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

Fei Tian; Xiaobo Liu; Qingchen Chao; Zhengmin Min Qian; Siqi Zhang; Li Qi; Yanlin Niu; Lauren D Arnold; Shiyu Zhang; Huan Li; Hualiang Lin; Qiyong Liu

doi:10.1016/j.xinn.2021.100139

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

Innovation (Camb). 2021 Aug 28;2(3):100139. doi: 10.1016/j.xinn.2021.100139. Epub 2021 Jun 18.

Authors

Fei Tian¹, Xiaobo Liu², Qingchen Chao³, Zhengmin Min Qian⁴, Siqi Zhang³, Li Qi², Yanlin Niu², Lauren D Arnold⁴, Shiyu Zhang¹, Huan Li¹, Hualiang Lin¹, Qiyong Liu²

Affiliations

¹ Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China.
² State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, WHO Collaborating Centre for Vector Surveillance and Management, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China.
³ Laboratory for Climate Studies, National Climate Center, China Meteorological Administration, Beijing 100081, China.
⁴ Department of Epidemiology and Biostatistics, College for Public Health & Social Justice, Saint Louis University, 3545 Lafayette Avenue, Saint Louis, MO 63104, USA.

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.

Keywords: COVID-19; air pollution; cohort study; fatality; temperature.