ABSTRACT
Long-term exposure to poor air quality has been associated with respiratory viral infections such as influenza and measles. Some epidemiological studies in North America, Europe, and Asia also suggest that exposure to air pollution is associated with increased SARS-CoV-2 infection and mortality associated with COVID-19. However, few studies have been conducted on this topic in South America. In this study, we investigate the association between ambient PM2.5, NO2, and O-3 and their interaction with COVID-19-associated deaths in Brazil, the largest country in South America. We apply a negative binomial mixed model with zero inflation using municipality-level COVID-19 deaths as the endpoint and the long-term average of PM2.5, NO2, and O-3 as the exposure. We added a random intercept by state to account for potential correlations between communities within the same state. After adjusting the model for several potential confounders, including meteorological variables, demographic characteristics, socioeconomic aspects, and healthcare conditions, we found a positive association between PM2.5 and COVID-19 deaths in Brazil, where a 1 mu g/m(3) increase in the long-term average of PM2.5 was associated with a 10.22% (95% CI: 9.35;11.09) increase in COVID-19 deaths. In contrast, O-3 and NO2 showed negative associations. As suggested by the literature in other countries, our results suggest that air pollution is an important cofactor that increases the risk of death from COVID-19 in Brazil. The effects of air pollution in Brazil are pronounced, indicating the need for improved air quality control policies.