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Ambient air pollution and low temperature associated with case fatality of COVID-19: A nationwide retrospective cohort study in China.

ABSTRACT: The evidence for the effects of environmental factors on COVID-19 case fatality remains controversial, and it is crucial to understand the role of preventable environmental factors in driving COVID-19 fatality. We thus conducted a nationwide cohort study to estimate the effects of environmental factors (temperature, particulate matter [PM_2.5, PM₁₀], sulfur dioxide [SO₂], nitrogen dioxide [NO₂], and ozone [O₃]) on COVID-19 case fatality. A total of 71,808 confirmed COVID-19 cases were identified and followed up for their vital status through April 25, 2020. Exposures to ambient air pollution and temperature were estimated by linking the city- and county-level monitoring data to the residential community of each participant. For each participant, two windows were defined: the period from symptom onset to diagnosis (exposure window I) and the period from diagnosis date to date of death/recovery or end of the study period (exposure window II). Cox proportional hazards models were used to estimate the associations between these environmental factors and COVID-19 case fatality. COVID-19 case fatality increased in association with environmental factors for the two exposure windows. For example, each 10 μg/m³ increase in PM_2.5, PM₁₀, O₃, and NO₂ in window I was associated with a hazard ratio of 1.11 (95% CI 1.09, 1.13), 1.10 (95% CI 1.08, 1.13), 1.09 (95 CI 1.03, 1.14), and 1.27 (95% CI 1.19, 1.35) for COVID-19 fatality, respectively. A significant effect was also observed for low temperature, with a hazard ratio of 1.03 (95% CI 1.01, 1.04) for COVID-19 case fatality per 1°C decrease. Subgroup analysis indicated that these effects were stronger in the elderly, as well as in those with mild symptoms and living in Wuhan or Hubei. Overall, the sensitivity analyses also yielded consistent estimates. Short-term exposure to ambient air pollution and low temperature during the illness would play a nonnegligible part in causing case fatality due to COVID-19. Reduced exposures to high concentrations of PM_2.5, PM₁₀, O₃, SO₂, and NO₂ and low temperature would help improve the prognosis and reduce public health burden.

SUBMITTER: Tian F

PROVIDER: S-EPMC8226106 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundAir pollution disparities by socioeconomic status (SES) are well documented for the United States, with most literature indicating an inverse relationship (i.e., higher concentrations for lower-SES populations). Few studies exist for China, a country accounting for 26% of global premature deaths from ambient air pollution.ObjectiveOur objective was to test the relationship between ambient air pollution exposures and SES in China.MethodsWe combined estimated year 2015 annual-average ambient levels of nitrogen dioxide (NO2) and fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] with national demographic information. Pollution estimates were derived from a national empirical model for China at 1-km spatial resolution; demographic estimates were derived from national gridded gross national product (GDP) per capita at 1-km resolution, and (separately) a national representative sample of 21,095 individuals from the China Health and Retirement Longitudinal Study (CHARLS) 2015 cohort. Our use of global data on population density and cohort data on where people live helped avoid the spatial imprecision found in publicly available census data for China. We quantified air pollution disparities among individual's rural-to-urban migration status; SES factors (education, occupation, and income); and minority status. We compared results using three approaches to SES measurement: individual SES score, community-averaged SES score, and gridded GDP per capita.ResultsAmbient NO2 and PM2.5 levels were higher for higher-SES populations than for lower-SES population, higher for long-standing urban residents than for rural-to-urban migrant populations, and higher for the majority ethnic group (Han) than for the average across nine minority groups. For the three SES measurements (individual SES score, community-averaged SES score, gridded GDP per capita), a 1-interquartile range higher SES corresponded to higher concentrations of 6-9 μg/m3 NO2 and 3-6 μg/m3 PM2.5; average concentrations for the highest and lowest 20th percentile of SES differed by 41-89% for NO2 and 12-25% for PM2.5. This pattern held in rural and urban locations, across geographic regions, across a wide range of spatial resolution, and for modeled vs. measured pollution concentrations.ConclusionsMultiple analyses here reveal that in China, ambient NO2 and PM2.5 concentrations are higher for high-SES than for low-SES individuals; these results are robust to multiple sensitivity analyses. Our findings are consistent with the idea that in China's current industrialization and urbanization stage, economic development is correlated with both SES and air pollution. To our knowledge, our study provides the most comprehensive picture to date of ambient air pollution disparities in China; the results differ dramatically from results and from theories to explain conditions in the United States. https://doi.org/10.1289/EHP9872.

Project description:BackgroundThe impacts of air pollution on circulatory and respiratory systems have been extensively studied. However, the associations between air pollution exposure and the risk of noncommunicable diseases of other organ systems, including diseases of the digestive, musculoskeletal, and genitourinary systems, remain unclear or inconclusive. We aimed to systematically assess the associations between short-term exposure to main air pollutants (fine particulate matter [PM2.5] and ozone) and cause-specific risk of hospital admission in China over a wide spectrum of human diseases.Methods and findingsDaily data on hospital admissions for primary diagnosis of 14 major and 188 minor disease categories in 252 Chinese cities (107 cities in North China and 145 cities in South China) from January 1, 2013, to December 31, 2017, were obtained from the Hospital Quality Monitoring System of China (covering 387 hospitals in North China and 614 hospitals in South China). We applied a 2-stage analytic approach to assess the associations between air pollution and daily hospital admissions. City-specific associations were estimated with quasi-Poisson regression models and then pooled by random-effects meta-analyses. Each disease category was analyzed separately, and the P values were adjusted for multiple comparisons. A total of 117,338,867 hospital admissions were recorded in the study period. Overall, 51.7% of the hospitalized cases were male, and 71.3% were aged <65 years. Robust positive associations were found between short-term PM2.5 exposure and hospital admissions for 7 major disease categories: (1) endocrine, nutritional, and metabolic diseases; (2) nervous diseases; (3) circulatory diseases; (4) respiratory diseases; (5) digestive diseases; (6) musculoskeletal and connective tissue diseases; and (7) genitourinary diseases. For example, a 10-μg/m3 increase in PM2.5 was associated with a 0.21% (95% CI 0.15% to 0.27%; adjusted P < 0.001) increase in hospital admissions for diseases of the digestive system on the same day in 2-pollutant models (adjusting for ozone). There were 35 minor disease categories significantly positively associated with same-day PM2.5 in both single- and 2-pollutant models, including diabetes mellitus, anemia, intestinal infection, liver diseases, gastrointestinal hemorrhage, renal failure, urinary tract calculus, chronic ulcer of skin, and back problems. The association between short-term ozone exposure and respiratory diseases was robust. No safety threshold in the exposure-response relationships between PM2.5 and hospital admissions was observed. The main limitations of the present study included the unavailability of data on personal air pollution exposures.ConclusionsIn the Chinese population during 2013-2017, short-term exposure to air pollution, especially PM2.5, was associated with increased risk of hospitalization for diseases of multiple organ systems, including certain diseases of the digestive, musculoskeletal, and genitourinary systems; many of these associations are important but still not fully recognized. The effect estimates and exposure-response relationships can inform policy making aimed at protecting public health from air pollution in China.

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Ambient air pollution and low temperature associated with case fatality of COVID-19: A nationwide retrospective cohort study in China.

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