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Environmental, climatic, socio-economic factors and non-pharmacological interventions: A comprehensive four-domain risk assessment of COVID-19 hospitalization and death in Northern Italy.

Department of Biomedical, Metabolic and Neural Sciences, Section of Public Health, University of Modena and Reggio Emilia, Modena, Italy; PhD Program in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, Section of Public Health, University of Modena and Reggio Emilia, Modena, Italy. Department of Biomedical, Metabolic and Neural Sciences, Section of Public Health, University of Modena and Reggio Emilia, Modena, Italy. Department of Chemical and Geological Sciences, University of Modena and Reggio Emilia, Modena, Italy. Department of Biomedical, Metabolic and Neural Sciences, Section of Public Health, University of Modena and Reggio Emilia, Modena, Italy; Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, Section of Public Health, University of Modena and Reggio Emilia, Modena, Italy; School of Public Health, University of California Berkeley, Berkeley, CA, USA. Electronic address: tommaso.filippini@unimore.it. Epidemiology and Risk Communication Service, Department of Public Health, Local Health Authority of Modena, Modena, Italy. Department of Communication and Economics, University of Modena and Reggio Emilia, Reggio Emilia, Italy. Marco Biagi Department of Economics, University of Modena and Reggio Emilia, Modena, Italy.

International journal of hygiene and environmental health. 2025;:114471
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Abstract

INTRODUCTION Up to now, studies on environmental, climatic, socio-economic factors, and non-pharmacological interventions (NPI) show diverse associations, often contrasting, with COVID-19 spread or severity. Most studies used large-scale, aggregated data, with limited adjustment for individual factors, most of them focused on viral spread than severe outcomes. Moreover, evidence simultaneously evaluating variables belonging to different exposure domains is scarce, and none analysing their collective impact on an individual level. METHODS Our population-based retrospective cohort study aimed to assess the comprehensive role played by exposure variables belonging to four different domains, environmental, climatic, socio-economic, and non-pharmacological interventions (NPI), on individual COVID-19-related risk of hospitalization and death, analysing data from all patients (no. 68472) tested positive to a SARS-CoV-2 swab in Modena Province (Northern Italy) between February 2020 and August 2021. Using adjusted Cox proportional hazard models, we estimated the risk of severe COVID-19 outcomes, investigating dose-response relationships through restricted cubic spline modelling for hazard ratios. RESULTS Several significant associations emerged: long-term exposure to air pollutants (NO2, PM10, PM2.5) was linked to hospitalization risk in a complex way and showed an increased risk for death; while humidity was inversely associated; temperature showed a U-shaped risk; wind speed showed a linear association with both outcomes. Precipitation increased hospitalization risk but decreased mortality. Socio-economic and NPI indices showed clear linear associations, respectively negative and positive, with both outcomes. CONCLUSIONS Our findings offer insights for evidence-based policy decisions, improving precision healthcare practices, and safeguarding public health in future pandemics. Refinement of pandemic response plans by healthcare authorities could benefit significantly.