Journal Article

Risk factors for COVID-19 symptom severity across clinical categories among hospitalised patients in Kuala Lumpur, Malaysia: a prospective cohort study

Salleh, Sharifah Azura, Abdullah, Noraidatulakma, Sulong, Anita, Mohammed Nawi, Azmawati, Ismail, Norliza, Dauni, Andri, Muhammad Azami, Nor Azila, Min, Joanna Ooi Su, Periyasamy, Petrick, Rashid, Noor Zetti Zainol, Mustafa, Norlaila, Nawawi, Khamsiah, Othman, Hanita, Ahmad, Norfazilah, Mhd Yusuf, Nurul Ain, Mohamed Said, Mohd Shahrir, Kamalul Arifin, Azwa Shawani, Khuzaimi, Aisyatul Najihah, Koon, Poh Bee, Abdul Jalal, Muhammad Irfan, Jamal, Shamsuriani Md, Sapuan, Norrafidah Md, Shafie, Ahmad Syafiq, Hamzah, Faizal Amri, Wan Sallam, Wan Ahmad Faisal, Jamal, Rahman, Wan Mat, Wan Rahiza, Jarmin, Razman, Hamid, Faisal, Hajib, Noriah, Alias, Hamidah, Hassan, Mohd Rohaizat, Mokhtar, Mohammad Nizam, Kori, Najma, Selvam, Sheela Bai Pannir, Othman, Siti Norlia, Johdi, Nor Adzimah, Harunarashid, Hanafiah, Kamaruddin, Mohd Arman, Goh, Ying-Xian, Abd Jalal, Nazihah

2026

Overview

ObjectivesThis 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.DesignProspective cohort study.SettingA secondary-care/tertiary-care hospital and linked community settings in Cheras, Kuala Lumpur, Malaysia.ParticipantsThis 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 measuresPrimary 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.Results141 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).ConclusionsAn 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.

• Publisher: British Medical Journal Publishing Group,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Adolescent / Adult / Aged / Asymptomatic / Child / Clinical outcomes / Cohort analysis / COVID-19 / COVID-19 - diagnosis / COVID-19 - epidemiology / COVID-19 - mortality / COVID-19 diagnostic tests / COVID-19 vaccines / Cytokines / Data collection / Disease prevention / Disease transmission / Epidemiology / Female / Hospital Mortality / Hospitalization - statistics & numerical data / Hospitals / Humans / Hypoxia / Immunization / Infection control / Infections / Infectious Diseases / Intensive Care Units - statistics & numerical data / Laboratories / Malaysia - epidemiology / Male / Medical records / MICROBIOLOGY / Middle Aged / Mortality / Original Research / Pandemics / Pneumonia / Polymerase chain reaction / Prospective Studies / Public health / Reproducibility / Risk Factors / SARS-CoV-2 / Severe acute respiratory syndrome coronavirus 2 / Severity of Illness Index / Tumor necrosis factor-TNF / VIROLOGY / Young Adult