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

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

Background The evidence of effects of environmental factors on case fatality of COVID-19 remain controversial, and it is crucial to understand the role of the 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 (PM2.5, 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 â… ), and the period from the diagnosis date to date of death/recovery or end of the study period (Exposure Window â…¡). 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 two exposure windows. For example, each 10 ug/m3 increase of PM2.5, 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 each 1°C decrease. Subgroup analysis indicated that these effects were stronger in the elderly, as well as those with mild symptoms and living in Wuhan or Hubei. Overall, the sensitivity analyses also yielded the consistent estimates. Short-term exposure to ambient air pollution and low temperature during the illness would play a nonnegligible part in causing case fatality of COVID-19. Reduced exposures to high concentration of PM2.5, PM10, O3, SO2 and NO2 and low temperature would help improve the prognosis and reduce public health burden.