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Particulate does matter: is Covid-19 another air pollution related disease?

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  • Italian Society of Digital Health and Telemedicine
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As Covid-19 spreads around the world, the level of uncertainty related to this infection remains high. Governments and health systems are following different and uncoordinated strategies to contain the epidemic. The use of personal protective devices aimed to protect people from air pollution may help to contain the spreading of the disease. Unfortunately, many people are using inapt facial masks and/or wearing improperly the mask itself. That could lead to risky behaviours that might eventually increase the transmission of the disease. We therefore point out how some of the strategies that we studied to fight air pollution can be useful to protect people also from Covid-19.
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Particulate does matter: is Covid-19 another air pollution
related disease?
Prof. Antonio Vittorino GADDI, MD, PhD1, Dr Fabio CAPELLO, MD, MSc2*
1 President SIT Emilia Romagna Region, Italian Society of Telemedicine and Digital Health, Bologna, Italy
2 Director Centro Studi SIT, Italian Society of Telemedicine and Digital Health, Bologna, Italy
*Correspondig author:
Fabio Capello
Primary email address: fabio.capello@ehealth.study
Cc email addres: info@fabiocapello.net
ORCID ID:
AVG: https://orcid.org/0000-0003-0147-1894
FC: https://orcid.org/0000-0002-1074-6979
Abstract: As Covid-19 spreads around the world, the level of uncertainty related to this infection remains
high. Governments and health systems are following different and uncoordinated strategies to contain the
epidemic. People are receiving confounding messages from experts and authorities: whereas some
countries decided to lock down their nation, other are experimenting a wait-and-see policy, as in the hope
that the problem will solve itself. According to the Lancet the actions taken so far “have been slow and
insufficient” with “scrambling to implement appropriate measures to delay spread of the virus”
Keywords: Covid-19, air pollution, facial masks, particulate matter.
As Covid-19 spreads around the world, the level of uncertainty related to this infection remains high.
Governments and health systems are following different and uncoordinated strategies to contain the
epidemic. People are receiving confounding messages from experts and authorities: whereas some
countries decided to lock down their nation, other are experimenting a wait-and-see policy, as in the hope
that the problem will solve itself. According to the Lancet the actions taken so far “have been slow and
insufficient” with “scrambling to implement appropriate measures to delay spread of the virus (1).
Protecting people at the moment and therefore reducing the speed and the peak of transmission is the
only possible options, until an antiviral drug or a vaccine will be ready.
Airborne virus can be considered bio-pollutants, and when it comes to respiratory infection, particulate
does matter. Aside from gaseous pollutants, the atmosphere can also be polluted by particles. These
particles (either in suspension, fluid or in solid state), have a divergent composition and size and are
sometimes called aerosols. They are often catalogued as 'floating dust', but are best known as particulate
matter (PM).
As long as we know, Coronavirus like other respiratory viruses need a watery nucleus (Flügge droplets) to
travel thought the air. Nevertheless, other carriers, as the particulate matter (PM), may be effective in
spreading the viruses (2, 3).
Are thus respiratory infections part of a larger cadre of diseases that are strictly related to or directly
caused by air pollution, as we have suggested in our recent publication (4)?
If this is the case, the way Covid-19 can spread may mimic the epidemiology of other diseases caused by air
pollutants. Therefore, some of the strategies specifically designed to protect people from air pollution may
be used also against Covid-19.
Facial mask are personal protective devices that limit the amount and the quality of particulate that can
reach the respiratory tract. The amount and the quality of particulate that they can block depend on the
mask and on the type of pollutant. Masks can stop microorganism, but they are not bidirectional filter:
germs spread in the environment from the respiratory airways via mainly via the droplets. Once in the air,
microrganisms can travel and lay on surfaces or can directly reach other people’s mucosae, starting a new
infection. Surgical masks are considered highly effective in reducing the risk of transmission from a positive
patient to a negative one, mainly stopping the Flügge droplets. On the other hand, surgical masks are not
so efficient in blocking the germs, and therefore the contagion, when a negative person is wearing the
device.
In addition, most of the masks currently in production are not so effective.
The WHO recently releases a guidance on when and how to use a medical masks to reduce Covid-19
transmission (5). However, no technical details are given.
SARS-CoV-2 diameter is around 100 nm. The dimension of the particle transporting the virus depend on the
carrier (1-10µm for droplets), between 0.3, to 2.5µm and 2.5 to 10µm for PM2.5 and PM10 respectively
(values refers to aerodynamic diameter). A mask unable to stop particles of this size is virtually invisible for
the virus.
Furthermore, the effectiveness of the filter depends on several factors, as the weft or the number of
impacts between the particles and the fibres of the mask. A s a consequence, unproperly designed facial
masks (see figure 1) do not stop droplets, PM, or virus.
This is crucial as those who unawares wear inapt masks may expose themselves to hazardous behaviours,
remaining exposed to the virus or unwillingly spreading the infection.
Future nano-technologies and active filters (active filtering fabrics and virucides) can help to overcome
these problems. Though, at the moment there are no perfect and cost-effective antiviral urban mask
available.
Other strategies may be studied, as the use of air cleaner with High Efficiency Particulate Air filter (HEPA)
devices (class H14 or higher), which may reduce the viral load in the air of indoor confined environments.
Besides, although there are no conclusive studies, some initial findings point out how SARS-CoV-2 can use
PM as a carrier, suggesting that tacking air pollution may lead to a reduction to the transmission and
therefore of the spreading of the disease (6, 7) .
We still do not know if Covid-19 will be washed out at the end of the epidemics, or if this infection will
become endemic. What we know is that we need properly designed and cost-effective personal protective
devices. We need to research and develop antiviral and virucide facial masks with a high filtering efficiency
in order to tackle the infection.
However, these or other devices alone are not enough. We need a synergic strategy to promote
environmental health. Our fight against respiratory viruses and against particulate matter (that causes
millions of deaths worldwide every years) (8, 9) in fact has a common ground, not only because particulate
can carry the virions. People must become aware of the hazards that surround them, and became
committed in reducing the risk and actively engaged in the fight for a healthier environment.
When it comes to viral infection, then, particle does matter, and we can ignore that, otherwise we will not
take responsibility for what is happening today with this new coronavirus epidemic.
In conclusion, Covid-19 shows how fragile is the ecosystem we live in, as well as how unprepared we are in
protecting ourselves from bio-pollutants as part of a wider fight against air pollution. It is thus paramount
to foster a behavioural change, taking immediate action and providing the right information to help people
to adopt effective measures against pollutants.
References
1. The L. COVID-19: too little, too late? Lancet. 2020;395(10226):755.
2. Wong CM, Thach TQ, Chau PY, Chan EK, Chung RY, Ou CQ, et al. Part 4. Interaction between air
pollution and respiratory viruses: time-series study of daily mortality and hospital admissions in Hong Kong.
Research report. 2010(154):283-362.
3. Silva DR, Viana VP, Muller AM, Livi FP, Dalcin Pde T. Respiratory viral infections and effects of
meteorological parameters and air pollution in adults with respiratory symptoms admitted to the
emergency room. Influenza and other respiratory viruses. 2014;8(1):42-52.
4. Capello F, Gaddi AV. Clinical handbook of air pollution-related diseases: Springer; 2018.
5. WHO. Advice on the use of masks in the community, during home care and in health care settings
in the context of the novel coronavirus (2019-nCoV) outbreak. In: Organization WH, editor.: WHO; 2020.
6. Setti L, Passarini F, Gennaro Gd, Gilio AD, Palmisani J, Buono P, et al. POSITION PAPER Relazione
circa l’effetto dell’inquinamento da particolato atmosferico e la diffusione di virus nella popolazione 2020.
Available from: http://www.simaonlus.it/wpsima/wp-content/uploads/2020/03/COVID19_Position-
Paper_Relazione-circa-l%E2%80%99effetto-dell%E2%80%99inquinamento-da-particolato-atmosferico-e-la-
diffusione-di-virus-nella-popolazione.pdf.
7. Wu X, Nethery RC, Sabath BM, Braun D, Dominici F. Exposure to air pollution and COVID-19
mortality in the United States. 2020.
8. Lelieveld J, Klingmuller K, Pozzer A, Poschl U, Fnais M, Daiber A, et al. Cardiovascular disease burden
from ambient air pollution in Europe reassessed using novel hazard ratio functions. European heart journal.
2019;40(20):1590-6.
9. Chen S, Bloom DE. The macroeconomic burden of noncommunicable diseases associated with air
pollution in China. PloS one. 2019;14(4):e0215663.
Figure 1. Structural differences that we found in different masks available on the market. The pictogram
visually shows how commercial masks differ among each other, with some of the device presenting a
structure inapt to block germs (from respiratory virus up to prokaryotes). Left column: structural layer.
Central and right column: filtering layer. Observations in: episcopic light, polarized light, and with mixed
technique (transmitted and episcopic light). Light source: white, colour temperature 5600K or blue, 405-
450 nm. Magnification: 100x. Microscopes: Olympus BX 60 and Leitz Ortholux.
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Book
This book examines in detail the clinical implications of those diseases that either are primarily triggered by air pollution or represent direct consequences of air pollutants. The aim is to provide medical practitioners with practical solutions to issues in diagnosis and treatment while simultaneously furnishing other interested parties with crucial information on the field. The book introduces the concept that air pollution-related diseases constitute a new class of pathologies. A wide range of conditions mainly attributable to air pollution are discussed, covering different body systems and pollution impacts in subsets of the population. In addition to presenting state of the art overviews of clinical aspects, the book carefully examines the implications of current knowledge for social and public health strategies aimed at disease prevention and prophylaxis. The Clinical Handbook of Air Pollution-Related Diseases will greatly assist doctors and healthcare workers when dealing with the consequences of air pollution in their everyday practice and will provide researchers, industry, and policymakers with valuable facts and insights.
Background: Populations in Asia are not only at risk of harm to their health through environmental degradation as a result of worsening pollution problems but also constantly threatened by recurring and emerging influenza epidemics and. pandemics. Situated in the area with the world's fastest growing economy and close to hypothetical epicenters of influenza transmission, Hong Kong offers a special opportunity for testing environmental management and public health surveillance in the region. In the Public Health and Air Pollution in Asia (PAPA*) project, the Hong Kong research team assessed the health effects of air pollution and influenza as well as the interaction between them. The team also assessed disparities in the health effects of air pollution between relatively deprived and more affluent areas in Hong Kong. The aim was to provide answers to outstanding research questions relating to the short-term effects of air pollution on mortality and hospital admissions; the health effects of influenza with a view to validating different measures of influenza activity according to virologic data; the confounding effects of influenza on estimates of the health effects of air pollution; the modifying effects of influenza on the health effects of air pollution; and the modifying effects of neighborhood social deprivation on the health effects of air pollution. Data: Data on mortality and hospital admissions for all natural causes, as well as the subcategories of cardiovascular diseases (CVD) and respiratory diseases (RD), were derived from the Hong Kong Census and Statistics Department and the Hospital Authority. Daily concentrations of nitrogen dioxide (NO2), sulfur dioxide (SO2), particulate matter with an aerodynamic diameter < or = 10 pm (PM10); and ozone (O3) were derived from eight monitoring stations with hourly data that were at least 75% complete during the study period. Three measures of influenza and respiratory syncytial virus (RSV) activity were derived from positive isolates of specimens in the virology laboratory of Queen Mary Hospital (QMH), the main clinical teaching center at The University of Hong Kong and part of the Hong Kong Hospital Authority network of teaching hospitals: influenza intensity (defined as the weekly proportion of positive isolates of influenza in the total number of specimens received for diagnostic tests); the presence of influenza epidemic (defined as a period when the weekly frequency of these positive isolates is > or = 4% of the annual total number of positive isolates [i.e., twice the expected mean value] in two or more consecutive weeks); and influenza predominance (defined as a period of influenza epidemic when the weekly frequency of RSV was less than 2% for two or more consecutive weeks). The weekly proportion of positive isolates of RSV in total specimens was determined in the same way as for influenza intensity. A social deprivation index (SDI) was defined by taking the average of the proportions of households or persons with the following six characteristics in each geographic area using the census statistics: unemployment; household income < U.S. $250 per month; no schooling at all; never-married status; one-person household; and subtenancy. A Poisson regression with quasi-likelihood to account for overdispersion was used to develop core models for daily health outcomes, with a natural spline smoothing function to filter out seasonal patterns and long-term trends in this time-series study of daily mortality and hospital admissions, and with adjustment for days of the week, temperature, and relative humidity (RH). Air pollutant concentration values were entered into the core model to assess the health effects of specific pollutants. The possible confounding effects of influenza were assessed by observing changes in magnitude of the effect estimate when each influenza measurement was entered into the model; and interactions between air pollution and influenza were assessed by entering the terms for the product of the air pollutant concentration and a measurement of influenza activity into the model. A Poisson regression analysis was performed to assess the effects of air pollution in each area belonging to low, middle, or high social deprivation strata according to the tertiles of the SDI. The differences in air pollution effects were tested by a case-only approach. RESULTS The excess risk (ER) estimates for the short-term effects of air pollution on mortality and hospitalization for broad categories of disease were greater in those 65 years and older than in the all-ages group and were consistent with other studies. The biggest health impacts were seen at the extremes of the age range. The three measures employed for influenza activity based on virologic data-one based on a proportion and the other two using frequencies of positive influenza isolates-were found to produce consistent health impact estimates, in terms of statistical significance. In general, we found that adjustment for influenza activity in air pollution health effect estimations took account of relatively small confounding effects. However, we conclude that it is worthwhile to make the adjustment in a sensitivity analysis and to obtain the best possible range of effect estimates from the data, especially for respiratory hospitalization. Interestingly, interaction effects were found between influenza activity and air pollution in the estimated risks for hospitalization for RD, particularly for 03. These results could be explained in terms of the detrimental effects of both influenza viruses and air pollutants, which may be synergistic or competing with each other, though the mechanism is still unknown. The results deserve further study and the attention of both public health policy makers and virologists in considering prevention strategies. IMPLICATIONS In Hong Kong, where air pollution may pose more of a health threat than in North American and Western European cities, the effects of air pollution also interact with influenza and with residence in socially deprived areas, potentially leading to additional harm. Asian governments should be aware of the combined risks to the health of the population when considering environmental protection and management in the context of economic, urban, and infrastructure development. This is the first study in Asia to examine the interactions between air pollution, influenza, and social deprivation from an epidemiologic perspective. The biologic mechanisms are still unclear, and further research is needed.
POSITION PAPER Relazione circa l'effetto dell'inquinamento da particolato atmosferico e la diffusione di virus nella popolazione 2020
  • L Setti
  • F Passarini
  • Gennaro Gd
  • A D Gilio
  • J Palmisani
  • P Buono
Setti L, Passarini F, Gennaro Gd, Gilio AD, Palmisani J, Buono P, et al. POSITION PAPER Relazione circa l'effetto dell'inquinamento da particolato atmosferico e la diffusione di virus nella popolazione 2020. Available from: http://www.simaonlus.it/wpsima/wp-content/uploads/2020/03/COVID19_Position-Paper_Relazione-circa-l%E2%80%99effetto-dell%E2%80%99inquinamento-da-particolato-atmosferico-e-ladiffusione-di-virus-nella-popolazione.pdf.