Air Pollution in Relation to COVID-19 Morbidity and Mortality: A Large Population-Based Cohort Study in Catalonia, Spain (COVAIR-CAT).

Abstract

Introduction: Evidence from epidemiological studies based on individual-level data indicates that air pollution may be associated with coronavirus disease 2019 (COVID-19) severity. We aimed to test whether (1) long-term exposure to air pollution is associated with COVID-19-related hospital admission or mortality in the general population; (2) short-term exposure to air pollution is associated with COVID-19-related hospital admission following COVID-19 diagnosis; (3) there are vulnerable population subgroups; and (4) the influence of long-term air pollution exposure on COVID-19-related hospital admissions differed from that for other respiratory infections.

Methods: We constructed a cohort covering nearly the full population of Catalonia through registry linkage, with follow- up from January 1, 2015, to December 31, 2020. Exposures at residential addresses were estimated using newly developed spatiotemporal models of nitrogen dioxide (NO₂³), particulate matter ≤2.5 μm in aerodynamic diameter (PM_2.5), particulate matter ≤10 μm in aerodynamic diameter (PM₁₀), and maximum 8-hr-average ozone (O₃) at a spatial resolution of 250 m for the period 2018-2020.

Results: The general population cohort included 4,660,502 individuals; in 2020 there were 340,608 COVID-19 diagnoses, 47,174 COVID-19-related hospital admissions, and 10,001 COVID-19 deaths. Mean (standard deviation) annual exposures were 26.2 (10.3) μg/m³ for NO₂, 13.8 (2.2) μg/m³ for PM_2.5, and 91.6 (8.2) μg/m³ for O₃. In Aim 1, an increase of 16.1 μg/m³ NO₂ was associated with a 25% (95% confidence interval [CI]: 22%-29%) increase in hospitalizations and an 18% (10%-27%) increase in deaths. In Aim 2, cumulative air pollution exposure over the previous 7 days was positively associated with COVID-19-related hospital admission in the second pandemic wave (June 20 to December 31, 2020). Associations of exposure were driven by exposure on the day of the hospital admission (lag0). Associations between short-term exposure to air pollution and COVID-19-related hospital admission were similar in all population subgroups. In Aim 3, individuals with lower individual- and area-level socioeconomic status (SES) were identified as particularly vulnerable to the effects of long-term exposure to NO₂ and PM_2.5 on COVID-19-related hospital admission. In Aim 4, long-term exposure to air pollution was associated with hospital admission for influenza and pneumonia: (6%; 95% CI: 2-11 per 16.4-μg/m³ NO₂ and 5%; 1-8 per 2.6-μg/m³ PM_2.5) as well as for all lower respiratory infections (LRIs) (18%; 14-22 per 16.4-μg/m³ NO₂ and 14%; 11-17 per 2.6-μg/m³ PM_2.5) before the COVID-19 pandemic. Associations for COVID-19-related hospital admission were larger than those for influenza or pneumonia for NO₂, PM_2.5, and O₃ when adjusted for NO₂.

Conclusions: Linkage across several registries allowed the construction of a large population-based cohort, tracking COVID-19 cases from primary care and testing data to hospital admissions, and death. Long- and short-term exposure to ambient air pollution were positively associated with severe COVID-19 events. The effects of long-term air pollution exposure on COVID-19 severity were greater among those with lower individual- and area-level SES.