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Mortality in COVID-19 disease patients: Correlating the association of major histocompatibility complex (MHC) with severe acute respiratory syndrome 2 (SARS-CoV-2) variants

Open AccessPublished:July 18, 2020DOI:https://doi.org/10.1016/j.ijid.2020.07.016

      Abstract

      Genetic factors such as the HLA type of patients may play a role in regard to disease severity and clinical outcome of patients with COVID-19. Taking the data deposited in the GISAID database, we made predictions using the IEDB analysis resource (TepiTool) to gauge how variants in the SARS-CoV-2 genome may change peptide binding to the most frequent MHC-class I and -II alleles in Africa, Asia and Europe. We caracterized how a single mutation in the wildtype sequence of of SARS-CoV-2 could influence the peptide binding of SARS-CoV-2 variants to MHC class II, but not to MHC class I alleles. Assuming the ORF8 (L84S) mutation is biologically significant, selective pressure from MHC class II alleles may select for viral varients and subsequently shape the quality and quantity of cellular immune responses aginast SARS-CoV-2. MHC 4-digit typing along with viral sequence analysis should be considered in studies examining clinical outcomes in patients with COVID-19.

      Keywords

      Introduction

      As the 2019 (COVID-19) pandemic caused by the novel coronavirus, SARS-CoV-2 spreads globally, differences in adverse clinical management outcomes have been associated with age >65 years, male gender, and comorbidities such as smoking, diabetes, hypertension, cardiovascular comorbidity, and immunosuppression. Ethnicity has been the focus of attention after data from the United Kingdom showed a disproportionate number of deaths among healthcare workers from Black, Asian, and other ethnic minority backgrounds (
      • Khunti K.
      • Singh A.K.
      • Pareek M.
      • Hanif W.
      Is ethnicity linked to incidence or outcomes of covid-19?.
      ). In addition to ethnicity, socioeconomic factors, prior vaccinations, exposure to other coronaviruses, and other factors need to be considered to explain the geographical and regional variations in susceptibility and severity of the clinical expression of COVID-19 disease and outcomes. In the United States, there have been disproportionate COVID-19 death rates among African Americans at around 2.6 times higher than that of other groups. Although these data could be due to multiple cultural and socioeconomic factors an underlying genetic susceptibility to SARS-CoV-2 infection may be a factor.
      Genetic factors were thought to play a causative role in the SARS outbreak's pathogenesis in 2003 in a group of Taiwanese patients, where the HLA-B*4601 haplotype was associated with the severity of the SARS infection (
      • Lin M.
      • Tseng H.K.
      • Trejaut J.A.
      • Lee H.L.
      • Loo J.H.
      • Chu C.C.
      • et al.
      Association of HLA class I with severe acute respiratory syndrome coronavirus infection.
      ). In Hong Kong Chinese patients, a strong association was shown between HLAB*0703 and HLA-DRB1*0301 alleles and increased susceptibility to SARS infection (
      • Ng M.H.
      • Lau K.M.
      • Li L.
      • Cheng S.H.
      • Chan W.Y.
      • Hui P.K.
      • et al.
      Association of human-leukocyte- antigen class I (B*0703) and class II (DRB1*0301) genotypes with susceptibility and resistance to the development of severe acute respiratory syndrome.
      ). In contrast, L-SIGN homozygote individuals seemed to have a significantly lower risk of SARS infection (
      • Chan V.S.
      • Chan K.Y.
      • Chen Y.
      • Poon L.L.
      • Cheung A.N.
      • Zheng B.
      • et al.
      Homozygous L-SIGN (CLEC4M) plays a protective role in SARS coronavirus infection.
      ).

      Covid-19, HLA, and ethnicity

      Generally, peripheral blood lymphocytes counts of Black Americans show lower neutrophil counts and a proportionally higher frequency of lymphocytes compared to the rest of the population (
      • Freedman D.S.
      • Gates L.
      • Flanders W.D.
      • Van Assendelft O.W.
      • Barboriak J.J.
      • Joesoef M.R.
      • et al.
      Black/white differences in leukocyte subpopulations in men.
      ). HLA-association studies of SARS-CoV-1 with HLA-ligands for SARS-CoV-2 have been compiled (
      • Sanchez-Mazas A.
      HLA studies in the context of coronavirus outbreaks.
      ). The biological and clinical relevance of immune responses to SARS-CoV-2 requires further discussion:

      Autoimmune associations with COVID-19

      Some individuals with COVID-19 experienced neurological symptoms, e.g., Guillain Barre Syndrome (
      • Zhao H.
      • Shen D.
      • Zhou H.
      • Liu J.
      • Chen S.
      Guillain-Barre syndrome associated with SARS-CoV-2 infection: causality or coincidence?.
      ), suggesting an autoimmune background, which has been associated with MHC alleles (
      • Hasan Z.N.
      • Zalzala H.H.
      • Mohammedsalih H.R.
      • Mahdi B.M.
      • Abid L.A.
      • Shakir Z.N.
      • et al.
      Association between human leukocyte antigen-DR and demyelinating Guillain-Barre syndrome.
      ). The role of MHC variants in increased susceptibility to infections or, vice versa, immune protection, is well known for a number of viral diseases, e.g., the role of MHC alleles in HIV-control, or increased risk for chronic hepatitis B (
      • Matzaraki V.
      • Kumar V.
      • Wijmenga C.
      • Zhernakova A.
      The MHC locus and genetic susceptibility to autoimmune and infectious diseases.
      ).

      MHC variants impact the quality of cellular immune responses and the potential for increased inflammation

      For instance, DRB1*15:01-DQA1*01:02-DQB1*06:02 (abbreviated ‘DR2’) dampens autoimmune responses and confers protection from type I Diabetes (
      • Noble J.A.
      • Valdes A.M.
      Genetics of the HLA region in the prediction of type 1 diabetes.
      ,
      • Siebold C.
      • Hansen B.E.
      • Wyer J.R.
      • Harlos K.
      • Esnouf R.E.
      • Svejgaard A.
      • et al.
      Crystal structure of HLA-DQ0602 that protects against type 1 diabetes and confers strong susceptibility to narcolepsy.
      ) associated with strong IFN-γ production. HLA-DQB1*06:02 has been selected for increased resistance to Yersinia pestis in immigrants from Africa to Europe; the engagement of CD4+ T-cells to HLA-DQB1*06:02 leads to increased, pro-inflammatory IL-17 production, independent of MHC class II presented peptides (
      • Mangalam A.K.
      • Taneja V.
      • David C.S.
      HLA class II molecules influence susceptibility versus protection in inflammatory diseases by determining the cytokine profile.
      ) and confers increased risk to the development of anti-myelin directed autoimmune responses (
      • Kaushansky N.
      • Ben-Nun A.
      DQB1*06:02-associated pathogenic anti-myelin autoimmunity in multiple sclerosis-like disease: potential function of DQB1*06:02 as a disease-predisposing allele.
      ). The haplotypes HLA-DR2-DQ6, DR4-DQ8, and DR3-DQ2 accommodate peptides from infectious pathogens to CD4+ T-cells from Europeans who survived the bottleneck of different, life-threatening infections prevalent in Europe (
      • Matzaraki V.
      • Kumar V.
      • Wijmenga C.
      • Zhernakova A.
      The MHC locus and genetic susceptibility to autoimmune and infectious diseases.
      ). These alleles have also shown to be associated with increased risk for autoimmune diseases, for instance, to dietary antigens (celiac disease) (
      • Cecilio L.A.
      • Bonatto M.W.
      The prevalence of HLA DQ2 and DQ8 in patients with celiac disease, in family and in general population.
      ) in part due to their intrinsic capacity to stimulate more robust IL-17 production, that facilitates Central Nervous System (CNS) associated disease manifestations (
      • Pierson E.
      • Simmons S.B.
      • Castelli L.
      • Goverman J.M.
      Mechanisms regulating regional localization of inflammation during CNS autoimmunity.
      ). Perhaps the most prominent example for MHC association with infection is the development of HLA-DQ*06:02 associated narcolepsy following H1N1 infection and H1N1-vaccination efforts in 2009/2010 (
      • Mahlios J.
      • De la Herran-Arita A.K.
      • Mignot E.
      The autoimmune basis of narcolepsy.
      ). Such aspects should be considered while examining neurological symptoms in patients after COVID-19 recovery, and also in SARS-CoV-2 vaccination efforts. Thus, certain MHC class II alleles are associated, in part independent of their antigenic peptides, with stronger inflammatory responses that are manifested as increased risks to the development of autoimmune diseases.

      Binding of (variant) antigenic peptides to certain MHC class I or class II alleles are the prerequisite for the quality of anti-virus directed cellular immune responses

      A prime example is the oncogene E6 from HPV 16, the causative agent of cervical cancer. European HPV-16 E6 variants, such as the E6 variant L83V (at the nucleotide position 350) is associated with increased risk of HPV infection and progression to malignant transformation (
      • de Araujo Souza P.S.
      • Sichero L.
      • Maciag P.C.
      HPV variants and HLA polymorphisms: the role of variability on the risk of cervical cancer.
      ). HPV E6 variability and clinical outcome are associated with different DRB1*04-DQB1*03 MHC haplotypes in the Swedish compared to other, e.g., Italian, populations: the association is between a viral variant and MHC haplotypes (
      • de Araujo Souza P.S.
      • Sichero L.
      • Maciag P.C.
      HPV variants and HLA polymorphisms: the role of variability on the risk of cervical cancer.
      ,
      • Zehbe I.
      • Mytilineos J.
      • Wikstrom I.
      • Henriksen R.
      • Edler L.
      • Tommasino M.
      Association between human papillomavirus 16 E6 variants and human leukocyte antigen class I polymorphism in cervical cancer of Swedish women.
      ). Such associations ought to be explored in SARS-CoV-2 variants as well. The tremendous impact of single amino acid substitutions in viral pathogens and MHC-restricted T-cell recognition has been described for over 30 years (
      • Rothbard J.B.
      • Busch R.
      • Howland K.
      • Bal V.
      • Fenton C.
      • Taylor W.R.
      • et al.
      Structural analysis of a peptide--HLA class II complex: identification of critical interactions for its formation and recognition by T cell receptor.
      ). Single mutations in HIV (
      • Klenerman P.
      • Rowland-Jones S.
      • McAdam S.
      • Edwards J.
      • Daenke S.
      • Lalloo D.
      • et al.
      Cytotoxic T-cell activity antagonized by naturally occurring HIV-1 Gag variants.
      ) and Hepatitis B (
      • Bertoletti A.
      • Sette A.
      • Chisari F.V.
      • Penna A.
      • Levrero M.
      • De Carli M.
      • et al.
      Natural variants of cytotoxic epitopes are T-cell receptor antagonists for antiviral cytotoxic T cells.
      ) annul cytolytic activities of epitope-specific T-cells. The mutant epitope still binds to the MHC molecule, yet serves as a T-cell antagonist. A similar phenomenon is called a partial agonist, where a mutation in the nominal T-cell epitope leads to the dissociation of IL-4 production and T-cell proliferation (
      • Evavold B.D.
      • Allen P.M.
      Separation of IL-4 production from Th cell proliferation by an altered T cell receptor ligand.
      ).
      Not only do peptide variants from the identical viral pathogen lead to abrogation or dissociation of immune functions in T-cells, but also in very similar peptides (regarding their amino acid composition), that stem from different, unrelated pathogens.This has been previously described for T-cell responses for cross-reactive T-cell responses to M. tuberculosis and HIV (
      • Hohn H.
      • Kortsik C.
      • Tully G.
      • Nilges K.
      • Necker A.
      • Freitag K.
      • et al.
      Longitudinal analysis of Mycobacterium tuberculosis 19-kDa antigen-specific T cells in patients with pulmonary tuberculosis: association with disease activity and cross-reactivity to a peptide from HIVenv gp120.
      ) associated with differential cytokine production. A different example is the cross-reactivity of HPV-specific T-cells to SARS-CoV-1 (
      • Nilges K.
      • Hohn H.
      • Pilch H.
      • Neukirch C.
      • Freitag K.
      • Talbot P.J.
      • et al.
      Human papillomavirus type 16 E7 peptide-directed CD8+ T cells from patients with cervical cancer are cross-reactive with the coronavirus NS2 protein.
      ). Thus, not only differential MHC-binding and T-cell responses should be considered in examining SARS-CoV-2 variants, but also potential similar ‘cross-reactive’ epitopes from other pathogens or ‘self’-proteins should be studied.
      The question arises, would single mutations in the wildtype of SARS-CoV-2 (or the so-called B strain (
      • Forster P.
      • Forster L.
      • Renfrew C.
      • Forster M.
      Phylogenetic network analysis of SARS-CoV-2 genomes.
      ) or L strain (
      • Tang X.
      • Lu J.
      • Cui J.
      • Qian Z.
      • Wang Y.
      • Zhang H.
      • et al.
      On the origin and continuing evolution of SARS-CoV-2.
      )) have an impact on potential MHC presentation?
      In order to test this possibility, we analyzed the most frequent MHC class I and II alleles in Europe, Asia, and Africa for binding to the mutations in ORF8 (L84S) and ORF3a (G251V) (see supplementary data sets). The MHC class I binding predictions were made with the IEDB analysis resource (TepiTool;
      • Paul S.
      • Sidney J.
      • Sette A.
      • Peters B.
      • TepiTool:
      A pipeline for computational prediction of T cell epitope candidates.
      ) using a consensus method (
      • Wang P.
      • Sidney J.
      • Kim Y.
      • Sette A.
      • Lund O.
      • Nielsen M.
      • et al.
      Peptide binding predictions for HLA DR, DP and DQ molecules.
      ) which employs a Stabilized Matrix, Artificial Neural Networks and combinatorial library methods; the MHC Class II binding predictions were done with the IEDB analysis resource (TepiTool;
      • Paul S.
      • Sidney J.
      • Sette A.
      • Peters B.
      • TepiTool:
      A pipeline for computational prediction of T cell epitope candidates.
      ) using the NetMHCIIpan method (
      • Karosiene E.
      • Rasmussen M.
      • Blicher T.
      • Lund O.
      • Buus S.
      • Nielsen M.
      NetMHCIIpan-3.0, a common pan-specific MHC class II prediction method including all three human MHC class II isotypes, HLA-DR, HLA-DP and HLA-DQ.
      ,
      • Nielsen M.
      • Lundegaard C.
      • Blicher T.
      • Peters B.
      • Sette A.
      • Justesen S.
      • et al.
      Quantitative predictions of peptide binding to any HLA-DR molecule of known sequence: NetMHCIIpan.
      ). These resources have been shown to produce satisfactory results for MHC binding predictions for SARS-CoV-1 and bona fide T-cell recognition and MHC class I-predictions of SARS-CoV-2 epitopes (
      • Sanchez-Mazas A.
      A review of HLA allele and SNP associations with highly prevalent infectious diseases in human populations.
      ). For MHC class I, starting with a peptide with the mutation site in the middle (flanked by seven amino acid residues to the left and right, resulting in a 15mer peptide) for ORF8 (L84S) (GNYTVSCLPFTINCQ and GNYTVSCSPFTINCQ) and for ORF3a (G251V) (VQIHTIDGSSGVVNP and VQIHTIDVSSGVVNP), we tested all possible combinations of length from 8 to 14 residues for MHC class I binding, For MHC class II, starting with a peptide with 33 residues with the mutation site in the middle for ORF8 (L84S) (KSPIQYIDIGNYTVSCL/SPFTINCQEPKLGSLVV) and for ORF3a (G251V) (KIVDEPEEHVQIHTIDG/VSSGVVNPVMEPIYDEP), we tested all possible combinations to bind to MHC class II alleles listed in the supplementary data set since MHC class II molecules can accommodate longer peptides, and nominal epitopes may ‘glide’ within the MHC class II peptide binding cleft (
      • Rammensee H.G.
      Chemistry of peptides associated with MHC class I and class II molecules.
      ).
      We could not identify differences in MHC class I or class II binding characteristics (see Appendix- supplementary data sets Tables S1, S2 and S3) except for three MHC class II alleles, i.e., DRB3*02:02, DRB1*09:01, and DRB1*04:01, that do not allow binding of the wildtype, but accommodate the SARS-CoV-2 ORF8 (L84S) variant (Table 1) and also two MHC class II alleles HLA-DPA1*01:03/DPB1*02:01 that do the opposite: they accommodate the wildtype but not the SARS-CoV-2 ORF8 (L84S) variant (Table 1).
      Table 1ORF8 variants and differential peptide binding.
      ProteinPeptideRank wtRank mutAllele
      HAPKYVKQNT(K)LKLATGM1.5041.00HLA-DRB1*04:01
      HACPKYVKQNT(K)LKLATG1.6041.00HLA-DRB1*04:01
      HAACPKYVKQNT(K)LKLAT1.7041.00HLA-DRB1*04:01
      HAGACPKYVKQNT(K)LKLA1.8041.00HLA-DRB1*04:01
      HAYGACPKYVKQNT(K)LKL2.0041.00HLA-DRB1*04:01
      HAYVKQNT(K)LKLATGMRN7.8032.00HLA-DRB1*04:01
      HAKYVKQNT(K)LKLATGMR8.5051.00HLA-DRB1*04:01
      ORF8DIGNYTVSCL(S)PFTIN9.6019.00HLA-DPA1*01:03/DPB1*02:01
      ORF8IDIGNYTVSCL(S)PFTI9.6022.00HLA-DPA1*01:03/DPB1*02:01
      ORF8IGNYTVSCL(S)PFTINC9.6019.00HLA-DPA1*01:03/DPB1*02:01
      ORF8PIQYIDIGNYTVSCL(S)9.6016.00HLA-DRB1*15:01
      ORF8DIGNYTVSCL(S)PFTIN17.004.40HLA-DRB3*02:02
      ORF8IGNYTVSCL(S)PFTINC18.004.50HLA-DRB3*02:02
      ORF8IDIGNYTVSCL(S)PFTI19.005.30HLA-DRB3*02:02
      ORF8GNYTVSCL(S)PFTINCQ21.006.20HLA-DRB3*02:02
      ORF8YIDIGNYTVSCL(S)PFT24.006.70HLA-DRB1*04:01
      ORF8IDIGNYTVSCL(S)PFTI28.004.90HLA-DRB1*09:01
      ORF8DIGNYTVSCL(S)PFTIN29.005.60HLA-DRB1*09:01
      ORF8YIDIGNYTVSCL(S)PFT30.005.80HLA-DRB1*09:01
      ORF8IGNYTVSCL(S)PFTINC30.007.10HLA-DRB1*09:01
      ORF8GNYTVSCL(S)PFTINCQ30.008.20HLA-DRB1*09:01
      ORF8IDIGNYTVSCL(S)PFTI39.007.90HLA-DRB1*04:01
      ORF8GNYTVSCL(S)PFTINCQ43.009.30HLA-DRB1*04:01
      ORF8DIGNYTVSCL(S)PFTIN44.008.30HLA-DRB1*04:01
      ORF8IGNYTVSCL(S)PFTINC45.008.60HLA-DRB1*04:01
      A lower ranking value designates better MHC class II binding; we used the default recommended rank <10 as the cutoff value for binding. Two MHC class II alleles accommodate the ORF8 wildtype, yet not the variant (L84S). Three MHC class II alleles predict binding to the SARS-CoV-2 ORF8 mut (L84S) variant. For comparison (top of the tablepa), a well-characterized Flu A hemagglutinin epitope showing strong binding of the wildtype, but not the mutant variant to HLA-DRB1*04:01; this epitope is also recognized by T-cells. In bold and underlined, the amino acid in the wildtype sequence, and in parentheses, the amino acid in the mutant variant.
      In order to show the validity of the peptide prediction methodology, we examined the literature for viral variants that bind differently to one of these alleles and identified the epitope PKYVKQNTLKLATGM, representing the wildtype hemagglutinin sequence from Influenza A virus subtype H3N2 that is recognized by a well-characterized T clone (
      • Hennecke J.
      • Wiley D.C.
      Structure of a complex of the human alpha/beta T cell receptor (TCR) HA1.7, influenza hemagglutinin peptide, and major histocompatibility complex class II molecule, HLA- DR4 (DRA*0101 and DRB1*0401): insight into TCR cross-restriction and alloreactivity.
      ). For this prediction we used a 33 residue peptide with the mutation site in the middle (VNKITYGACPKYVKQNTLKLATGMRNVPEKQTR) and the best fitting peptide with 15 residues that were predicted to bind to HLA-DRB1*04:01, is exactly the peptide reported earlier (
      • Hennecke J.
      • Wiley D.C.
      Structure of a complex of the human alpha/beta T cell receptor (TCR) HA1.7, influenza hemagglutinin peptide, and major histocompatibility complex class II molecule, HLA- DR4 (DRA*0101 and DRB1*0401): insight into TCR cross-restriction and alloreactivity.
      ) recognized by a Flu epitope-specific T-cell clone. In contrast, one of the Flu variant (T314K) peptides does not bind to to HLA-DRB1*04:01 (Table 1).
      Of the 11,970 SARS-CoV-2 sequences deposited in the GISAID database by April 27th, 2020, 85% exhibit the amino acid Leucine at the position 84 and 15% exhibit Serine. From the countries that have submitted more than 100 sequences, there are four where the distribution of ORF8 (L84S) is different from the worldwide trend: in China, 38% SARS-CoV-2 sequences account for ORF8 (L84S), in Spain 43%, in the USA 32% and in Canada 31% (Figure 1). Based on the information from previous studies (
      • Solberg O.D.
      • Mack S.J.
      • Lancaster A.K.
      • Single R.M.
      • Tsai Y.
      • Sanchez-Mazas A.
      • et al.
      Balancing selection and heterogeneity across the classical human leukocyte antigen loci: a meta-analytic review of 497 population studies.
      ), the allele frequency of HLA-DRB1*04:01 is around 0.03 in Spain, around 0.1 in Caucasians in the USA but around 0.02 in other ethnicities in the USA, around 0.01 in China and around 0.008 in Canada (Figure 2); for HLA-DRB1*09:01 the allele frequency is around 0.008 in Spain, around 0.1 in Asians in the USA but around 0.01 in other ethnicities in the USA, and around 0.07 in Canada (Figure 3); there is insufficient information available regarding HLA-DRB3*02:02. Thus, ORF8 L84S variant in SARS-CoV-2, but not the wildtype, can be accommodated by DRB1*0401, which has been reported to be associated with susceptibility to HPV infections (
      • de Araujo Souza P.S.
      • Sichero L.
      • Maciag P.C.
      HPV variants and HLA polymorphisms: the role of variability on the risk of cervical cancer.
      ,
      • Zhao J.
      • Wang L.
      • Lin H.
      • Yu W.
      • Xu X.
      • Hu H.
      • et al.
      Association of HLA-DRB1/DQB1 polymorphism with high-risk HPV infection and cervical intraepithelial neoplasia women from Shanghai.
      ,
      • Chambuso R.
      • Gray C.M.
      • Kaambo E.
      • Rebello G.
      • Ramesar R.
      Impact of host molecular genetic variations and HIV/HPV co-infection on cervical cancer progression: a systematic review.
      ,
      • Chen Q.Y.
      • Huang W.
      • She J.X.
      • Baxter F.
      • Volpe R.
      • Maclaren N.K.
      HLA-DRB1*08, DRB1*03/DRB3*0101, and DRB3*0202 are susceptibility genes for Graves’ disease in North American Caucasians, whereas DRB1*07 is protective.
      ,
      • Chen Z.
      • Jing Y.
      • Wen Q.
      • Ding X.
      • Wang T.
      • Mu X.
      • et al.
      E6 and E7 gene polymorphisms in human papillomavirus types-58 and 33 identified in Southwest China.
      ), Multiple Sclerosis (
      • Laroni A.
      • Calabrese M.
      • Perini P.
      • Albergoni M.P.
      • Ranzato F.
      • Tiberio M.
      • et al.
      Multiple sclerosis and autoimmune diseases: epidemiology and HLA-DR association in North-east Italy.
      ), Rheumatoid Arthritis (
      • Angelini G.
      • Morozzi G.
      • Delfino L.
      • Pera C.
      • Falco M.
      • Marcolongo R.
      • et al.
      Analysis of HLA DP, DQ, and DR alleles in adult Italian rheumatoid arthritis patients.
      ), type 1 diabetes (
      • Fernandez-Vina M.
      • Ramirez L.C.
      • Raskin P.
      • Stastny P.
      Genes for insulin-dependent diabetes mellitus (IDDM) in the major histocompatibility complex (MHC) of African-Americans.
      ,
      • Undlien D.E.
      • Friede T.
      • Rammensee H.G.
      • Joner G.
      • Dahl-Jorgensen K.
      • Sovik O.
      • et al.
      HLA-encoded genetic predisposition in IDDM: DR4 subtypes may be associated with different degrees of protection.
      ), and Lyme disease-induced arthritis (
      • Gross D.M.
      • Forsthuber T.
      • Tary-Lehmann M.
      • Etling C.
      • Ito K.
      • Nagy Z.A.
      • et al.
      Identification of LFA- 1 as a candidate autoantigen in treatment-resistant Lyme arthritis.
      ). DRB1*09:01 is associated with early childhood myasthenia gravis (
      • Shinomiya N.
      • Nomura Y.
      • Segawa M.
      A variant of childhood-onset myasthenia gravis: HLA typing and clinical characteristics in Japan.
      ). DRB3*02:02 is linked to Grave's disease (
      • Shinomiya N.
      • Nomura Y.
      • Segawa M.
      A variant of childhood-onset myasthenia gravis: HLA typing and clinical characteristics in Japan.
      ), serum IgG antibodies to Chlamydia pneumoniae with essential hypertension (
      • Zabay J.M.
      • Marco J.
      • Soler J.
      • Contu L.
      • Cappai L.
      • Carcassi C.
      • et al.
      Association of HLA-DRB3*0202 and serum IgG antibodies to Chlamydia pneumoniae with essential hypertension in a highly homogeneous population from Majorca (Balearic Islands, Spain).
      ), and acute necrotizing encephalopathy (
      • Oh H.H.
      • Kwon S.H.
      • Kim C.W.
      • Choe B.H.
      • Ko C.W.
      • Jung H.D.
      • et al.
      Molecular analysis of HLA class II-associated susceptibility to neuroinflammatory diseases in Korean children.
      ). In contrast, the ORF8 L84S variant annuls binding to two MHC class II alleles that the wildtype virus allows: HLA-DPA1*01:03/DPB1*02:01 and DRB1*15:01. DPA1 and DPB1 encode different amino acid residues in the peptide-binding groove of MHC class II alleles that determine which peptides can be presented to CD4+ T-cells. HLA-DPA1*01:03-DPB1*04:02 (but not DPB1*02:01) was associated with an increased risk of developing narcolepsy (
      • Ollila H.M.
      • Ravel J.M.
      • Han F.
      • Faraco J.
      • Lin L.
      • Zheng X.
      • et al.
      HLA-DPB1 and HLA class I confer risk of and protection from narcolepsy.
      ). We have not been able to identify reports of associations of the HLA-DPA1*01:03/DPB1*02:01 heterodimers with increased or decreased risk for disease. DRB1*15:01 represents a significant risk factor for multiple sclerosis and is strongly expressed, due to hypomethylation, in monocytes from DRB1*15:01-positive individuals (
      • Kular L.
      • Liu Y.
      • Ruhrmann S.
      • Zheleznyakova G.
      • Marabita F.
      • Gomez-Cabrero D.
      • et al.
      DNA methylation as a mediator of HLA-DRB1*15:01 and a protective variant in multiple sclerosis.
      ). It remains to be demonstrated whether these MHC class II alleles can present the nominal ORF8 epitope – and whether there are MHC class II-peptide specific T-cells in the TCR repertoire that would recognize the MHC II-peptide complex. Peptide binding to specific MHC alleles has been shown to be associated with increased risk for autoimmune diseases. Conceptually, this may argue that more robust cellular immune responses may help in viral clearance, yet also present potential increased risks for subsequent autoimmune diseases affecting the CNS.
      Figure 1
      Figure 1Distribution of the SARS-CoV-2 ORF8 S residue at position 84. 11970 SARS-CoV-2 sequences deposited in the GISAID database by April 27th, 2020. 87% have the Leucine amino acid at position 84 and 13% exhibit Serine. In the countries that submitted more than 100 sequences where the proportion is different: in China, 38% SARS-CoV-2 sequences account for ORF8 (S84L), in Spain 43%, in the USA 32% and in Canada 31%.
      Figure 2
      Figure 2Frequency of HLA-DRB1*04:01 that allows binding of the ORF8 variant epitope. Based on previous studies (
      • Solberg O.D.
      • Mack S.J.
      • Lancaster A.K.
      • Single R.M.
      • Tsai Y.
      • Sanchez-Mazas A.
      • et al.
      Balancing selection and heterogeneity across the classical human leukocyte antigen loci: a meta-analytic review of 497 population studies.
      ), the allele frequency of HLA-DRB1*04:01 is around 0.03 in Spain, around 0.1 in Caucasians in the USA, but around 0.02 in other ethnicities in the USA, around 0.01 in China, and 0.008 in Canada.
      Figure 3
      Figure 3Frequency of HLA-DRB1*09:01. Based on previous studies (
      • Solberg O.D.
      • Mack S.J.
      • Lancaster A.K.
      • Single R.M.
      • Tsai Y.
      • Sanchez-Mazas A.
      • et al.
      Balancing selection and heterogeneity across the classical human leukocyte antigen loci: a meta-analytic review of 497 population studies.
      ) for HLA-DRB1*09:01, the allele frequency is around 0.008 in Spain, approximately 0.1 in Asians in the USA, but around 0.01 in other ethnicities in the USA, and approximately 0.07 in Canada.
      In conclusion, there appears to be no selective pressure from MHC class I alleles for the tested SARS-CoV-2 variants. Most likely, there is selective pressure from MHC class II alleles regarding the binding of the ORF8 (L84S) variants, assuming that this mutation may be biologically relevant (
      • Forster P.
      • Forster L.
      • Renfrew C.
      • Forster M.
      Phylogenetic network analysis of SARS-CoV-2 genomes.
      ,
      • Tang X.
      • Lu J.
      • Cui J.
      • Qian Z.
      • Wang Y.
      • Zhang H.
      • et al.
      On the origin and continuing evolution of SARS-CoV-2.
      ). These data underlines the need to examine SARS-CoV-2 variants and MHC-associations along with clinical outcomes, a detailed longtime observation with a specific focus on CNS-associated symptoms, chiefly in individuals with an increased risk to develop autoimmune responses. Functional analysis applying ‘real-world’ T-cell recognition assays in association with MHC 4-digit typing is required to determine and gauge SARS-CoV-2 directed cellular immune responses associated with the clinical expression of severity of disease and relevant management endpoints including deaths.

      Ethical approval

      No ethical approval was required; we used publicly available data and performed predictive in silico analyses

      Conflict of interest

      All authors declare no conflicts of interest.

      Acknowledgments

      Professor Ippolito, Sir Zumla, and Prof Mohamed Osman are co-investigators of the Pan-African Network on Emerging and Re-emerging Infections (PANDORA-ID-NET) funded by the European and Developing Countries Clinical Trials Partnership the EU Horizon 2020 Framework Programme for Research and Innovation. Sir Zumla is in receipt of a UK-NIHR Senior Investigatorship. Professor Maeurer is a member of the Gates Foundation's innate immunity advisory group, and the Champalimaud Foundation funds his work. All authors are members of the Global Cancer and Infectious Diseases consortium for Host-directed therapies: Web link: https://fchampalimaud.org/covid19/aci.

      Appendix A. Supplementary data

      The following are Supplementary data to this article:

      References

        • Angelini G.
        • Morozzi G.
        • Delfino L.
        • Pera C.
        • Falco M.
        • Marcolongo R.
        • et al.
        Analysis of HLA DP, DQ, and DR alleles in adult Italian rheumatoid arthritis patients.
        Human Immunol. 1992; 34: 135-141
        • Bertoletti A.
        • Sette A.
        • Chisari F.V.
        • Penna A.
        • Levrero M.
        • De Carli M.
        • et al.
        Natural variants of cytotoxic epitopes are T-cell receptor antagonists for antiviral cytotoxic T cells.
        Nature. 1994; 369: 407-410
        • Cecilio L.A.
        • Bonatto M.W.
        The prevalence of HLA DQ2 and DQ8 in patients with celiac disease, in family and in general population.
        Arq Bras Cir Dig. 2015; 28: 183-185
        • Chambuso R.
        • Gray C.M.
        • Kaambo E.
        • Rebello G.
        • Ramesar R.
        Impact of host molecular genetic variations and HIV/HPV co-infection on cervical cancer progression: a systematic review.
        Oncomedicine. 2018; 3: 82-93
        • Chan V.S.
        • Chan K.Y.
        • Chen Y.
        • Poon L.L.
        • Cheung A.N.
        • Zheng B.
        • et al.
        Homozygous L-SIGN (CLEC4M) plays a protective role in SARS coronavirus infection.
        Nat Genet. 2006; 38: 38-46
        • Chen Q.Y.
        • Huang W.
        • She J.X.
        • Baxter F.
        • Volpe R.
        • Maclaren N.K.
        HLA-DRB1*08, DRB1*03/DRB3*0101, and DRB3*0202 are susceptibility genes for Graves’ disease in North American Caucasians, whereas DRB1*07 is protective.
        J Clin Endocrinol Metab. 1999; 84: 3182-3186
        • Chen Z.
        • Jing Y.
        • Wen Q.
        • Ding X.
        • Wang T.
        • Mu X.
        • et al.
        E6 and E7 gene polymorphisms in human papillomavirus types-58 and 33 identified in Southwest China.
        PLOS ONE. 2017; 12: e0171140
        • de Araujo Souza P.S.
        • Sichero L.
        • Maciag P.C.
        HPV variants and HLA polymorphisms: the role of variability on the risk of cervical cancer.
        Future Oncol. 2009; 5: 359-370
        • Evavold B.D.
        • Allen P.M.
        Separation of IL-4 production from Th cell proliferation by an altered T cell receptor ligand.
        Science. 1991; 252: 1308-1310
        • Fernandez-Vina M.
        • Ramirez L.C.
        • Raskin P.
        • Stastny P.
        Genes for insulin-dependent diabetes mellitus (IDDM) in the major histocompatibility complex (MHC) of African-Americans.
        Tissue Antigens. 1993; 41: 57-64
        • Forster P.
        • Forster L.
        • Renfrew C.
        • Forster M.
        Phylogenetic network analysis of SARS-CoV-2 genomes.
        Proc Natl Acad Sci USA. 2020;
        • Freedman D.S.
        • Gates L.
        • Flanders W.D.
        • Van Assendelft O.W.
        • Barboriak J.J.
        • Joesoef M.R.
        • et al.
        Black/white differences in leukocyte subpopulations in men.
        Int J Epidemiol. 1997; 26: 757-764
        • Gross D.M.
        • Forsthuber T.
        • Tary-Lehmann M.
        • Etling C.
        • Ito K.
        • Nagy Z.A.
        • et al.
        Identification of LFA- 1 as a candidate autoantigen in treatment-resistant Lyme arthritis.
        Science. 1998; 281: 703-706
        • Hasan Z.N.
        • Zalzala H.H.
        • Mohammedsalih H.R.
        • Mahdi B.M.
        • Abid L.A.
        • Shakir Z.N.
        • et al.
        Association between human leukocyte antigen-DR and demyelinating Guillain-Barre syndrome.
        Neurosciences (Riyadh). 2014; 19: 301-305
        • Hennecke J.
        • Wiley D.C.
        Structure of a complex of the human alpha/beta T cell receptor (TCR) HA1.7, influenza hemagglutinin peptide, and major histocompatibility complex class II molecule, HLA- DR4 (DRA*0101 and DRB1*0401): insight into TCR cross-restriction and alloreactivity.
        J Exp Med. 2002; 195: 571-581
        • Hohn H.
        • Kortsik C.
        • Tully G.
        • Nilges K.
        • Necker A.
        • Freitag K.
        • et al.
        Longitudinal analysis of Mycobacterium tuberculosis 19-kDa antigen-specific T cells in patients with pulmonary tuberculosis: association with disease activity and cross-reactivity to a peptide from HIVenv gp120.
        Eur J Immunol. 2003; 33: 1613-1623
        • Karosiene E.
        • Rasmussen M.
        • Blicher T.
        • Lund O.
        • Buus S.
        • Nielsen M.
        NetMHCIIpan-3.0, a common pan-specific MHC class II prediction method including all three human MHC class II isotypes, HLA-DR, HLA-DP and HLA-DQ.
        Immunogenetics. 2013; 65: 711-724
        • Kaushansky N.
        • Ben-Nun A.
        DQB1*06:02-associated pathogenic anti-myelin autoimmunity in multiple sclerosis-like disease: potential function of DQB1*06:02 as a disease-predisposing allele.
        Front Oncol. 2014; 4: 280
        • Khunti K.
        • Singh A.K.
        • Pareek M.
        • Hanif W.
        Is ethnicity linked to incidence or outcomes of covid-19?.
        BMJ. 2020; 369: m1548
        • Klenerman P.
        • Rowland-Jones S.
        • McAdam S.
        • Edwards J.
        • Daenke S.
        • Lalloo D.
        • et al.
        Cytotoxic T-cell activity antagonized by naturally occurring HIV-1 Gag variants.
        Nature. 1994; 369: 403-407
        • Kular L.
        • Liu Y.
        • Ruhrmann S.
        • Zheleznyakova G.
        • Marabita F.
        • Gomez-Cabrero D.
        • et al.
        DNA methylation as a mediator of HLA-DRB1*15:01 and a protective variant in multiple sclerosis.
        Nat Commun. 2018; 9: 2397
        • Laroni A.
        • Calabrese M.
        • Perini P.
        • Albergoni M.P.
        • Ranzato F.
        • Tiberio M.
        • et al.
        Multiple sclerosis and autoimmune diseases: epidemiology and HLA-DR association in North-east Italy.
        J Neurol. 2006; 253: 636-639
        • Lin M.
        • Tseng H.K.
        • Trejaut J.A.
        • Lee H.L.
        • Loo J.H.
        • Chu C.C.
        • et al.
        Association of HLA class I with severe acute respiratory syndrome coronavirus infection.
        BMC Med Genet. 2003; 4: 9
        • Mahlios J.
        • De la Herran-Arita A.K.
        • Mignot E.
        The autoimmune basis of narcolepsy.
        Curr Opin Neurobiol. 2013; 23: 767-773
        • Mangalam A.K.
        • Taneja V.
        • David C.S.
        HLA class II molecules influence susceptibility versus protection in inflammatory diseases by determining the cytokine profile.
        J Immunol. 2013; 190: 513-518
        • Matzaraki V.
        • Kumar V.
        • Wijmenga C.
        • Zhernakova A.
        The MHC locus and genetic susceptibility to autoimmune and infectious diseases.
        Genome Biol. 2017; 18: 76
        • Ng M.H.
        • Lau K.M.
        • Li L.
        • Cheng S.H.
        • Chan W.Y.
        • Hui P.K.
        • et al.
        Association of human-leukocyte- antigen class I (B*0703) and class II (DRB1*0301) genotypes with susceptibility and resistance to the development of severe acute respiratory syndrome.
        J Infect Dis. 2004; 190: 515-518
        • Nielsen M.
        • Lundegaard C.
        • Blicher T.
        • Peters B.
        • Sette A.
        • Justesen S.
        • et al.
        Quantitative predictions of peptide binding to any HLA-DR molecule of known sequence: NetMHCIIpan.
        PLoS Comput Biol. 2008; 4: e1000107
        • Nilges K.
        • Hohn H.
        • Pilch H.
        • Neukirch C.
        • Freitag K.
        • Talbot P.J.
        • et al.
        Human papillomavirus type 16 E7 peptide-directed CD8+ T cells from patients with cervical cancer are cross-reactive with the coronavirus NS2 protein.
        J Virol. 2003; 77: 5464-5474
        • Noble J.A.
        • Valdes A.M.
        Genetics of the HLA region in the prediction of type 1 diabetes.
        Curr Diab Rep. 2011; 11: 533-542
        • Oh H.H.
        • Kwon S.H.
        • Kim C.W.
        • Choe B.H.
        • Ko C.W.
        • Jung H.D.
        • et al.
        Molecular analysis of HLA class II-associated susceptibility to neuroinflammatory diseases in Korean children.
        J Korean Med Sci. 2004; 19: 426-430
        • Ollila H.M.
        • Ravel J.M.
        • Han F.
        • Faraco J.
        • Lin L.
        • Zheng X.
        • et al.
        HLA-DPB1 and HLA class I confer risk of and protection from narcolepsy.
        Am J Hum Genet. 2015; 96: 136-146
        • Paul S.
        • Sidney J.
        • Sette A.
        • Peters B.
        • TepiTool:
        A pipeline for computational prediction of T cell epitope candidates.
        Curr Protoc Immunol. 2016; 114 (18 9 1- 9 24)
        • Pierson E.
        • Simmons S.B.
        • Castelli L.
        • Goverman J.M.
        Mechanisms regulating regional localization of inflammation during CNS autoimmunity.
        Immunol Rev. 2012; 248: 205-215
        • Rammensee H.G.
        Chemistry of peptides associated with MHC class I and class II molecules.
        Curr Opin Immunol. 1995; 7: 85-96
        • Rothbard J.B.
        • Busch R.
        • Howland K.
        • Bal V.
        • Fenton C.
        • Taylor W.R.
        • et al.
        Structural analysis of a peptide--HLA class II complex: identification of critical interactions for its formation and recognition by T cell receptor.
        Int Immunol. 1989; 1: 479-486
        • Sanchez-Mazas A.
        HLA studies in the context of coronavirus outbreaks.
        Swiss Med Wkly. 2020; 150: w20248
        • Sanchez-Mazas A.
        A review of HLA allele and SNP associations with highly prevalent infectious diseases in human populations.
        Swiss Med Wkly. 2020; 150: w20214
        • Shinomiya N.
        • Nomura Y.
        • Segawa M.
        A variant of childhood-onset myasthenia gravis: HLA typing and clinical characteristics in Japan.
        Clin Immunol. 2004; 110: 154-158
        • Siebold C.
        • Hansen B.E.
        • Wyer J.R.
        • Harlos K.
        • Esnouf R.E.
        • Svejgaard A.
        • et al.
        Crystal structure of HLA-DQ0602 that protects against type 1 diabetes and confers strong susceptibility to narcolepsy.
        Proc Natl Acad Sci USA. 2004; 101: 1999-2004
        • Solberg O.D.
        • Mack S.J.
        • Lancaster A.K.
        • Single R.M.
        • Tsai Y.
        • Sanchez-Mazas A.
        • et al.
        Balancing selection and heterogeneity across the classical human leukocyte antigen loci: a meta-analytic review of 497 population studies.
        Hum Immunol. 2008; 69: 443-464
        • Tang X.
        • Lu J.
        • Cui J.
        • Qian Z.
        • Wang Y.
        • Zhang H.
        • et al.
        On the origin and continuing evolution of SARS-CoV-2.
        Natl Sci Rev. 2020;
        • Undlien D.E.
        • Friede T.
        • Rammensee H.G.
        • Joner G.
        • Dahl-Jorgensen K.
        • Sovik O.
        • et al.
        HLA-encoded genetic predisposition in IDDM: DR4 subtypes may be associated with different degrees of protection.
        Diabetes. 1997; 46: 143-149
        • Wang P.
        • Sidney J.
        • Kim Y.
        • Sette A.
        • Lund O.
        • Nielsen M.
        • et al.
        Peptide binding predictions for HLA DR, DP and DQ molecules.
        BMC Bioinformatics. 2010; 11: 568
        • Zabay J.M.
        • Marco J.
        • Soler J.
        • Contu L.
        • Cappai L.
        • Carcassi C.
        • et al.
        Association of HLA-DRB3*0202 and serum IgG antibodies to Chlamydia pneumoniae with essential hypertension in a highly homogeneous population from Majorca (Balearic Islands, Spain).
        J Hum Hypertens. 2005; 19: 615-622
        • Zehbe I.
        • Mytilineos J.
        • Wikstrom I.
        • Henriksen R.
        • Edler L.
        • Tommasino M.
        Association between human papillomavirus 16 E6 variants and human leukocyte antigen class I polymorphism in cervical cancer of Swedish women.
        Hum Immunol. 2003; 64: 538-542
        • Zhao J.
        • Wang L.
        • Lin H.
        • Yu W.
        • Xu X.
        • Hu H.
        • et al.
        Association of HLA-DRB1/DQB1 polymorphism with high-risk HPV infection and cervical intraepithelial neoplasia women from Shanghai.
        Int J Clin Exp Pathol. 2018; 11: 748-756
        • Zhao H.
        • Shen D.
        • Zhou H.
        • Liu J.
        • Chen S.
        Guillain-Barre syndrome associated with SARS-CoV-2 infection: causality or coincidence?.
        Lancet Neurol. 2020; 19: 383-384