Does Polluted Air Increase COVID-19 Severity? A Critical Review of the Evidence and Proposals to Clarify a Potentially Dramatic Interaction
Abstract
1. Introduction
2. Research Questions
- -
- Among individuals infected with SARS-CoV-2, does exposure to higher levels of long-term outdoor air pollution worsen the course of infection and disease?
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- Among individuals infected with SARS-CoV-2, does exposure to higher levels of short-term outdoor air pollution worsen the course of infection and disease?
2.1. Measurement Issues: Diagnostic Tests, Infection Severity, Air Pollution Levels
2.2. Confounding Effects and Possible Strategies to Untangle Them
2.3. What Have We Learnt from Studies Other than Ecological Studies?
Authors | Publication Year Study Design | Setting | Sample Size | Population | Environmental Exposure (Pollutants, Geographical Resolution and Periods) | Measured Outcome | Adjustment | Findings | Newcastle-Ottawa Scale |
---|---|---|---|---|---|---|---|---|---|
Beloconi et al. [33] | 2023 Cohort | Switzerland | n = 28,540 | Hospitalized patients | PM2.5 and NO2 1 sq km 5-year averages | ICU admission Death | Individual comorbidities, Aggregated socio-economics | PM2.5 associated with higher mortality (OR 1.16 [95% CI 1.04–1.28] but not with ICU admission NO2 associated with both (OR 1.17 [95% CI 1.05, 1.30] and 1.15 [1.03, 1.27] Results held only for the first pandemic wave | 8 * |
Bowe et al. [34] | 2021 Cohort | USA | n = 169,102 | US Armed Forces Veterans COVID-19 cases | PM2.5 1 sq km 2018 averages | Hospitalizations | Individual demographics, race, Aggregated socio-economics | PM2.5 associated with a 10% (95% CI: 8–12%) higher risk of hospitalization | 8 * |
Bozack et al. [28] | 2022 Cohort | New York City | n = 6542 | Hospitalized patients | PM2.5, black carbon and NO2 1 km radius 2019 averages | Death ICU Intubation | Individual demographics, race, individual insurance | PM2.5 associated with death and ICU admission (RR 1.11 [95% CI 1.02–1.21] and 1.13 [95% CI 1.00–1.28] Black carbon and NO2 were not | 8 * |
Chen C et al. [35] | 2022 Cohort | Ontario | n = 151,105 | Ontario’s Case and Contact Management System COVID-19 cases | PM2.5, NO2, and O3 average postal code–specific annual concentrations 5-year averages | Death ICU admission Hospitalizations | Individual demographics (age, sex, and race), healthcare access, Aggregated socio-economics | PM2.5 associated with hospital and ICU admission (OR 1.06 [95% CI 1.01–1.12] and death (1.09 [95% CI 0.98–1.21]) O3 associated with all three outcomes (1.15 [95% CI 1.06–1.23], 1.30 [95% CI 1.12–1.50] and 1.18 [95% CI 1.02–1.36] NO2 associated with hospital admission (OR 1.09 [95% CI 0.97–1.21]) | 8 * |
Elliott J et al. [29] | 2021 Cohort | UK | n = 473,550 (459 COVID deaths) | UK Biobank COVID-19 cases | PM2.5, PM10, and NOx Unspecified spatial resolution 2010 averages | COVID-19 mortality | Individual demographics (age, sex, and ethnicity), comorbidities, and socio-economics | No associations found between pollutants and mortality | 6 * |
Chen Z et al. [36] | 2022 Cohort | California, USA | n = 75,010 | Kaiser Permanente (insurance company) COVID-19 cases | NOx Residential address 1-month and 1-year (previous to COVID diagnosis) averages | ICU admissions Intensive respiratory support (IRS) Death | Individual demographics (Age, sex, ethnicity), comorbidities, insurance type, Aggregated socio-economics | Exposure to non-freeway near roadway NOx associated with increased risk of IRS and ICU admission [OR (95% CI): 1.07 (1.01, 1.13) and 1.11 (1.04, 1.19), respectively]; increased risk of mortality (HR = 1.10, 95% CI = 1.03, 1.18) | 6 * |
Hoskovec L et al. [37] | 2022 Cohort | Denver, USA | n= 55,273 | Denver Public Health COVID-19 cases | PM2.5 Address-based inverse distance weighing 2019 averages | ICU admission Death | Individual demographics (age, sex, pregnancy, and ethnicity) Aggregated socio-economic data | Exposure to PM2.5 was associated with an increased risk of being hospitalized (OR 1.24 [95% CI 1.08–1.43]) and admitted to the ICU when combined with high levels of ozone (1.83 [95% CI 1.01–3.33]) and temperature (1.48 [95% CI 1.12–2.00]) | 6 * |
Hyman S et al. [38] | 2023 Cohort | Manchester, UK | n = 313,657 | Greater Manchester COVID-19 cases | PM2.5, PM10, O3, NO2, SO2, and benzene 1 sq km grid 2019 averages | Hospitalization Death | Individual age, sex, ethnicity, BMI, smoking status, history of comorbidities Area-level socio-economic status | Significant associations with hospital admissions and PM2.5, PM10, NO2 (OR 1.27 [95% CI 1.25–1.30], 1.15 [95% CI 1.13–1.17], and 1.12 [95% CI 1.10–1.14]; death and PM2.5 and PM10 (OR 1.39 [95% CI 1.31–1.48] and 1.23 [95% CI 1.17–1.30]) | 8 * |
Jerrett M et al. [39] | 2023 Cohort | Southern California, USA | n = 21,415 | Insurance network hospitalized patients | PM2.5, O3, NO2, ultra-fine particulate matter (PM0.1), PM chemical species, and PM sources 1 sq km 5-year averages | Death | Individual age, sex, ethnicity, comorbidities, insurance (Medicaid) Community-level socio-economics | PM2.5 associated with death among hospitalized patients HR = 1.12 [95% CI 1.06, 1.17] | 6 * |
Lavigne E et al. [24] | 2023 Case-crossover | Alberta and Ontario, Canada | n = 78,255 | Emergency Department visits of COVID-19 cases | PM2.5, O3, NO2 10 sq km Daily averages over a 3-day period | Emergency Department visits | Aggregated sex and age No socio-economic data | Exposure to PM2.5 and NO2 were associated with ED visits for COVID-19 (OR 1.010; 95% CI 1.004 to 1.015 and OR 1.021; 95% CI 1.015 to 1.028) | 4 * |
Lopez-Feldman et al. [40] | 2021 Cohort | Mexico | No info on sample size | Mexico City confirmed COVID-19 cases | PM2.5 Mexico City municipalities short- (daily) and long-term (2000–2018) | Death | Individual age and sex Aggregated socio-economics | Long-term PM2.5 exposure related to death (p = 0.048) | 7 * |
Mendy et al. [41] | 2021 Cohort | Ohio | n = 14,783 | COVID-19 cases diagnosed at the University of Cincinnati healthcare system | PM2.5 0.01° × 0.01° grid 2009–2018 averages | COVID-19 hospitalization | Individual sex, age, and comorbidities Aggregated socio-economics | Long-term PM2.5 exposure is associated with increased hospitalization in COVID-19 OR: 1.18, 95% CI: 1.11–1.26 | 7 * |
Pegoraro et al. [30] | 2021 Cohort | Italy | n = 6483 | COVID-19 cases diagnosed at GP’s in Italy IQVIA Database | PM10 Italian regions 30-day period preceding the Index Date | Pneumonia cases | Individual age, sex, and comorbidities No socio-economic data | PM10 exposure associated with higher likelihood of pneumonia (OR 1.93 [95% CI 1.55–2.39]) | 6 * |
Ponzano et al. [26] | 2022 Case–control | Italy | n = 49 | Multiple sclerosis patients diagnosed with COVID-19 | PM2.5, PM10, and NO2 resolution not specified 2018–2020 | Pneumonia cases | Individual age, sex, comorbidities, disease type, and treatment No socio-economic data | Higher long-term exposure to PM2.5, PM10, and NO2 increased the odds of COVID-19 pneumonia (OR 2.26 [95% CI 1.29;3.96], 2.12 [95% CI 1.22;3.68], and 2.12 [95% CI 1.22;3.69]) | 8 * |
Rigolon et al. [42] | 2023 Cohort | Denver, USA | n = 18,042 | COVID-19 cases diagnosed at Uni Colorado health system | PM2.5 Census block groups 2016 | Hospitalization | Individual demographics, race, comorbidities; Aggregated socio-economics | Incidence Rate Ratio for hospitalization 1.19 [95% CI 1.151–1.230] | 7 * |
Di Ciaula et al. [32] | 2022 Cohort | Apulia, Italy | n = 147 | Hospitalized patients | NO2 and PM2.5 Unspecified spatial resolution 2 weeks before admission | Mortality | Individual demographics, comorbidities No socio-enconomic data | NO2 OR for mortality 1.045 [95% CI 1.003–1.088]; PM2.5 not significant | 7 * |
Kogevinas et al. [43] | 2021 Cohort | Catalonia | n = 481 | COVID-19 and non-COVID-19 individuals recruited from previous healthy cohorts | PM2.5 100 sq m grids based on hybrid models 2018–2019 averages | Hospitalization | Individual demographics, BMI, comorbidities Aggregated socio-economics | Relative Risk Ratio for hospitalization 1.83 (1.01, 3.31) for NO2; 2.12 (1.13, 3.96) | 7 * |
English et al. [44] | 2022 Cohort | California, USA | n = 3.1 million (n = 49,691 deaths) | COVID-19 cases obtained from the California Department of Public Health | PM2.5 1 sq km 2000–2018 averages | Death | Individual demographics Aggregated race/ethnicity and socio-economics | Individuals living in the highest quintile of exposure had mortality risks 51% higher than those in the lowest quintile | 7 * |
Bronte et al. [45] | 2023 Cohort | Spain | n = 1548 | Hospitalized patients | PM10, PM2.5, O3, NO2, NO, and NOx Spatial resolution not specified 2019 averages | Death C Reactive Protein levels PaO2/FiO2 | Individual demographics and comorbidities Aggregated socio-economics | PM10, NO2, NO, and NOx increased risk of death (5.33%, 3.59%, 10.79%, and 2.24% p < 0.05) | 7 * |
Zhang et al. [27] | 2023 Cohort | Danmark | n = 3.7 million (n = 138,742 infections) | Nationwide cohort | NO2, PM2.5, PM10, black carbon, and O3 1 sq km complex land model 1979–2019 averages | Hospitalization Death | Individual age and sex, individual and aggregated socio-economics No comorbidities | PM2.5 and NO2 associated with hospitalizations (HR 1.09 (95% CI 1.01–1.17) and HR 1.19 (95% CI 1.12–1.27) and death (HR 1.23 (95% CI 1.04–1.44) and HR 1.18 (95% CI 1.03–1.34) | 9 * |
Kim H et al. [25] | 2022 Case-crossover | Cook County, USA | n = 7462 | COVID-19 death reports | PM2.5 and O3 Inverse-distance weighing interpolation 21 days before death | Death | Individual age, sex, race, and comorbidities No socio-economic data | Short-term increases in PM2.5 and O3 associated with increased risk of death (69.3% [95% confidence interval (CI): 34.6, 113.8] and 29.0% (95% CI: 9.9, 51.5), respectively) | 7 * |
Izadi et al. [31] | 2022 Cohort | 23 countries | n = 14,044 | Global Rheumatic Alliance Registry | Average monthly PM2.5 Country and US state | COVID-19 mortality | Individual demographics, comorbidities; characteristics of rheumatic disease; No socio-enconomic adjustment | PM2.5 increased odds of death (OR 1·10 per 10 μg/m3 [95% CI 1·01–1·17]) | 7 * |
2.4. Beyond Ecological and Large Registry-Based Cohort Studies
3. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Air Pollutant | Anthropogenic Sources | Health Effects a |
---|---|---|
Particulate matter (PM) | Motor vehicles Engines Industrial processes Construction sites Unpaved roads Cigarette smoke Biomass burning Agriculture | Cardiovascular disease Cerebrovascular disease Dementia Chronic obstructive lung disease Eye irritation and eye disease Cancer Adverse birth outcomes |
Nitrogen oxides (NOx) | Fuel-burning motor vehicles Power plants Residential fuel-burning | Reduced lung function Asthma Exacerbation of chronic respiratory and cardiovascular disease Cancer |
Ozone (O3) | Nitrogen oxides Volatile organic compounds | Lung irritation and damage Aggravated chronic respiratory disease Immune system impairment |
Sulfur dioxide (SO2) | Petroleum derivates and coal burning Motor vehicles Refineries Power plants Paper mills | Headaches and anxiety Cardiovascular disease |
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Almeida, A.; Neves, D.; Serra, S.S.; Mertens, T.E. Does Polluted Air Increase COVID-19 Severity? A Critical Review of the Evidence and Proposals to Clarify a Potentially Dramatic Interaction. World 2025, 6, 133. https://doi.org/10.3390/world6040133
Almeida A, Neves D, Serra SS, Mertens TE. Does Polluted Air Increase COVID-19 Severity? A Critical Review of the Evidence and Proposals to Clarify a Potentially Dramatic Interaction. World. 2025; 6(4):133. https://doi.org/10.3390/world6040133
Chicago/Turabian StyleAlmeida, André, Diana Neves, Sofia Silvério Serra, and Thierry E. Mertens. 2025. "Does Polluted Air Increase COVID-19 Severity? A Critical Review of the Evidence and Proposals to Clarify a Potentially Dramatic Interaction" World 6, no. 4: 133. https://doi.org/10.3390/world6040133
APA StyleAlmeida, A., Neves, D., Serra, S. S., & Mertens, T. E. (2025). Does Polluted Air Increase COVID-19 Severity? A Critical Review of the Evidence and Proposals to Clarify a Potentially Dramatic Interaction. World, 6(4), 133. https://doi.org/10.3390/world6040133