key: cord-0958802-3tn3lj2l authors: Fattorini, Daniele; Regoli, Francesco title: Role of the chronic air pollution levels in the Covid-19 outbreak risk in Italy date: 2020-05-04 journal: Environ Pollut DOI: 10.1016/j.envpol.2020.114732 sha: b3c86eb6336f0c8b5b5b063eb2c50683bb0aad09 doc_id: 958802 cord_uid: 3tn3lj2l Abstract After the initial outbreak in China, the diffusion in Italy of SARS-CoV-2 is exhibiting a clear regional trend with more elevated frequency and severity of cases in Northern areas. Among multiple factors possibly involved in such geographical differences, a role has been hypothesized for atmospheric pollution. We provide additional evidence on the possible influence of air quality, particularly in terms of chronicity of exposure on the spread viral infection in Italian regions. Actual data on Covid-19 outbreak in Italian provinces and corresponding long-term air quality evaluations, were obtained from Italian and European agencies, elaborated and tested for possible interactions. Our elaborations reveal that, beside concentrations, the chronicity of exposure may influence the anomalous variability of SARS-CoV-2 in Italy. Data on distribution of atmospheric pollutants (NO2, O3, PM2.5 and PM10) in Italian regions during the last 4 years, days exceeding regulatory limits, and years of the last decade (2010–2019) in which the limits have been exceeded for at least 35 days, highlight that Northern Italy has been constantly exposed to chronic air pollution. Long-term air-quality data significantly correlated with cases of Covid-19 in up to 71 Italian provinces (updated April 27, 2020) providing further evidence that chronic exposure to atmospheric contamination may represent a favourable context for the spread of the virus. Pro-inflammatory responses and high incidence of respiratory and cardiac affections are well known, while the capability of this coronavirus to bind particulate matters remains to be established. Atmospheric and environmental pollution should be considered as part of an integrated approach for sustainable development, human health protection and prevention of epidemic spreads but in a long-term and chronic perspective, since adoption of mitigation actions during a viral outbreak could be of limited utility. In December 2019, several pneumonia cases were suddenly observed in the metropolitan 35 city of Wuhan (China), as the result of infection to a novel coronavirus (Li et al., 2020 ; Wu et al., 36 2020; Xu et al., 2020) . This virus was termed SARS-CoV-2 for its similarity with that responsible of 37 the global epidemic Severe Acute Respiratory Syndrome (SARS) occurred between 2002 and 2003 38 (Xu et al., 2020) . Patients affected by SARS-CoV-2 infection often experienced serious 39 complications, including organ failure, septic shock, pulmonary oedema, severe pneumonia and (Sohrabi et al., 2020; WHO, 2020a) . 46 The drastic containment measures adopted by Chinese government did not prevent the diffusion of SARS-CoV-2, which in a few weeks has spread globally. Italy was the first country in 48 Europe to be affected by the epidemic Covid-19, with an outbreak even larger than that originally 49 observed in China (Fanelli and Piazza, 2020; Remuzzi and Remuzzi, 2020). Other European 50 countries and United States rapidly registered an exponential growth of clinical cases, leading to 51 restrictions and a global lockdown with evident social and economic repercussions (Cohen and 52 Kupferschmidt, 2020; ECDC, 2020). The WHO has recently declared the pandemic state of Covid-53 19 with over 2.8 million of cases reported and over 201.000 victims worldwide (Cucinotta and 54 Vanelli, 2020; WHO, 2020b; ECDC, 2020, accessed on 27 April 2020). 55 The ongoing epidemic trend in Italy immediately showed strong regional differences in the 56 spread of infections, with most cases concentrated in the north of the country (Remuzzi and 57 Remuzzi, 2020). The distribution of positive cases reported from February 24 th to April 27 th is 58 summarized in Figure 1A : some areas of Lombardy and Piedmont clearly exceeded 10.000 cases, 59 e.g. 18.371 at Milan, 12.564 at Brescia, 11.113 at Bergamo, 12199 at Turin (data re-elaborated 60 from the official daily reports of the Department of Civil Protection, ICPD, 2020, accessed on 27 61 April 2020). Also, the relative percentage distribution of the positive test rate ( Figure 1B ) exhibit 62 higher values in Northern Italy despite a certain uncertainty of data due to the different numbers 63 and frequency of oropharyngeal swabs performed in various regions to test coronavirus positivity; mortality rate ranged from 18% in the northern regions to less than 5% in the others ( Figure 1C ). 65 Overall these trends closely parallel the rates of reported Covid-19 cases and of fatal events, 66 expressed as percentage values normalized to the number of inhabitants for regional populations 67 ( Figures 1D and 1E ), further evidencing a significantly greater diffusion in Northern Italy, both in 68 terms of number of infections and the severity of cases (mortality). 69 To explain such geographical trend, it was initially assumed that restrictions decided by The percentage of European population exposed to levels higher than the regulatory limits 90 is about 7-8% for NO 2 , 6-8% for PM 2.5 , 13-19% for PM 10 and 12-29% for O 3 (EEA, 2019). Premature 91 deaths due to acute respiratory diseases from such pollutants are estimated to be over to two per day) has been exceeded for at least 35 days ( Figure 3C ). Once again, these data would provide 109 evidence that the whole Northern area below the Alpine arc has been constantly exposed to 110 significantly higher levels of these contaminants. 111 The hypothesis that atmospheric pollution may influence the SARS-CoV-2 outbreak in Italy Air pollution and health. The Lancet The early phase of the COVID-19 outbreak in Is short-term exposure to ambient fine particles associated with measles incidence in China? 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The authors, Daniele Fattorini and Francesco Regoli, declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.25 April 2020