{
  "abstract": "Objectives This study aimed to quantify how patient risk factors relate to COVID-19 severity across categories 1–5 in a prospective, hospital-based cohort. We hypothesised that greater severity would be associated with higher odds of intensive care unit (ICU) admission and in-hospital mortality. Secondary aims were to assess associations with age, viral variants, symptom clusters, lymphocyte count, fasting blood glucose and cytokine profiles.Design Prospective cohort study.Setting A secondary-care/tertiary-care hospital and linked community settings in Cheras, Kuala Lumpur, Malaysia.Participants This study was nested within the COVGEN project, a prospective COVID-19 cohort conducted at Hospital Canselor Tuanku Muhriz UKM (HCTM), Cheras Health Clinic and the Bandar Tun Razak COVID-19 Assessment Centre in Cheras, Kuala Lumpur, Malaysia, from 1 August 2021 to 31 October 2022. 2532 participants were enrolled at baseline. Eligible participants were Malaysian citizens aged 12–18 years (paediatric/adolescent) or ≥18 years who had reverse transcription-polymerase chain reaction–confirmed COVID-19 at recruitment and resided in Kuala Lumpur or Selangor. Patients who had a clinically unstable condition and those who declined participation (personally or via a next-of-kin or legal representative) were excluded. This analysis included 559 patients hospitalised at HCTM; after excluding five with incomplete questionnaires, 554 remained for analysis (413 admitted to general wards and 141 to ICUs). Categories 3–5 comprised hospitalised patients, whereas categories 1–2 included hospitalised individuals and a subset recruited from community settings.Primary and secondary outcome measures Primary outcomes included disease severity (categories 4–5 vs 1–3), ICU admission and in-hospital mortality. Secondary outcomes included associations with age strata, viral variant (delta vs omicron), symptom clusters, lymphocyte count, fasting blood glucose and cytokines: interferon gamma-inducible protein 10, interferon gamma, interleukins 8, 10, 2, 6 and 7 and tumour necrosis factor alpha.Results 141 of 554 (25.5%) patients required ICU care. Compared with milder categories, category 5 was associated with markedly higher odds of ICU admission (OR 204.50; 95% CI 37.54 to 1114.18; p<0.001) and death (OR 13.20, 95% CI 3.97 to 43.86; p<0.05). Older age was associated with greater severity: >55 versus <36 years for categories 3 (OR 4.575; 95% CI 1.472 to 14.218; p=0.009) and 5 (OR 18.003; 95% CI 1.139 to 284.601; p=0.040) and 36–55 versus <36 years for category 5 (OR 18.412; 95% CI 1.094 to 309.951; p=0.043). Delta accounted for 47.7% of infections compared with 17.9% for omicron, with a higher proportion of category 4 presentations among delta cases. Systemic, pulmonary/respiratory and gastrointestinal symptoms, lymphopenia, hyperglycaemia and elevated cytokines were each associated with increasing severity (p<0.05).Conclusions An increasing clinical severity category was strongly associated with ICU admission and mortality. Age, delta infection, specific symptom clusters, lymphopenia, hyperglycaemia and pro-inflammatory cytokines identified higher-risk patients, supporting risk-stratified management and prioritisation for enhanced monitoring.",
  "authors": [
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Nor Adzimah Johdi"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Noraidatulakma Abdullah"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Ying-Xian Goh"
    },
    {
      "affiliations": [
        "Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Joanna Ooi Su Min"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Nor Azila Muhammad Azami"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Muhammad Irfan Abdul Jalal"
    },
    {
      "affiliations": [
        "Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Azmawati Mohammed Nawi"
    },
    {
      "affiliations": [
        "Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Norfazilah Ahmad"
    },
    {
      "affiliations": [
        "Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Mohd Rohaizat Hassan"
    },
    {
      "affiliations": [
        "Department of Microbiology and Medical Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Anita Sulong"
    },
    {
      "affiliations": [
        "Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Najma Kori"
    },
    {
      "affiliations": [
        "Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Petrick Periyasamy"
    },
    {
      "affiliations": [
        "Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Faisal Hamid"
    },
    {
      "affiliations": [
        "Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Norrafidah Md Sapuan"
    },
    {
      "affiliations": [
        "Cheras Health Clinic, Ministry of Health Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Sheela Bai Pannir Selvam"
    },
    {
      "affiliations": [
        "Cheras Health Clinic, Ministry of Health Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Noriah Hajib"
    },
    {
      "affiliations": [
        "Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Norlaila Mustafa"
    },
    {
      "affiliations": [
        "Department of Microbiology and Medical Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Noor Zetti Zainol Rashid"
    },
    {
      "affiliations": [
        "Infection Control Unit, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Sharifah Azura Salleh"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Hamidah Alias"
    },
    {
      "affiliations": [
        "Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Mohd Shahrir Mohamed Said"
    },
    {
      "affiliations": [
        "Department of Microbiology and Medical Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Siti Norlia Othman"
    },
    {
      "affiliations": [
        "Centre for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia"
      ],
      "name": "Poh Bee Koon"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Faizal Amri Hamzah"
    },
    {
      "affiliations": [
        "Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Shamsuriani Md Jamal"
    },
    {
      "affiliations": [
        "Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Razman Jarmin"
    },
    {
      "affiliations": [
        "Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Hanita Othman"
    },
    {
      "affiliations": [
        "Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Khamsiah Nawawi"
    },
    {
      "affiliations": [
        "Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Hanafiah Harunarashid"
    },
    {
      "affiliations": [
        "Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Mohammad Nizam Mokhtar"
    },
    {
      "affiliations": [
        "Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Wan Rahiza Wan Mat"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Azwa Shawani Kamalul Arifin"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Aisyatul Najihah Khuzaimi"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Nazihah Abd Jalal"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Norliza Ismail"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Nurul Ain Mhd Yusuf"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Andri Dauni"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Wan Ahmad Faisal Wan Sallam"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Ahmad Syafiq Shafie"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Mohd Arman Kamaruddin"
    },
    {
      "affiliations": [
        "UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"
      ],
      "name": "Rahman Jamal"
    }
  ],
  "title": "Risk factors for COVID-19 symptom severity across clinical categories among hospitalised patients in Kuala Lumpur, Malaysia: a prospective cohort study",
  "uid": "d8edcbb7-1c35-5779-9ac5-f022ae248ce4"
}