Monday, March 27, 2023
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 0.25 ABIM MOC points
Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)
Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)
Physician Assistant - 0.25 AAPA hour(s) of Category I credit
IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit
This activity is intended for infectious disease clinicians, internists, public health and prevention officials, physician assistants, nurses, pulmonologists, pharmacists, and other members of the healthcare team who take of patients with COVID-19 who may be at risk for worse outcomes because of exposure to air pollution.
The goal of this activity is that learners will be better able to describe the association of long-term exposure to ambient air pollution with COVID-19 severity, reflected in risk for COVID-19-related hospital admission, intensive care unit (ICU) admission and death, according to a prospective cohort study of all people with confirmed SARS-CoV-2 infection, aged ≥ 20 years and not residing in a long-term care facility in Ontario, Canada during 2020.
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Clinical manifestations of SARS-CoV-2 infection range from asymptomatic to multiple organ failure and death. By November 2021, COVID-19 caused > 5 million deaths globally. Therefore, it is important to identify risk factors to better understand the background etiological mechanisms.
Known risk factors for COVID-19 severity include male sex, older age, preexisting medical conditions, and being from racialized communities. Ambient air pollution has more recently been implicated as a potential driver of COVID-19 severity.
Patients exposed to common air pollutants are at risk for more severe outcomes after they become infected with the SARS-CoV-2 virus, data suggest.
In a prospective study of more than 150,000 patients with COVID-19, incremental increases in exposure to common pollutants were associated with increases in the risks for hospitalization, admission to an intensive care unit (ICU), or death that ranged from 6% to 30%.
"This study reinforces the idea that air pollution is a pervasive and silent killer and that the association of air pollution and COVID-19 severity reflects the tip of an iceberg of the wide-ranging impacts air pollution has on human health," study author Hong Chen, PhD, MSc, researcher at Public Health Ontario and assistant professor of occupational and environmental health at the University of Toronto, Canada.
The study was published May 24 in theCanadian Medical Association Journal.[1]
Focus of the studyCOVID-19 is associated with a tremendous global health burden. Understanding the factors that influence disease severity is important for prevention and treatment, said the investigators.
Exposure to common air pollutants such as fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ground-level ozone (O3) contributes to the global burden of disease. The current investigators evaluated the associations between exposure to these pollutants and indicators of COVID-19 severity.
To identify patients with COVID-19, they examined hospital discharge data from the Health Information Discharge Abstract Database and physician service claims in the Health Insurance Plan database. They used annual exposure surfaces of the 3 pollutants to calculate participants' long-term exposures.
A total of 151,105 people became infected with SARS-CoV-2, the virus that causes COVID-19, in Ontario in 2020. Of this cohort, 5.7% required a COVID-19--related hospital admission, 1.3% required admission to an ICU, and 1.4% died, according to the authors.
The median of long-term exposure to air pollutants was 7.64 µg/m3 for PM2.5, 7.75 ppb for NO2, and 44.8 ppb for O3. In the final, adjusted model, each interquartile range (IQR) increase of 1.7 µg/m3 in exposure to PM2.5 was associated with an odds ratio (OR) of 1.06 for hospital admission and an OR of 1.09 for ICU admission. Although death was positively associated with PM2.5, "we did not observe an effect in the fully adjusted model," said the authors.
In the same model, each IQR increase of 2.5 ppb in exposure to NO2 was associated with an OR of 1.09 for ICU admission. The researchers did not observe any effect of exposure on risk for hospital admission or death.
Each IQR increase of 5.14 ppb in exposure to O3 was associated with an OR of 1.15 for hospital admission, an OR of 1.3 for ICU admission, and an OR of 1.18 for death.
Public Health Implications"Given the ongoing pandemic, our findings that underscore the link between chronic exposure to air pollution and more severe COVID-19 could have important implications for public health and health systems," said the authors.
Several mechanisms could explain the association between long-term exposure to air pollution and COVID-19 outcomes. First, air pollutants can reduce patients' pulmonary immune responses and antimicrobial activities, boosting viral loads. Pollutants also can induce chronic inflammation and overexpression of the alveolar angiotensin-converting enzyme 2 (ACE) receptor, which facilitates the entry of SARS-CoV-2 into cells. Evidence also has shown that exposure to air pollution increases susceptibility to respiratory viral infections and pneumonia, said Chen.
"It has been suggested that people with chronic conditions and socioeconomically disadvantaged subgroups are more likely to have poorer prognosis after the infection, [because] air pollution has long been known to contribute to poor health among these subgroups," said Chen.
These results support targeted interprofessional public health actions to protect residents from COVID-19 in heavily polluted regions with historically high NO2 levels, according to the authors.
"Rigorous Statistical Modeling"Commenting on the findings for Medscape Medical News, Donghai Liang, PhD, MPH, assistant professor of environmental health, Emory University, Atlanta, Georgia, said that this prospective cohort study is important and underscores the link between chronic exposure to air pollution and more severe COVID-19.
The impact of ambient air pollution on excess morbidity and mortality has been well established over the past several decades, said Liang.
"In particular, major ubiquitous ambient air pollutants, including PM2.5, NO2, and O3 may have both a direct and an indirect systemic impact on the body by enhancing oxidative stress, inflammation, and respiratory infection risk, eventually leading to numerous adverse health effects," Liang added.
It is therefore possible that long-term exposures to air pollution may have a detrimental effect on COVID-19 outcomes, Liang added. He and his colleagues previously conducted a nationwide study[2] that investigated associations between the same key ambient air pollutants and COVID-19 case fatality and mortality rates in the United States. They reported that long-term exposure to NO2, which largely arises from urban combustion sources such as traffic, may enhance susceptibility to severe COVID-19 outcomes, independent of long-term PM2.5 and O3 exposure.
The study was funded by Health Canada. Chen and Liang have disclosed no relevant financial relationships.
