Association between Short-Term Exposure to Air Pollution and COVID-19 Mortality: A Population-Based Case-Crossover Study Using Individual-Level Mortality Registry Confirmed by Medical Examiners

Abstract

Background: Studies have suggested links between ambient air pollution and coronavirus 2019 (COVID-19) mortality, yet confirmation by well-designed epidemiological studies with individual data is needed.

Objectives: We aimed to examine whether short-term exposure to air pollution is associated with risk of mortality from COVID-19 for those infected with COVID-19.

Methods: The Cook County Medical Examiner's Office reports individual-level data for deaths from COVID-19 that occur in its jurisdiction, which includes all confirmed COVID-19 deaths in Cook County, Illinois. Case-crossover analysis was conducted to estimate the associations of estimated short-term exposures to particulate matter (PM) with aerodynamic diameter $\le 2.5\mu m$ (${\mathrm{PM}}_{2.5}$) and ozone ($O_3$) on the day of death and up to 21 d before death at location of death with COVID-19. A total of 7,462 deaths from COVID-19 that occurred up to 28 February 2021 were included in the final analysis. We adjusted for potential confounders by time-stratified case-crossover design and by covariate adjustments (i.e., time-invariant factors, meteorological factors, viral transmission, seasonality, and time trend).

Results: Of the 7,462 case and 25,457 self-control days, almost all were days with exposure levels below the ${\mathrm{PM}}_{2.5}$ 24-h National Ambient Air Quality Standard (NAAQS) ($35{\mu g/m}^3$); 98.9% had $O_3$ levels below the maximum 8-h NAAQS ($35.7{\mu g/m}^3$ or 70 parts per billion). An interquartile range (IQR) increase ($5.2{\mu g/m}^3$) in cumulative 3-wk ${\mathrm{PM}}_{2.5}$ exposure was associated with a 69.6% [95% confidence interval (CI): 34.6, 113.8] increase in risk of COVID-19 mortality. An IQR increase ($8.2{\mu g/m}^3$) in 3-d $O_3$ exposure was associated with a 29.0% (95% CI: 9.9, 51.5) increase in risk of COVID-19 mortality. The associations differed by demographics or race/ethnicity. There was indication of modification of the associations by some comorbid conditions.

Discussion: Short-term exposure to air pollution below the NAAQS may increase the mortality burden from COVID-19. https://doi.org/10.1289/EHP10836.