A global meta-analysis of particulate and gaseous air pollutants in relation to COVID-19 mortality and hospitalization
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Abstract
A growing body of evidence implicates ambient air pollution in the exacerbation of clinical outcomes after SARS-CoV-2 infection. To synthesize this evidence, we performed a global systematic review and meta-analysis to precisely quantify the associations between exposure to specific atmospheric ontaminants and the subsequent risks of COVID-19-related mortality and hospital admission. Our methodology adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework, involving a comprehensive search of scientific databases for literature published until the end of August 2025. From this search, 44 publications were deemed eligible for inclusion. We employed random-effects models to compute summary Risk Ratios (RRs) representing the change in health risk per 1 µg/m³ increment in atmospheric pollutant concentration. Our findings indicate that long term exposure to fine Particulate Matter (PM2.5), coarse Particles (PM₁₀), Nitrogen dioxide (NO₂), and Sulfur dioxide (SO₂) significantly increased the likelihood of fatal outcomes from COVID-19. The respective pooled RRs were 1.046 (95% CI: 1.031–1.062), 1.079 (95% CI: 1.005–1.154), 1.017 (95% CI: 1.004–1.029), and 1.077 (95% CI: 1.021–1.133). Acute exposures to ambient PM2.5 and NO₂ concentrations were similarly associated with increased mortality, demonstrating risk ratios of 1.043 (95% CI: 1.033–1.053) and 1.033 (95% CI: 1.019–1.048) respectively per 1 µg/m³ increment. Additionally, both acute and chronic exposures to PM2.5, PM₁₀, and NO₂ showed significant associations with higher COVID-19 hospitalization rates. This meta-analysis provides robust quantitative suggestion that ambient PM2.5, PM10, NO₂, and SO₂ are significant and modifiable risk factors for severe COVID-19 outcomes. These results emphasize the critical need for enhanced air quality standards as a fundamental element of public health policy to alleviate the impact of COVID-19 and bolster defenses against forthcoming respiratory epidemics.
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3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The lancet. 2020;395(10229):1054-62.
4. Sierra-Vargas MP, Montero-Vargas JM, Debray-García Y, Vizuet-de-Rueda JC, Loaeza-Román A, Terán LM. Oxidative stress and air pollution: its impact on chronic respiratory diseases. International Journal of Molecular Sciences. 2023;24(1):853.
5. Mukharesh L, Phipatanakul W, Gaffin JM. Air pollution and childhood asthma. Current Opinion in Allergy and Clinical Immunology. 2023;23(2):100-10.
6. Karimi B, Shokrinezhad B. Spatial variation of ambient PM2.5 and PM10 in the industrial city of Arak, Iran: A land-use regression. Atmospheric Pollution Research. 2021;12(12):101235.
7. Bennett JE, Tamura-Wicks H, Parks RM, Burnett RT, Pope III CA, Bechle MJ, et al. Particulate matter air pollution and national and county life expectancy loss in the USA: A spatiotemporal analysis. PLoS medicine. 2019;16(7):e1002856.
8. Karimi B, Samadi S. Mortality associated with fine particulate and its components: A systematic review and meta-analysis. Atmospheric Pollution Research. 2023:101648.
9. Karimi B, Samadi S. Mortality and hospitalizations due to cardiovascular and respiratory diseases associated with air pollution in Iran: A systematic review and meta-analysis. Atmospheric environment. 2019;198:438-47.
10. Mariscal-Aguilar P, Gómez-Carrera L, Carpio C, Zamarrón E, Bonilla G, Fernández-Velilla M, et al. Relationship between air pollution exposure and the progression of idiopathic pulmonary fibrosis in Madrid: chronic respiratory failure, hospitalizations, and mortality. A retrospective study. Frontiers in Public Health. 2023;11:1135162.
11. Alsina-Pujols M, Vall Castelló J. Air Pollution and COVID-19 Severity. Environmental and Resource Economics. 2025:1-27.
12. Jin X, Chen Y, Xu B, Tian H. Exercise-mediated protection against Air Pollution-Induced Immune damage: mechanisms, challenges, and future directions. Biology. 2024;13(4):247.
13. Pouri N, Karimi B, Kolivand A, Mirhoseini SH. Ambient dust pollution with all-cause, cardiovascular and respiratory mortality: A systematic review and meta-analysis. Science of The Total Environment. 2023:168945.
14. Zheng J, Wang Y, Li K, Meyerholz DK, Allamargot C, Perlman S. Severe acute respiratory syndrome coronavirus 2–induced immune activation and death of monocyte-derived human macrophages and dendritic cells. The Journal of infectious diseases. 2021;223(5):785-95.
15. Yang C, Hao Y, Irfan M. Energy consumption structural adjustment and carbon neutrality in the post-COVID-19 era. Structural Change and Economic Dynamics. 2021;59:442-53.
16. Wen C, Akram R, Irfan M, Iqbal W, Dagar V, Acevedo-Duqued Á, et al. The asymmetric nexus between air pollution and COVID-19: Evidence from a non-linear panel autoregressive distributed lag model. Environmental research. 2022;209:112848.
17. Chang Y, Bai M, You Q. Associations between serum interleukins (IL-1β, IL-2, IL-4, IL-6, IL-8, and IL-10) and disease severity of COVID-19: A systematic review and meta-analysis. BioMed Research International. 2022;2022.
18. Comunian S, Dongo D, Milani C, Palestini P. Air pollution and COVID-19: the role of particulate matter in the spread and increase of COVID-19’s morbidity and mortality. International journal of environmental research and public health. 2020;17(12):4487.
19. Beyerstedt S, Casaro EB, Rangel ÉB. COVID-19: angiotensin-converting enzyme 2 (ACE2) expression and tissue susceptibility to SARS-CoV-2 infection. European journal of clinical microbiology & infectious diseases. 2021;40(5):905-19.
20. Fattorini D, Regoli F. Role of the chronic air pollution levels in the Covid-19 outbreak risk in Italy. Environmental pollution. 2020;264:114732.
21. Tello-Leal E, Macías-Hernández BA. Association of environmental and meteorological factors on the spread of COVID-19 in Victoria, Mexico, and air quality during the lockdown. Environmental Research. 2021;196:110442.
22. Bashir MF, Jiang B, Komal B, Bashir MA, Farooq TH, Iqbal N, et al. Correlation between environmental pollution indicators and COVID-19 pandemic: a brief study in Californian context. Environmental research. 2020;187:109652.
23. Jiang Y, Wu X-J, Guan Y-J. Effect of ambient air pollutants and meteorological variables on COVID-19 incidence. Infection Control & Hospital Epidemiology. 2020;41(9):1011-15.
24. Li H, Xu X-L, Dai D-W, Huang Z-Y, Ma Z, Guan Y-J. Air pollution and temperature are associated with increased COVID-19 incidence: a time series study. International journal of infectious diseases. 2020;97:278-82.
25. Rodriguez-Villamizar LA, Belalcázar-Ceron LC, Fernández-Niño JA, Marín-Pineda DM, Rojas-Sánchez OA, Acuña-Merchán LA, et al. Air pollution, sociodemographic and health conditions effects on COVID-19 mortality in Colombia: an ecological study. Science of the Total Environment. 2021;756:144020.
26. Wu X, Nethery RC, Sabath MB, Braun D, Dominici F. Air pollution and COVID-19 mortality in the United States: Strengths and limitations of an ecological regression analysis. Science advances. 2020;6(45):eabd4049.
27. De Angelis E, Renzetti S, Volta M, Donato F, Calza S, Placidi D, et al. COVID-19 incidence and mortality in Lombardy, Italy: an ecological study on the role of air pollution, meteorological factors, demographic and socioeconomic variables. Environmental research. 2021;195:110777.
28. Atalan A. Is the lockdown important to prevent the COVID-19 pandemic? Effects on psychology, environment and economy-perspective. Annals of medicine and surgery. 2020;56:38-42.
29. OHAT. Handbook for Conducting a Literature-Based Health Assessment Using OHAT Approach for Systematic Review and Evidence Integration. Office of Health Assessment and Translation, Division of National Toxicology Program, National Institute of Environmental Health Sciences. 2015.
30. DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled clinical trials. 1986;7(3):177-88.
31. Nhung NTT, Amini H, Schindler C, Joss MK, Dien TM, Probst-Hensch N, et al. Short-term association between ambient air pollution and pneumonia in children: A systematic review and meta-analysis of time-series and case-crossover studies. Environmental pollution. 2017;230:1000-08.
32. Kim H-B, Shim J-Y, Park B, Lee Y-J. Long-term exposure to air pollutants and cancer mortality: a meta-analysis of cohort studies. International journal of environmental research and public health. 2018;15(11):2608.
33. Borroni E, Pesatori AC, Bollati V, Buoli M, Carugno M. Air pollution exposure and depression: A comprehensive updated systematic review and meta-analysis. Environmental Pollution. 2022;292:118245.
34. Solimini A, Filipponi F, Fegatelli DA, Caputo B, De Marco C, Spagnoli A, et al. A global association between Covid-19 cases and airborne particulate matter at regional level. Scientific reports. 2021;11(1):1-7.
35. Travaglio M, Yu Y, Popovic R, Selley L, Leal NS, Martins LM. Links between air pollution and COVID-19 in England. Environmental pollution. 2021;268:115859.
36. Sanchez-Piedra C, Cruz-Cruz C, Gamiño-Arroyo A-E, Prado-Galbarro F-J. Effects of air pollution and climatology on COVID-19 mortality in Spain. Air Quality, Atmosphere & Health. 2021;14(11):1869-75.
37. Mendy A, Wu X, Keller JL, Fassler CS, Apewokin S, Mersha TB, et al. Air pollution and the pandemic: Long‐term PM2. 5 exposure and disease severity in COVID‐19 patients. Respirology. 2021;26(12):1181-87.
38. Konstantinoudis G, Padellini T, Bennett J, Davies B, Ezzati M, Blangiardo M. Long-term exposure to air-pollution and COVID-19 mortality in England: a hierarchical spatial analysis. Environment international. 2021;146:106316.
39. Bowe B, Xie Y, Gibson AK, Cai M, van Donkelaar A, Martin RV, et al. Ambient fine particulate matter air pollution and the risk of hospitalization among COVID-19 positive individuals: cohort study. Environment international. 2021;154:106564.
40. Tchicaya A, Lorentz N, Omrani H, de Lanchy G, Leduc K. Impact of long-term exposure to PM2. 5 and temperature on coronavirus disease mortality: observed trends in France. Environmental Health. 2021;20(1):1-14.
41. Zheng P, Chen Z, Liu Y, Song H, Wu C-H, Li B, et al. Association between coronavirus disease 2019 (COVID-19) and long-term exposure to air pollution: Evidence from the first epidemic wave in China. Environmental Pollution. 2021;276:116682.
42. Norouzi N, Asadi Z. Air pollution impact on the Covid-19 mortality in Iran considering the comorbidity (obesity, diabetes, and hypertension) correlations. Environmental Research. 2022;204:112020.
43. Hutter H-P, Poteser M, Moshammer H, Lemmerer K, Mayer M, Weitensfelder L, et al. Air pollution is associated with COVID-19 incidence and mortality in Vienna, Austria. International Journal of Environmental Research and Public Health. 2020;17(24):9275.
44. Bozack A, Pierre S, DeFelice N, Colicino E, Jack D, Chillrud SN, et al. Long-term air pollution exposure and COVID-19 mortality: a patient-level analysis from New York City. American journal of respiratory and critical care medicine. 2022;205(6):651-62.
45. Marquès M, Correig E, Ibarretxe D, Anoro E, Arroyo JA, Jericó C, et al. Long-term exposure to PM10 above WHO guidelines exacerbates COVID-19 severity and mortality. Environment international. 2022;158:106930.
46. Garcia E, Marian B, Chen Z, Li K, Lurmann F, Gilliland F, et al. Long-term air pollution and COVID-19 mortality rates in California: Findings from the Spring/Summer and Winter surges of COVID-19. Environmental Pollution. 2022;292:118396.
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| Files | ||
| Issue | Vol 10 No 4 (2025): Autumn 2025 | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/japh.v10i4.20620 | |
| Keywords | ||
| Air pollutants; COVID-19 mortality; COVID-19 hospitalization; Meta analysis | ||
| Rights and permissions | |
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Karimi B, Moradi Farahani M. A global meta-analysis of particulate and gaseous air pollutants in relation to COVID-19 mortality and hospitalization. JAPH. 2025;10(4):569-588.
