Here, we discuss the strengths and limitations of conducting ecological regression analyses of air pollution and COVID-19 health outcomes and describe additional challenges related to evolving data quality, statistical modeling, and control of measured and unmeasured confounding, paving the way for future research on this topic. With this study design, publicly available area-level COVID-19 mortality rates are regressed against area-level air pollution concentrations while accounting for area-level potential confounding factors. Therefore, the only way to generate preliminary evidence on the link between PM 2.5 and COVID-19 severity and outcomes using these aggregate data is to use an ecological regression analysis. One key challenge is that, to our knowledge, individual-level data on COVID-19 health outcomes for large, representative populations are not publicly available or accessible to the scientific community. However, because of the unprecedented nature of the pandemic, researchers face serious challenges when conducting these studies. Two studies have been published using data from European countries ( 7, 8), and many more are available as preprints. Motivated by this study, we lay the groundwork for future research on this important topic, describe the challenges, and outline promising directions and opportunities.Įpidemiological studies to estimate the association between long-term exposure to air pollution and COVID-19 hospitalization and death is a rapidly expanding area of research that is attracting attention around the world. We describe these challenges in the context of one of the first preliminary investigations of this question in the United States, where we found that higher historical PM 2.5 exposures are positively associated with higher county-level COVID-19 mortality rates after accounting for many area-level confounders. Therefore, studies of long-term exposure to air pollution and COVID-19 outcomes using these data must use an ecological regression analysis, which precludes controlling for individual-level COVID-19 risk factors. At present, publicly available COVID-19 outcome data for representative populations are available only as area-level counts. Limitations in COVID-19 data availability and quality remain obstacles to conducting conclusive studies on this topic. Assessing whether long-term exposure to air pollution increases the severity of COVID-19 health outcomes, including death, is an important public health objective.
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