LETTERS
We were left with the choice of either publishing these 2 The referenced URLs included Web pages from commer-
commentaries without the completed authorship forms and
providing our readers with valuable information about the
candidates’ views or withholding publication and depriv-
ing our readers access to this highly relevant and impor-
tant content. In my judgment, the best course of action in
this case was to make an exception and publish these 2 ar-
ticles. However, I assure our readers that this rare excep-
tion (it only happens with presidential nominees) of pub-
lication without submission of completed authorship forms
will not be extended to any other authors. We can add this
exception to the long list of things in this world that are con-
sidered not fair, but I am sure it would rank way at the bot-
tom of that list.
Catherine D. DeAngelis, MD, MPH
Editor-in-Chief, JAMA
Permanence of Web Page References
To the Editor: The Research Letter by Dr Crichlow and col-
leagues1 addresses an important problem faced by readers of
medical literature: elusive Web-based references. In re-
sponse to this challenge, the US National Library of Medi-
cine (NLM) has recently begun to assign permanence levels
to its Web-based documents2 and to make these ratings avail-
able to users. Documents within this system are assigned 1
of the following ratings: permanent-unchanging content, per-
manent-stable content, permanent-dynamic content, or per-
manence not guaranteed. In the case of the first 3 (ie, per-
manence-guaranteed documents), the uniform resource
locator (URL) link remains unchanged even if the contents
are changed in the future, as may occur with documents hav-
ing dynamic or stable content. This may serve as an example
for other online sources of medical information. Journals may
decide to stipulate that only “permanence-guaranteed” Web
pages be cited as references and a brief description of the per-
manence level may be provided to the reader along with the
URL link (as shown here in reference 2).
Tamilarasu Kadhiravan, MD
kadhiravant@yahoo.co.in
Department of Medicine
All India Institute of Medical Sciences
Ansari Nagar
New Delhi, India
1. Crichlow R, Davies S, Winbush N. Accessibility and accuracy of web page ref-
erences in 5 major medical journals. JAMA. 2004;292:2723-2724.
2. National Library of Medicine. Developing Permanence Levels and the Archives
for NLM’s Permanent Web Documents. Available at: http://www.nlm.nih.gov
/psd/pcm/devpermanence.html [permanent: stable content]. Accessed Decem-
ber 24, 2004.
In Reply: While Dr Kadhiravan is correct in the descrip-
tion of the NLM initiatives regarding the labeling of per-
manence levels for URLs,1 unfortunately none of the URL
references in our study would have been affected by this
change. Although the citations evaluated were from 5 ma-
jor medical journals, no citation referenced an NLM URL.
1450 JAMA, March 23/30, 2005—Vol 293, No. 12 (Reprinted)
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cial resources, nonprofit organizations, and academic re-
search and government Web-based sources.
Dr Kadhiravan’s suggestion that journals only accept URLs
whose permanence level is guaranteed addresses 2 core ques-
tions: Do the major journals feel that this issue of URL ci-
tations is significant, and are they prepared to pursue a con-
sensus to establish new standards for authors regarding
maintaining and/or archiving this reference data for future
citation?
Renée Crichlow, MD
reneec4@u.washington.edu
University of Washington
Montana Family Medicine Residency Program
Billings, Mont
Nicole Winbush, MD
Saint Vincent Healthcare
Billings
1. National Library of Medicine. Developing Permanence Levels and the Archives
for NLM’s Permanent Web Documents. Available at: http://www.nlm.nih.gov
/psd/pcm/devpermanence.html. Accessed January 25, 2005 and archived by au-
thor.
RESEARCH LETTER
ABO Blood Group and Susceptibility
to Severe Acute Respiratory Syndrome
To the Editor: ABO blood group has been reported to in-
fluence susceptibility to the Norwalk virus and Helicobac-
ter pylori infections.1,2 The prevalence of H pylori infection
in Taiwan is significantly higher in patients with blood group
O than in those with other blood groups,3 possibly due to a
reduced number of H pylori receptors in persons with group
A or group B blood. We studied the relationship between
ABO blood group and the development of severe acute res-
piratory syndrome coronavirus (SARS-CoV) infection in a
group of health care workers who were exposed to an in-
dex SARS patient and who were not wearing any personal
protective equipment.
Methods. The first major SARS outbreak in Hong Kong
occurred in March 2003. The index case was a patient who
was admitted to Prince of Wales Hospital, a 1000-bed gen-
eral hospital.4 The patient had been placed in an open ward
with 20 other patients because the outbreak had not been
recognized. The staff did not use any personal protective
equipment during that period. We studied all physicians,
nurses, medical students, and allied health staff who had
worked at least one 4-hour shift in that ward during the 8
days between the patient’s admission and recognition of the
outbreak. Visitors to the ward were excluded from the study.
SARS was confirmed in the staff by presence of SARS-CoV
IgG antibody using SARS-CoV–infected Vero cells fluores-
cent assay.5 ABO and Lewis phenotypes were determined us-
ing DiaMed gel card (DiaMed AG, Cressier sur Morat, Swit-
©2005 American Medical Association. All rights reserved.
 LETTERS

zerland). The study was approved by the institutional review

Table. Odds of SARS-CoV Infection According to Blood Groups
board of the Department of Medicine and Therapeutics, Chi-
No. of Participants
nese University of Hong Kong. Oral informed consent was
obtained from all participants. SARS-CoV SARS-CoV
ABO Infected Noninfected P
Categorical data were analyzed using the 2-tailed ␹2 or System (n = 34) (n = 11) OR (95% CI) Value*
Fisher exact test with SPSS for Windows version 11.0 (SPSS O 11 8 0.18 (0.04-0.81) .03
Inc, Chicago, Ill). Based on the sample size, we had 90% A 8 0 Undefined .17
power to detect at least a 90% increase or decrease in odds B 12 3 1.46 (0.32-6.53) .73
ratio (OR), ␣=.05. AB 3 0 Undefined .57
Results. Forty-five staff fulfilled the inclusion criteria. ABO Abbreviations: CI, confidence interval; OR, odds ratio; SARS-CoV, severe acute respi-
distributions were similar to that reported for the local popu- ratory syndrome coronavirus.
*P value was calculated by 2-tailed ␹2 or Fisher exact test comparing each group indi-
lation6: O (42.2%), A (17.8%), B (33.3%), and AB (6.7%). vidually to all other groups combined.
All participants were Le(a − b⫹) and therefore ABH secre-
tors. Thirty-four exposed participants had serologically con-
firmed SARS-CoV infection with symptom onset within 10 than a 90% increase or decrease in risk. However, investi-
days of exposure to the index case. Eleven exposed partici- gating exposure to additional patients after the index out-
pants remained seronegative after 2 months. Group O par- break would be difficult because of the effects of different
ticipants were less likely to become infected when com- SARS-CoV strains and the use of personal protective gear.
pared with non-O participants (OR, 0.18; 95% confidence These results should be considered very preliminary, but sug-
interval, 0.04-0.81) (TABLE). An increased likelihood in group gest that factors related to ABO blood type may be related
B participants was present (OR, 1.46) but not statistically to susceptibility to SARS. If these results can be replicated,
significant. further research should focus on the mechanism of this effect;
Comment. There appears to be an association between understanding this could lead to development of prophy-
ABO blood type and the likelihood of SARS infection after lactic and therapeutic strategies for this fatal disease, as well
exposure. Our study closely resembled a challenge model as risk stratification in infection control.
because all participants had worked in the vicinity of a single Yufeng Cheng, MD, PhD
index case without wearing protective equipment. Because Gregory Cheng, MD, PhD
SARS is a fatal disease, it would not be ethical to do a true C. H. Chui, PhD
human challenge model as was done in the Norwalk virus F. Y. Lau, PhD
study.2 Department of Medicine & Therapeutics
Persons with type O phenotype have been reported to be Paul K. S. Chan, MBBS, MSc, MRCPath, FHKCPath
Department of Microbiology
more susceptible to the Norwalk virus, and saliva from group
O secretors binds more efficiently to Norwalk virus–like par- Margaret H. L. Ng, MBChB, MRCPath
Department of Anatomical & Cellular Pathology
ticles.2 Group O secretors had a relative risk of 1.56 for Nor-
Joseph J. Y. Sung, MD, PhD
walk virus infection compared with other ABO blood groups. Department of Medicine & Therapeutics
The H pylori blood group antigen binding adhesin (BabA)
Raymond S. M. Wong, MBChB, MRCP
mediates binding of H pylori to the fucosylated Le(b) histo- raymondwong@cuhk.edu.hk
blood group antigen present on the surface of gastric epi- Department of Medicine & Therapeutics
thelial cells, resulting in increased risk of gastric disease.1 Chinese University of Hong Kong
The prevalence of H pylori infection is twice as high in group Hong Kong, China
O participants compared with other ABO groups. In con- 1. Boren T, Falk P, Roth KA, Larson G, Normark S. Attachment of Helicobacter
trast, we found that blood group O was associated with re- pylori to human gastric epithelium mediated by blood group antigens. Science.
1993;262:1892-1895.
duced susceptibility to SARS infection. It is possible that the 2. Lindesmith L, Moe C, Marionneau S, et al. Human susceptibility and resistance
SARS-CoV, like H pylori, may have variable binding affinity to Norwalk virus infection. Nat Med. 2003;9:548-553.
to differing ABH substances present on gut epithelial cells. 3. Lin CW, Chang YS, Wu SC, Cheng KS. Helicobacter pylori in gastric biopsies
of Taiwanese patients with gastroduodenal diseases. Jpn J Med Sci Biol. 1998;51:
A difference in binding could affect viral entry and suscep- 13-23.
tibility to SARS infection. 4. Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syn-
drome in Hong Kong. N Engl J Med. 2003;348:1986-1994.
There are important limitations to consider in interpret- 5. Chan PK, Ip M, Ng KC, et al. Severe acute respiratory syndrome–associated
ing this study. There was likely unequal exposure to the in- coronavirus infection. Emerg Infect Dis. 2004;10:530-532.
6. Mak KH, Cheng S, Yuen C, Chua E, Lin CK, Leong S. Survey of blood group
dex patient among the participants; we could not quantify distribution among Chinese blood donors in Hong Kong: an update. Vox Sang.
this. The small sample size limits our power to detect less 1994;67:50.

©2005 American Medical Association. All rights reserved. (Reprinted) JAMA, March 23/30, 2005—Vol 293, No. 12 1451

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