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. 2021 Sep:154:106564.
doi: 10.1016/j.envint.2021.106564. Epub 2021 Apr 9.

Ambient fine particulate matter air pollution and the risk of hospitalization among COVID-19 positive individuals: Cohort study

Benjamin Bowe  1 , Yan Xie  1 , Andrew K Gibson  2 , Miao Cai  2 , Aaron van Donkelaar  3 , Randall V Martin  3 , Richard Burnett  4 , Ziyad Al-Aly  5
Affiliations

Ambient fine particulate matter air pollution and the risk of hospitalization among COVID-19 positive individuals: Cohort study

Benjamin Bowe et al. Environ Int. 2021 Sep.

Abstract

Background: Ecologic analyses suggest that living in areas with higher levels of ambient fine particulate matter air pollution (PM2.5) is associated with higher risk of adverse COVID-19 outcomes. Studies accounting for individual-level health characteristics are lacking.

Methods: We leveraged the breadth and depth of the US Department of Veterans Affairs national healthcare databases and built a national cohort of 169,102 COVID-19 positive United States Veterans, enrolled between March 2, 2020 and January 31, 2021, and followed them through February 15, 2021. Annual average 2018 PM2.5 exposure, at an approximately 1 km2 resolution, was linked with residential street address at the year prior to COVID-19 positive test. COVID-19 hospitalization was defined as first hospital admission between 7 days prior to, and 15 days after, the first COVID-19 positive date. Adjusted Poisson regression assessed the association of PM2.5 with risk of hospitalization.

Results: There were 25,422 (15.0%) hospitalizations; 5,448 (11.9%), 5,056 (13.0%), 7,159 (16.1%), and 7,759 (19.4%) were in the lowest to highest PM2.5 quartile, respectively. In models adjusted for State, demographic and behavioral factors, contextual characteristics, and characteristics of the pandemic a one interquartile range increase in PM2.5 (1.9 µg/m3) was associated with a 10% (95% CI: 8%-12%) increase in risk of hospitalization. The association of PM2.5 and risk of hospitalization among COVID-19 individuals was present in each wave of the pandemic. Models of non-linear exposure-response suggested increased risk at PM2.5 concentrations below the national standard 12 µg/m3. Formal effect modification analyses suggested higher risk of hospitalization associated with PM2.5 in Black people compared to White people (p = 0.045), and in those living in socioeconomically disadvantaged neighborhoods (p < 0.001).

Conclusions: Exposure to higher levels of PM2.5 was associated with increased risk of hospitalization among COVID-19 infected individuals. The risk was evident at PM2.5 levels below the regulatory standards. The analysis identified those of Black race and those living in disadvantaged neighborhoods as population groups that may be more susceptible to the untoward effect of PM2.5 on risk of hospitalization in the setting of COVID-19.

Keywords: Air pollution; Ambient fine particulate matter; COVID-19; COVID-19 outcomes; Hospitalization; Severity.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Non-linear exposure response curve of the association between PM2.5 and risk of hospitalization among a national cohort of US Veterans who tested positive for COVID-19. Bands represent the 95% confidence intervals. The optimal and ensembled models are presented. Results were obtained from an adapted Shape Constrained Health Impact Function Model applied to Poisson regression. Model was adjusted for State, age, race, sex, smoking status, ADI, population density, percentage with limited access to healthy food, percentage with adequate access to exercise opportunities, percentage of adults reporting excessive drinking in the county they live, NDVI, election margin of victory, month of testing positive, health system testing capacity, positivity rates, and hospital bed occupancy.
Fig. 2
Fig. 2
Effect modification of the association between PM2.5 and risk of hospitalization by age, race, gender, and ADI among a national cohort of US Veterans who tested positive for COVID-19. Results were obtained from individual models that incorporated interaction terms between PM2.5 and the effect modifier being investigated. Relative risks are presented for every one IQR (1.9 µg/m3) increase in PM2.5. Risk associated with a one IQR PM2.5 above and below the median age and ADI are presented for interactions with continuous effect modifiers.
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