Background: Health conditions and immune dysfunction associated with trisomy 21 (Down syndrome, DS) may impact the clinical course of COVID-19 once infected by SARS-CoV-2. Methods: The T21RS COVID-19 Initiative launched an international survey for clinicians or caregivers/family members on patients with COVID-19 and DS (N=1046). De-identified survey data collected between April and October 2020 were analysed and compared with the UK ISARIC4C survey of hospitalized COVID-19 patients with and without DS. COVID-19 patients with DS from the ISARIC4C survey (ISARIC4C DS cases=100) were matched to a random set of patients without DS (ISARIC4C controls=400) and hospitalized DS cases in the T21RS survey (T21RS DS cases=100) based on age, gender, and ethnicity. Findings: The mean age in the T21RS survey was 29 years (SD=18), 73% lived with their family. Similar to the general population, the most frequent signs and symptoms of COVID-19 were fever, cough, and shortness of breath. Pain and nausea were reported less frequently (p<0.01), whereas altered consciousness/confusion were reported more frequently (p<0.01). Risk factors for hospitalization and mortality were similar to the general population (age, male gender, diabetes, obesity, dementia) with the addition of congenital heart defects as a risk factor for hospitalization. Mortality rates showed a rapid increase from age 40 and were higher than for controls (T21RS DS versus controls: risk ratio (RR)=3.5 (95%-CI=2.6;4.4), ISARIC4C DS versus controls: RR=2.9 (95%-CI=2.1;3.8)) even after adjusting for known risk factors for COVID-19 mortality. Interpretation: Leading signs/symptoms of COVID-19 and risk factors for severe disease course are similar to the general population. However, individuals with DS present significantly higher rates of mortality, especially from age 40. Funding: Down Syndrome Affiliates in Action, Down Syndrome Medical Interest Group-USA, GiGi's Playhouse, Jerome Lejeune Foundation, LuMind IDSC Foundation, Matthews Foundation, National Down Syndrome Society, National Task Group on Intellectual Disabilities and Dementia Practices.

Background: Air pollution has been associated with cognitive decline among the elderly. Previous studies have not evaluated the simultaneous effect of neighborhood-level socioeconomic status (N-SES), which can be an essential source of bias. Objectives: We explored N-SES as a confounder and effect modifier in a cross-sectional study of air pollution and cognitive function among the elderly. Methods: We included 12,058 participants age 50+ years from the Emory Healthy Aging Study in Metro Atlanta using the Cognitive Function Instrument (CFI) score as our outcome, with higher scores representing worse cognition. We estimated 9-year average ambient carbon monoxide (CO), nitrogen oxides (NOx), and fine particulate matter (PM2.5) concentrations at residential addresses using a fusion of dispersion and chemical transport models. We collected census-tract level N-SES indicators and created two composite measures using principal component analysis and k-means clustering. Associations between pollutants and CFI and effect modification by N-SES were estimated via linear regression models adjusted for age, education, race and N-SES. Results: N-SES confounded the association between air pollution and CFI, independent of individual characteristics. We found significant interactions between all air pollutants and N-SES for CFI (p-values<0.001) suggesting that effects of air pollution differ depending on N-SES. Participants living in areas with low N-SES were most vulnerable to air pollution. In the lowest N-SES urban areas, interquartile range (IQR) increases in CO, NOx, and PM2.5 were associated with 5.4% (95%-confidence interval, -0.2,11.4), 4.9% (-0.4,10.4), and 9.8% (2.2,18.0) increases in CFI, respectively. In lowest N-SES suburban areas, IQR increases in CO, NOx, and PM2.5 were associated with higher increases in CFI, namely 13.4% (1.3,26.9), 13.4% (0.3,28.2), and 17.6% (2.8,34.5), respectively. Discussion: N-SES is an important confounder and effect modifier in our study. This finding could have implications for studying health effects of air pollution in the context of environmental injustice.

Objective: The first two years of life are a critical period of rapid brain development. Since early neurodevelopment is influenced by prenatal risk factors and genetics, neonatal biomarkers can potentially provide the opportunity to detect early signs of neurodevelopmental delay. We analyzed associations between DNA methylation (DNAm) levels from cord blood, neonatal magnetic resonance imaging (MRI) neuroimaging data, and neurodevelopment at two years of age. Methods: Neurodevelopment was assessed in 161 children from the South African Drakenstein Child Health Study at two years of age using the Bayley Scales of Infant and Toddler Development III. We performed an epigenome-wide association study of neurodevelopmental delay using DNAm levels from cord blood. A mediation analysis was conducted in 51 children to analyze if associations between differential DNAm and neurodevelopmental delay were mediated by altered neonatal brain volumes. Results: We found epigenome-wide significant associations between differential DNAm at the SPTBN4 locus (cg26971411, p-value=3.10x10-08), an intergenic region on chromosome 11 (cg00490349, p-value=2.41x10-08) and a differentially methylated region on chromosome 1 (FDR p-value for the region=9.06x10-05) and severe neurodevelopmental delay. While these associations were not mediated by neonatal brain volume, neonatal caudate volumes were independently associated with neurodevelopmental delay, particularly in language (p=0.0443) and motor (p=0.0082) domains. Conclusion: Differential DNAm levels from cord blood and increased neonatal caudate volumes were independently associated with severe neurodevelopmental delay at two years of age. These findings suggest that neurobiological signals for severe developmental delay may be detectable in very early life with implications for identification and intervention design.

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