{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T20:09:50Z","timestamp":1787170190888,"version":"build-2736575974"},"reference-count":58,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T00:00:00Z","timestamp":1773100800000},"content-version":"unspecified","delay-in-days":9,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003093","name":"Ministry of Higher Education. Malaysia","doi-asserted-by":"crossref","award":["PRIHATIN-2021-001\/1"],"award-info":[{"award-number":["PRIHATIN-2021-001\/1"]}],"id":[{"id":"10.13039\/501100003093","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,2,12]]},"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>This study aimed to quantify how patient risk factors relate to COVID-19 severity across categories 1\u20135 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Prospective cohort study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>A secondary-care\/tertiary-care hospital and linked community settings in Cheras, Kuala Lumpur, Malaysia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>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\u201318 years (paediatric\/adolescent) or \u226518 years who had reverse transcription-polymerase chain reaction\u2013confirmed 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\u20135 comprised hospitalised patients, whereas categories 1\u20132 included hospitalised individuals and a subset recruited from community settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>Primary outcomes included disease severity (categories 4\u20135 vs 1\u20133), 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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&lt;0.001) and death (OR 13.20, 95%\u2009CI 3.97 to 43.86; p&lt;0.05). Older age was associated with greater severity: &gt;55 versus &lt;36 years for categories 3 (OR 4.575; 95%\u2009CI 1.472 to 14.218; p=0.009) and 5 (OR 18.003; 95%\u2009CI 1.139 to 284.601; p=0.040) and 36\u201355 versus &lt;36 years for category 5 (OR 18.412; 95%\u2009CI 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&lt;0.05).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-103389","type":"journal-article","created":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T14:55:19Z","timestamp":1773154519000},"page":"e103389","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Risk factors for COVID-19 symptom severity across clinical categories among hospitalised patients in Kuala Lumpur, Malaysia: a prospective cohort study"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1953-112X","authenticated-orcid":false,"given":"Nor Adzimah","family":"Johdi","sequence":"first","affiliation":[{"name":"UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan 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Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7724-6023","authenticated-orcid":false,"given":"Nor Azila","family":"Muhammad Azami","sequence":"additional","affiliation":[{"name":"UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6911-3335","authenticated-orcid":false,"given":"Muhammad Irfan","family":"Abdul Jalal","sequence":"additional","affiliation":[{"name":"UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Azmawati","family":"Mohammed Nawi","sequence":"additional","affiliation":[{"name":"Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, 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