 shows that 53.1% of hospitalized COVID-19 patients died. Figure 1. Patients’ outcome. 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 ). Table 2. COVID-19 case fatalities according to their patients' characteristics. 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 *** • 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%) † Statistically significant (p<0.05). *** Statistically significant (p<0.001). 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 ). Table 3. Logistic regression analysis for variables associated with patients' outcome. 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 † † Statistically significant (p<0.05). *** Statistically significant (p<0.001). Discussion 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 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. Study limitations 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. Data availability 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. 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Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 18 Aug 2025 ADD YOUR COMMENT Comment Author details Author details 1 Resident, Saudi Board of Preventive Medicine, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia 2 Consultant, Preventive Medicine and Public Health Program, Saudi Board of Preventive Medicine, Aseer Branch of the Ministry of Health, Abha, Aseer Province, Saudi Arabia 3 Preventive Medicine Consultant, Communicable Diseases Control Department, Aseer Branch of the Ministry of Health, Abha, Aseer Province, Saudi Arabia 4 Public Health Specialist, Vaccination Unit, Communicable Diseases Control Department, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia 5 Lab Technician, Health Programs Administration Department, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia 6 Lab Specialist, Aseer Central Hospital, Aseer Health Cluster, Abha, Aseer Province, Saudi Arabia Mohammed Aldail Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation Khalid Almosa Roles: Conceptualization, Supervision, Writing – Review & Editing Naif S. Abdullah Roles: Methodology, Supervision, Validation Faris Saeed Alsulayyim Roles: Data Curation, Formal Analysis, Writing – Original Draft Preparation Abdullah Mohammed Alshehri Roles: Data Curation, Project Administration, Resources Saja Saeed Hussain Roles: Data Curation, Resources, Validation Ibrahim S. Al-Jabbar Roles: Data Curation, Resources, Visualization Ibrahim Muhayya Roles: Project Administration, Resources, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 28 Oct 2025, 14:795 https://doi.org/10.12688/f1000research.167889.2 version 1 Published: 18 Aug 2025, 14:795 https://doi.org/10.12688/f1000research.167889.1 Copyright © 2025 Aldail M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Aldail M, Almosa K, Abdullah NS et al. Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.12688/f1000research.167889.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 28 Oct 2025 Revised Views 0 Cite How to cite this report: Coccia M. Reviewer Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.189799.r427755 ) The direct URL for this report is: https://f1000research.com/articles/14-795/v2#referee-response-427755 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Nov 2025 Mario Coccia , CNR -- National Research Council of Italy, Turin Research Area of the National Research Council, Turin, Italy Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.189799.r427755 Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia The topics of this paper are well known. Although the revision, the paper was and is inconsistent in results. All suggested ... Continue reading READ ALL Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia The topics of this paper are well known. Although the revision, the paper was and is inconsistent in results. All suggested comments have not been incorporated properly and as a consequence the paper does not show robust results that remain vague. The discussion does not explain how this study advances these research topics, and support effective policy implications. Now, after these revisions, a real scientific advance from this paper, it is difficult to grasp. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public Health, Vaccination Policies, Pandemic Crises I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Coccia M. Reviewer Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.189799.r427755 ) The direct URL for this report is: https://f1000research.com/articles/14-795/v2#referee-response-427755 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 18 Aug 2025 Views 0 Cite How to cite this report: Ngatu NR. Reviewer Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.185033.r413340 ) The direct URL for this report is: https://f1000research.com/articles/14-795/v1#referee-response-413340 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Sep 2025 Nlandu Roger Ngatu , Department of Public Health, Kagawa University, Miki, Japan Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.185033.r413340 The authors have analyzed data of 606 hospitalized COVID-19 patients at a ICU unit and sought to determine risk factors associated with SARS-CoV-2 associated fatality. Though they tried their best to communicate their findings, the manuscript should have undergone a ... Continue reading READ ALL The authors have analyzed data of 606 hospitalized COVID-19 patients at a ICU unit and sought to determine risk factors associated with SARS-CoV-2 associated fatality. Though they tried their best to communicate their findings, the manuscript should have undergone a thorough editing by a scientist in the field of epidemiology and/or infectious diseases. Here are some of selected comments: - from the Abstract to the Discussion section, issue related the use of English syntax is found through the entire manuscript text; - redundant words or terms in Introduction, Methods and Discussion; - study design not specified, as "retrospective study" cannot be considered as research design; - unnecessary repetitions of groups of words or sentences; - the methodology used for data analysis is unclear, in Methods section authors mention "binary logistic regression" whereas they discuss the use of multivariate logistic regression in the last section of the manuscript; - the health indicators used as "outcome variables" are not specified. 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). I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ngatu NR. Reviewer Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.185033.r413340 ) The direct URL for this report is: https://f1000research.com/articles/14-795/v1#referee-response-413340 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Coccia M. Reviewer Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.185033.r413346 ) The direct URL for this report is: https://f1000research.com/articles/14-795/v1#referee-response-413346 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Sep 2025 Mario Coccia , CNR -- National Research Council of Italy, Turin Research Area of the National Research Council, Turin, Italy Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.185033.r413346 Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 The topics of this paper are interesting, though well known. The structure and content must be revised, and results have to be better explained by authors ... Continue reading READ ALL Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 The topics of this paper are interesting, though well known. The structure and content must be revised, and results have to be better explained by authors before to be reconsidered. The title has to clarify that is a case study in Abha City, Saudi Arabia. Abstract has to clarify the goal, empirical results and health and social implications to face next pandemics. Introduction has to better clarify the research questions of this study, indicating the gap presents in literature that this study endeavors to cover, and provide more theoretical background about role of vaccination, optimal rate of vaccination, and other factors. After that authors can focus on the topics of this study to provide a correct analysis for fruitful discussion (See suggested readings that must be all read and used in the text). The methods of this study are not clear. The section of Materials and methods must be re-structured with the following three sections and same order: • Sample and data • Measures of variables • Models and Data analysis procedure. Results This study offers important insights into the relationship between COVID-19 vaccination status and patient outcomes in a critical care setting. However, several limitations must be acknowledged to contextualize the findings and guide future research. The research was conducted in a single tertiary hospital in Abha City, Saudi Arabia, which may limit the generalizability of the results. Regional differences in healthcare infrastructure, patient demographics, and treatment protocols could influence outcomes in other settings. Moreover, the retrospective design of the study introduces inherent limitations, including potential biases related to data completeness and accuracy. Since the data were extracted from existing medical records, there may have been inconsistencies or missing information that could not be controlled. Another important limitation is the lack of detailed information regarding the type of COVID-19 vaccines administered and the time elapsed since vaccination. These factors are critical in evaluating vaccine effectiveness, especially in light of waning immunity and the emergence of new SARS-CoV-2 variants. The study also did not stratify patients based on the specific viral variants they were infected with, which could have influenced disease severity and mortality. While multivariate logistic regression was employed to adjust for confounding variables, several potentially influential factors—such as socioeconomic status, time from symptom onset to hospital admission, and access to healthcare—were not included in the analysis. These unmeasured variables may have affected both vaccination uptake and clinical outcomes. The study population was limited to patients admitted to the intensive care unit, inherently selecting for more severe cases. As a result, the observed case fatality rate may not reflect the broader population of COVID-19 patients, particularly those with milder disease. Furthermore, the analysis did not include long-term follow-up data, which limits understanding of post-discharge outcomes and potential long COVID complications. Although the study observed differences in case fatality rates across ABO blood groups, the adjusted odds ratios were not statistically significant. These findings should therefore be interpreted with caution. While previous studies have suggested associations between blood group and susceptibility to infectious diseases, including SARS-CoV-2 (Batool, Durrani & Tariq 2017; Zhao et al. 2020), the evidence remains inconclusive and warrants further investigation in larger, multi-center cohorts. The observed higher case fatality among non-Saudi patients may reflect disparities in healthcare access or delayed presentation rather than biological differences. This highlights the importance of considering social determinants of health in future analyses. Additionally, while the study confirms a high prevalence of diabetes among hospitalized patients—consistent with other reports from Saudi Arabia (Hindawi et al. 2023; Jarrar et al. 2023)—it does not explore the impact of glycemic control or other comorbidities in detail. Discussion. First, authors have to synthesize the main results in a simple table to be clear for readers and then show what this study adds compared to other studies. Although the Results section provides a detailed description of the data collected and analyzed, there needs to be a more critical synthesis and comparison of the findings with the literature. The discussion section has to interpret and describe the significance of your findings in relation to what was already known about the research problem being investigated and explain any new understanding or insights that emerged from your research. The discussion has better to connect to the introduction through the research questions, and the literature you reviewed. The discussion clearly has to explain how this study advances these research topics. Comment on whether the results were expected for each set of findings; go into greater depth to explain unexpected findings. Moreover, either compare your results with the findings from other studies or use the studies to support your results. A claim for how the results can be applied more generally, also in other countries similar to Saudi Arabia. Describe lessons learned, proposing recommendations that can help improve the vaccination policy with optimal rates in society, other measure of health policies because vaccination cannot be sufficient….highlighting best practices of health policy to prevent mortality and negative effects of next pandemic crises (see suggested papers to read and use). Conclusion has to be a separate section. Conclusion has not to be a summary, but authors have to focus on manifold limitations of this study. In addition to the limitations already acknowledged, several other important considerations should be discussed to provide a more comprehensive understanding of the study’s constraints. While the study explored associations between ABO blood groups and COVID-19 case fatality, the findings must be interpreted with caution. Although patients with blood group [O] exhibited the highest case fatality and those with blood group [B] the lowest, the multivariate logistic regression analysis revealed that these associations were not statistically significant. This discrepancy suggests that the observed differences may be confounded by other variables or due to sample distribution rather than a true biological effect. Previous studies have reported conflicting results regarding the role of blood groups in COVID-19 susceptibility and severity. For instance, Zhao et al. (2020) and Solhpour et al. (2020) found that individuals with blood group [A] were at higher risk, while those with blood group [O] were less susceptible. However, other investigations, including those by Jawdat et al. (2022), Nasif et al. (2022), and Latz et al. (2020), failed to establish significant associations between blood type and COVID-19 outcomes. Similarly, studies conducted in Sudan (Taha et al. 2020), Iran (Dal et al. 2021), and Turkey (Abdollahi et al. 2020) did not find meaningful correlations between Rh-type and ICU admission, mechanical ventilation, or mortality. Another limitation lies in the lack of immunological profiling of the patients. The study did not assess antibody levels, cellular immune responses, or prior infection history, which are crucial for understanding the true protective effect of vaccination. Without this data, it is difficult to determine whether vaccinated patients had adequate immune protection at the time of hospitalization. This is particularly relevant given the evolving nature of SARS-CoV-2 and the emergence of immune-evasive variants. Additionally, the study did not account for the potential impact of treatment protocols, medication regimens, or timing of therapeutic interventions. Variations in clinical management—such as the use of antivirals, corticosteroids, or monoclonal antibodies—could significantly influence patient outcomes but were not analyzed. This omission limits the ability to isolate the effect of vaccination and other risk factors from the influence of medical care. The absence of data on viral load and disease progression also represents a limitation. Viral load at admission has been shown to correlate with disease severity and mortality, yet this parameter was not included in the analysis. Similarly, the study did not explore the duration of symptoms prior to hospitalization, which could reflect delays in seeking care and influence prognosis. Furthermore, the study did not investigate behavioral or environmental factors that may contribute to disease severity, such as occupational exposure, housing conditions, or adherence to public health measures. These social determinants of health are particularly relevant in explaining disparities in case fatality between Saudi and non-Saudi patients, as highlighted by the authors. Lastly, while the study emphasizes the protective role of vaccination, it does not explore vaccine hesitancy or barriers to vaccine access, which are critical for public health planning. Understanding why a large proportion of patients remained unvaccinated could inform targeted interventions to improve vaccine coverage and reduce mortality. The Conclusion does not adequately discuss the theoretical and managerial implications of the study. Discuss how the gap in the literature has been addressed about the research problem. Make sure you create 3 subsections in the Conclusion: 1) Theoretical Implications, 2) Managerial or Policy Implications, and 3) Ideas for Future Research. In short, while the study contributes valuable data on COVID-19 outcomes in a critical care context, its findings should be interpreted within the context of these methodological and contextual limitations. A prospective designs, and a broader range of clinical and sociodemographic variables can enhance the robustness and applicability of the results. Overall, then, the paper is interesting, but the theoretical framework is weak, and some results create confusion… structure of the paper has to be improved; study design, discussion and presentation of results have to be clarified using suggested comments. I strongly suggest improving the paper by using all comments (suggested papers included to read and use all) that I will verify in depth, and maybe it can be considered. Suggested readings of relevant papers to be read and uses to improve theoretical framework and discussion. Elamin, M.Y., Maslamani, Y.A., Alsheikh, F.A., ... Dahlan, A.A., Gosadi, I.M. 2024. Impact of vaccination on morbidity and mortality in adults hospitalized with COVID-19 during the omicron wave in the Jazan Region, Saudi Arabia | Saudi Medical Journal, 45(2), pp. 179–187 Agrupis, K.A., Ylade, M., Qi, Y.Y., ... Wang, X., Deen, J. 2025. Effectiveness of CoronaVac primary series with and without booster against hospitalized COVID-19 during the Omicron-predominant epidemic wave in the Philippines: a test-negative case–control study.Expert Review of Vaccines, 24(1), pp. 738–749 Coccia M. 2023. Sources, diffusion and prediction in COVID-19 pandemic: lessons learned to face next health emergency[J]. AIMS Public Health, 2023, 10(1): 145-168. doi: 10.3934/publichealth.2023012 Alkhafaji, D., Argan, R.A., Albahrani, S., ... Alhwiesh, A., Alrubaish, N. 2022. The impact of obesity on hospitalized patients with COVID-19 infection in the Eastern Province of Saudi Arabia.Journal of Medicine and Life, 2022(3), pp. 425–432 Maleki, B., Sadeghian, A.M., Ranjbar, M. 2025. Impact of vaccination against SARS-CoV-2 on mortality risk, ICU admission rate, and hospitalization length in hospitalized COVID-19 patients: a cross-sectional study.BMC Infectious Diseases, 25(1), 144 Coccia M. 2022. Optimal levels of vaccination to reduce COVID-19 infected individuals and deaths: A global analysis. Environmental Research, vol. 204, Part C, March 2022, Article number 112314, https://doi.org/10.1016/j.envres.2021.112314 Sábato, S., Benet, S., Rogers, A.J., ... Tierney, J., Vogel, S.E. 2025. SARS-Cov-2 vaccination strategies in hospitalized recovered COVID-19 patients: a randomized clinical trial (VATICO Trial).Scientific Reports, 15(1), 9882 2025 Coccia, M. and Benati, I. (2024), "Effective health systems facing pandemic crisis: lessons from COVID-19 in Europe for next emergencies", International Journal of Health Governance, Vol. 29 No. 2, pp. 89-111. https://doi.org/10.1108/IJHG-02-2024-0013 Grady, C.B., Bhattacharjee, B., Silva, J., ... Krumholz, H.M., Iwasaki, A. 2025. Impact of COVID-19 vaccination on symptoms and immune phenotypes in vaccine-naïve individuals with Long COVID.Communications Medicine, 5(1), 163 Coccia M. 2021. Pandemic Prevention: Lessons from COVID-19. Encyclopedia, vol. 1, n. 2, pp. 433-444. doi: 10.3390/encyclopedia1020036 Chuang, M.-H., Hsu, W., Tsai, Y.-W., ... Huang, P.-Y., Lai, C.-C. 2024. New-onset obstructive airway disease following COVID-19: a multicenter retrospective cohort study.BMC Medicine, 22(1), 360 Coccia M. 2022. COVID-19 Vaccination is not a Sufficient Public Policy to face Crisis Management of next Pandemic Threats. Public Organization Review, https://doi.org/10.1007/s11115-022-00661-6 Jiang, J., Lam, K.F., Lau, E.H.Y., ... Lin, Y., Cowling, B.J. 2025. Joint analysis of time-varying effect of vaccine and antiviral drug for preventing severe complications and mortality.Scientific Reports, 15(1), 5640 Coccia M. 2022. Improving preparedness for next pandemics: Max level of COVID-19 vaccinations without social impositions to design effective health policy and avoid flawed democracies. Environmental Research, vol. 213, October 2022, n. 113566. https://doi.org/10.1016/j.envres.2022.113566 Chong, K.C., Wei, Y., Jia, K.M., ... Yeoh, E.K., Guo, Z. 2025. SARS-CoV-2 rebound and post-acute mortality and hospitalization among patients admitted with COVID-19: cohort study.Nature Communications, 16(1), 6924 Kargı, B. Coccia M., 2024. Rethinking the Role of Vaccinations in Mitigating COVID-19 Mortality: A Cross-National Analysis. KMU Journal of Social and Economic Research 26(47), 1173-1192, https://doi.org/10.18493/kmusekad.1529330 Alshukairi, A.N., Al-Omari, A., Al-Tawfiq, J.A., ... Qushmaq, I., Azhar, E.I. 2022. Active viral shedding in a vaccinated hospitalized patient infected with the delta variant (B.1.617.2) of SARS-CoV-2 and challenges of de-isolation.Journal of Infection and Public Health, 15(6), pp. 628–630 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 I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Coccia M. Reviewer Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.185033.r413346 ) The direct URL for this report is: https://f1000research.com/articles/14-795/v1#referee-response-413346 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 16 Dec 2025 Mohammed Aldail , Resident, Saudi Board of Preventive Medicine, Aseer Health Cluster, Abha, Saudi Arabia 16 Dec 2025 Author Response We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns ... Continue reading We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns raised. Methodological clarifications, improved theoretical framing, and additional discussion of limitations and policy implications were incorporated. All revisions are highlighted in the revised manuscript. We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns raised. Methodological clarifications, improved theoretical framing, and additional discussion of limitations and policy implications were incorporated. All revisions are highlighted in the revised manuscript. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 16 Dec 2025 Mohammed Aldail , Resident, Saudi Board of Preventive Medicine, Aseer Health Cluster, Abha, Saudi Arabia 16 Dec 2025 Author Response We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns ... Continue reading We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns raised. Methodological clarifications, improved theoretical framing, and additional discussion of limitations and policy implications were incorporated. All revisions are highlighted in the revised manuscript. We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns raised. Methodological clarifications, improved theoretical framing, and additional discussion of limitations and policy implications were incorporated. All revisions are highlighted in the revised manuscript. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 18 Aug 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 28 Oct 25 read Version 1 18 Aug 25 read read Mario Coccia , Turin Research Area of the National Research Council, Turin, Italy Nlandu Roger Ngatu , Kagawa University, Miki, Japan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Coccia M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Nov 2025 | for Version 2 Mario Coccia , CNR -- National Research Council of Italy, Turin Research Area of the National Research Council, Turin, Italy 0 Views copyright © 2025 Coccia M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia The topics of this paper are well known. Although the revision, the paper was and is inconsistent in results. All suggested comments have not been incorporated properly and as a consequence the paper does not show robust results that remain vague. The discussion does not explain how this study advances these research topics, and support effective policy implications. Now, after these revisions, a real scientific advance from this paper, it is difficult to grasp. Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health, Vaccination Policies, Pandemic Crises I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Coccia M. Peer Review Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.189799.r427755) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-795/v2#referee-response-427755 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ngatu N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Sep 2025 | for Version 1 Nlandu Roger Ngatu , Department of Public Health, Kagawa University, Miki, Japan 0 Views copyright © 2025 Ngatu N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have analyzed data of 606 hospitalized COVID-19 patients at a ICU unit and sought to determine risk factors associated with SARS-CoV-2 associated fatality. Though they tried their best to communicate their findings, the manuscript should have undergone a thorough editing by a scientist in the field of epidemiology and/or infectious diseases. Here are some of selected comments: - from the Abstract to the Discussion section, issue related the use of English syntax is found through the entire manuscript text; - redundant words or terms in Introduction, Methods and Discussion; - study design not specified, as "retrospective study" cannot be considered as research design; - unnecessary repetitions of groups of words or sentences; - the methodology used for data analysis is unclear, in Methods section authors mention "binary logistic regression" whereas they discuss the use of multivariate logistic regression in the last section of the manuscript; - the health indicators used as "outcome variables" are not specified. 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). I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Ngatu NR. Peer Review Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.185033.r413340) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-795/v1#referee-response-413340 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Coccia M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Sep 2025 | for Version 1 Mario Coccia , CNR -- National Research Council of Italy, Turin Research Area of the National Research Council, Turin, Italy 0 Views copyright © 2025 Coccia M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 The topics of this paper are interesting, though well known. The structure and content must be revised, and results have to be better explained by authors before to be reconsidered. The title has to clarify that is a case study in Abha City, Saudi Arabia. Abstract has to clarify the goal, empirical results and health and social implications to face next pandemics. Introduction has to better clarify the research questions of this study, indicating the gap presents in literature that this study endeavors to cover, and provide more theoretical background about role of vaccination, optimal rate of vaccination, and other factors. After that authors can focus on the topics of this study to provide a correct analysis for fruitful discussion (See suggested readings that must be all read and used in the text). The methods of this study are not clear. The section of Materials and methods must be re-structured with the following three sections and same order: • Sample and data • Measures of variables • Models and Data analysis procedure. Results This study offers important insights into the relationship between COVID-19 vaccination status and patient outcomes in a critical care setting. However, several limitations must be acknowledged to contextualize the findings and guide future research. The research was conducted in a single tertiary hospital in Abha City, Saudi Arabia, which may limit the generalizability of the results. Regional differences in healthcare infrastructure, patient demographics, and treatment protocols could influence outcomes in other settings. Moreover, the retrospective design of the study introduces inherent limitations, including potential biases related to data completeness and accuracy. Since the data were extracted from existing medical records, there may have been inconsistencies or missing information that could not be controlled. Another important limitation is the lack of detailed information regarding the type of COVID-19 vaccines administered and the time elapsed since vaccination. These factors are critical in evaluating vaccine effectiveness, especially in light of waning immunity and the emergence of new SARS-CoV-2 variants. The study also did not stratify patients based on the specific viral variants they were infected with, which could have influenced disease severity and mortality. While multivariate logistic regression was employed to adjust for confounding variables, several potentially influential factors—such as socioeconomic status, time from symptom onset to hospital admission, and access to healthcare—were not included in the analysis. These unmeasured variables may have affected both vaccination uptake and clinical outcomes. The study population was limited to patients admitted to the intensive care unit, inherently selecting for more severe cases. As a result, the observed case fatality rate may not reflect the broader population of COVID-19 patients, particularly those with milder disease. Furthermore, the analysis did not include long-term follow-up data, which limits understanding of post-discharge outcomes and potential long COVID complications. Although the study observed differences in case fatality rates across ABO blood groups, the adjusted odds ratios were not statistically significant. These findings should therefore be interpreted with caution. While previous studies have suggested associations between blood group and susceptibility to infectious diseases, including SARS-CoV-2 (Batool, Durrani & Tariq 2017; Zhao et al. 2020), the evidence remains inconclusive and warrants further investigation in larger, multi-center cohorts. The observed higher case fatality among non-Saudi patients may reflect disparities in healthcare access or delayed presentation rather than biological differences. This highlights the importance of considering social determinants of health in future analyses. Additionally, while the study confirms a high prevalence of diabetes among hospitalized patients—consistent with other reports from Saudi Arabia (Hindawi et al. 2023; Jarrar et al. 2023)—it does not explore the impact of glycemic control or other comorbidities in detail. Discussion. First, authors have to synthesize the main results in a simple table to be clear for readers and then show what this study adds compared to other studies. Although the Results section provides a detailed description of the data collected and analyzed, there needs to be a more critical synthesis and comparison of the findings with the literature. The discussion section has to interpret and describe the significance of your findings in relation to what was already known about the research problem being investigated and explain any new understanding or insights that emerged from your research. The discussion has better to connect to the introduction through the research questions, and the literature you reviewed. The discussion clearly has to explain how this study advances these research topics. Comment on whether the results were expected for each set of findings; go into greater depth to explain unexpected findings. Moreover, either compare your results with the findings from other studies or use the studies to support your results. A claim for how the results can be applied more generally, also in other countries similar to Saudi Arabia. Describe lessons learned, proposing recommendations that can help improve the vaccination policy with optimal rates in society, other measure of health policies because vaccination cannot be sufficient….highlighting best practices of health policy to prevent mortality and negative effects of next pandemic crises (see suggested papers to read and use). Conclusion has to be a separate section. Conclusion has not to be a summary, but authors have to focus on manifold limitations of this study. In addition to the limitations already acknowledged, several other important considerations should be discussed to provide a more comprehensive understanding of the study’s constraints. While the study explored associations between ABO blood groups and COVID-19 case fatality, the findings must be interpreted with caution. Although patients with blood group [O] exhibited the highest case fatality and those with blood group [B] the lowest, the multivariate logistic regression analysis revealed that these associations were not statistically significant. This discrepancy suggests that the observed differences may be confounded by other variables or due to sample distribution rather than a true biological effect. Previous studies have reported conflicting results regarding the role of blood groups in COVID-19 susceptibility and severity. For instance, Zhao et al. (2020) and Solhpour et al. (2020) found that individuals with blood group [A] were at higher risk, while those with blood group [O] were less susceptible. However, other investigations, including those by Jawdat et al. (2022), Nasif et al. (2022), and Latz et al. (2020), failed to establish significant associations between blood type and COVID-19 outcomes. Similarly, studies conducted in Sudan (Taha et al. 2020), Iran (Dal et al. 2021), and Turkey (Abdollahi et al. 2020) did not find meaningful correlations between Rh-type and ICU admission, mechanical ventilation, or mortality. Another limitation lies in the lack of immunological profiling of the patients. The study did not assess antibody levels, cellular immune responses, or prior infection history, which are crucial for understanding the true protective effect of vaccination. Without this data, it is difficult to determine whether vaccinated patients had adequate immune protection at the time of hospitalization. This is particularly relevant given the evolving nature of SARS-CoV-2 and the emergence of immune-evasive variants. Additionally, the study did not account for the potential impact of treatment protocols, medication regimens, or timing of therapeutic interventions. Variations in clinical management—such as the use of antivirals, corticosteroids, or monoclonal antibodies—could significantly influence patient outcomes but were not analyzed. This omission limits the ability to isolate the effect of vaccination and other risk factors from the influence of medical care. The absence of data on viral load and disease progression also represents a limitation. Viral load at admission has been shown to correlate with disease severity and mortality, yet this parameter was not included in the analysis. Similarly, the study did not explore the duration of symptoms prior to hospitalization, which could reflect delays in seeking care and influence prognosis. Furthermore, the study did not investigate behavioral or environmental factors that may contribute to disease severity, such as occupational exposure, housing conditions, or adherence to public health measures. These social determinants of health are particularly relevant in explaining disparities in case fatality between Saudi and non-Saudi patients, as highlighted by the authors. Lastly, while the study emphasizes the protective role of vaccination, it does not explore vaccine hesitancy or barriers to vaccine access, which are critical for public health planning. Understanding why a large proportion of patients remained unvaccinated could inform targeted interventions to improve vaccine coverage and reduce mortality. The Conclusion does not adequately discuss the theoretical and managerial implications of the study. Discuss how the gap in the literature has been addressed about the research problem. Make sure you create 3 subsections in the Conclusion: 1) Theoretical Implications, 2) Managerial or Policy Implications, and 3) Ideas for Future Research. In short, while the study contributes valuable data on COVID-19 outcomes in a critical care context, its findings should be interpreted within the context of these methodological and contextual limitations. A prospective designs, and a broader range of clinical and sociodemographic variables can enhance the robustness and applicability of the results. Overall, then, the paper is interesting, but the theoretical framework is weak, and some results create confusion… structure of the paper has to be improved; study design, discussion and presentation of results have to be clarified using suggested comments. I strongly suggest improving the paper by using all comments (suggested papers included to read and use all) that I will verify in depth, and maybe it can be considered. Suggested readings of relevant papers to be read and uses to improve theoretical framework and discussion. Elamin, M.Y., Maslamani, Y.A., Alsheikh, F.A., ... Dahlan, A.A., Gosadi, I.M. 2024. Impact of vaccination on morbidity and mortality in adults hospitalized with COVID-19 during the omicron wave in the Jazan Region, Saudi Arabia | Saudi Medical Journal, 45(2), pp. 179–187 Agrupis, K.A., Ylade, M., Qi, Y.Y., ... Wang, X., Deen, J. 2025. Effectiveness of CoronaVac primary series with and without booster against hospitalized COVID-19 during the Omicron-predominant epidemic wave in the Philippines: a test-negative case–control study.Expert Review of Vaccines, 24(1), pp. 738–749 Coccia M. 2023. Sources, diffusion and prediction in COVID-19 pandemic: lessons learned to face next health emergency[J]. AIMS Public Health, 2023, 10(1): 145-168. doi: 10.3934/publichealth.2023012 Alkhafaji, D., Argan, R.A., Albahrani, S., ... Alhwiesh, A., Alrubaish, N. 2022. The impact of obesity on hospitalized patients with COVID-19 infection in the Eastern Province of Saudi Arabia.Journal of Medicine and Life, 2022(3), pp. 425–432 Maleki, B., Sadeghian, A.M., Ranjbar, M. 2025. Impact of vaccination against SARS-CoV-2 on mortality risk, ICU admission rate, and hospitalization length in hospitalized COVID-19 patients: a cross-sectional study.BMC Infectious Diseases, 25(1), 144 Coccia M. 2022. Optimal levels of vaccination to reduce COVID-19 infected individuals and deaths: A global analysis. Environmental Research, vol. 204, Part C, March 2022, Article number 112314, https://doi.org/10.1016/j.envres.2021.112314 Sábato, S., Benet, S., Rogers, A.J., ... Tierney, J., Vogel, S.E. 2025. SARS-Cov-2 vaccination strategies in hospitalized recovered COVID-19 patients: a randomized clinical trial (VATICO Trial).Scientific Reports, 15(1), 9882 2025 Coccia, M. and Benati, I. (2024), "Effective health systems facing pandemic crisis: lessons from COVID-19 in Europe for next emergencies", International Journal of Health Governance, Vol. 29 No. 2, pp. 89-111. https://doi.org/10.1108/IJHG-02-2024-0013 Grady, C.B., Bhattacharjee, B., Silva, J., ... Krumholz, H.M., Iwasaki, A. 2025. Impact of COVID-19 vaccination on symptoms and immune phenotypes in vaccine-naïve individuals with Long COVID.Communications Medicine, 5(1), 163 Coccia M. 2021. Pandemic Prevention: Lessons from COVID-19. Encyclopedia, vol. 1, n. 2, pp. 433-444. doi: 10.3390/encyclopedia1020036 Chuang, M.-H., Hsu, W., Tsai, Y.-W., ... Huang, P.-Y., Lai, C.-C. 2024. New-onset obstructive airway disease following COVID-19: a multicenter retrospective cohort study.BMC Medicine, 22(1), 360 Coccia M. 2022. COVID-19 Vaccination is not a Sufficient Public Policy to face Crisis Management of next Pandemic Threats. Public Organization Review, https://doi.org/10.1007/s11115-022-00661-6 Jiang, J., Lam, K.F., Lau, E.H.Y., ... Lin, Y., Cowling, B.J. 2025. Joint analysis of time-varying effect of vaccine and antiviral drug for preventing severe complications and mortality.Scientific Reports, 15(1), 5640 Coccia M. 2022. Improving preparedness for next pandemics: Max level of COVID-19 vaccinations without social impositions to design effective health policy and avoid flawed democracies. Environmental Research, vol. 213, October 2022, n. 113566. https://doi.org/10.1016/j.envres.2022.113566 Chong, K.C., Wei, Y., Jia, K.M., ... Yeoh, E.K., Guo, Z. 2025. SARS-CoV-2 rebound and post-acute mortality and hospitalization among patients admitted with COVID-19: cohort study.Nature Communications, 16(1), 6924 Kargı, B. Coccia M., 2024. Rethinking the Role of Vaccinations in Mitigating COVID-19 Mortality: A Cross-National Analysis. KMU Journal of Social and Economic Research 26(47), 1173-1192, https://doi.org/10.18493/kmusekad.1529330 Alshukairi, A.N., Al-Omari, A., Al-Tawfiq, J.A., ... Qushmaq, I., Azhar, E.I. 2022. Active viral shedding in a vaccinated hospitalized patient infected with the delta variant (B.1.617.2) of SARS-CoV-2 and challenges of de-isolation.Journal of Infection and Public Health, 15(6), pp. 628–630 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 I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 16 Dec 2025 Mohammed Aldail, Resident, Saudi Board of Preventive Medicine, Aseer Health Cluster, Abha, Saudi Arabia We carefully reviewed the reviewer’s detailed comments and substantially revised the manuscript accordingly. The title, abstract, introduction, methods, results, discussion, and conclusion were restructured and expanded to address all concerns raised. Methodological clarifications, improved theoretical framing, and additional discussion of limitations and policy implications were incorporated. All revisions are highlighted in the revised manuscript. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Coccia M. Peer Review Report For: Risk Factors for Fatality of Hospitalized Patients with Coronavirus Infection-2019 in Abha City, Saudi Arabia [version 2; peer review: 2 not approved] . F1000Research 2025, 14 :795 ( https://doi.org/10.5256/f1000research.185033.r413346) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-795/v1#referee-response-413346 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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