Climate change and health: global to local influences on disease risk.

The World Health Organization has concluded that the climatic changes that have occurred since the mid 1970s could already be causing annually over 150,000 deaths and five million disability-adjusted life-years (DALY), mainly in developing countries. The less developed countries are, ironically, those least responsible for causing global warming. Many health outcomes and diseases are sensitive to climate, including: heat-related mortality or morbidity; air pollution-related illnesses; infectious diseases, particularly those transmitted, indirectly, via water or by insect or rodent vectors; and refugee health issues linked to forced population migration. Yet, changing landscapes can significantly affect local weather more acutely than long-term climate change. Land-cover change can influence micro-climatic conditions, including temperature, evapo-transpiration and surface run-off, that are key determinants in the emergence of many infectious diseases. To improve risk assessment and risk management of these synergistic processes (climate and land-use change), more collaborative efforts in research, training and policy-decision support, across the fields of health, environment, sociology and economics, are required.

The association between extreme precipitation and waterborne disease outbreaks in the United States, 1948-1994.

OBJECTIVES: Rainfall and runoff have been implicated in site-specific waterborne disease outbreaks. Because upward trends in heavy precipitation in the United States are projected to increase with climate change, this study sought to quantify the relationship between precipitation and disease outbreaks. METHODS: The US Environmental Protection Agency waterborne disease database, totaling 548 reported outbreaks from 1948 through 1994, and precipitation data of the National Climatic Data Center were used to analyze the relationship between precipitation and waterborne diseases. Analyses were at the watershed level, stratified by groundwater and surface water contamination and controlled for effects due to season and hydrologic region. A Monte Carlo version of the Fisher exact test was used to test for statistical significance. RESULTS: Fifty-one percent of waterborne disease outbreaks were preceded by precipitation events above the 90th percentile (P = .002), and 68% by events above the 80th percentile (P = .001). Outbreaks due to surface water contamination showed the strongest association with extreme precipitation during the month of the outbreak; a 2-month lag applied to groundwater contamination events. CONCLUSIONS: The statistically significant association found between rainfall and disease in the United States is important for water managers, public health officials, and risk assessors of future climate change.

Climate variability and change in the United States: potential impacts on water- and foodborne diseases caused by microbiologic agents.

Exposure to waterborne and foodborne pathogens can occur via drinking water (associated with fecal contamination), seafood (due to natural microbial hazards, toxins, or wastewater disposal) or fresh produce (irrigated or processed with contaminated water). Weather influences the transport and dissemination of these microbial agents via rainfall and runoff and the survival and/or growth through such factors as temperature. Federal and state laws and regulatory programs protect much of the U.S. population from waterborne disease; however, if climate variability increases, current and future deficiencies in areas such as watershed protection, infrastructure, and storm drainage systems will probably increase the risk of contamination events. Knowledge about transport processes and the fate of microbial pollutants associated with rainfall and snowmelt is key to predicting risks from a change in weather variability. Although recent studies identified links between climate variability and occurrence of microbial agents in water, the relationships need further quantification in the context of other stresses. In the marine environment as well, there are few studies that adequately address the potential health effects of climate variability in combination with other stresses such as overfishing, introduced species, and rise in sea level. Advances in monitoring are necessary to enhance early-warning and prevention capabilities. Application of existing technologies, such as molecular fingerprinting to track contaminant sources or satellite remote sensing to detect coastal algal blooms, could be expanded. This assessment recommends incorporating a range of future scenarios of improvement plans for current deficiencies in the public health infrastructure to achieve more realistic risk assessments.

Climate variability and change in the United States: potential impacts on vector- and rodent-borne diseases.

Diseases such as plague, typhus, malaria, yellow fever, and dengue fever, transmitted between humans by blood-feeding arthropods, were once common in the United States. Many of these diseases are no longer present, mainly because of changes in land use, agricultural methods, residential patterns, human behavior, and vector control. However, diseases that may be transmitted to humans from wild birds or mammals (zoonoses) continue to circulate in nature in many parts of the country. Most vector-borne diseases exhibit a distinct seasonal pattern, which clearly suggests that they are weather sensitive. Rainfall, temperature, and other weather variables affect in many ways both the vectors and the pathogens they transmit. For example, high temperatures can increase or reduce survival rate, depending on the vector, its behavior, ecology, and many other factors. Thus, the probability of transmission may or may not be increased by higher temperatures. The tremendous growth in international travel increases the risk of importation of vector-borne diseases, some of which can be transmitted locally under suitable circumstances at the right time of the year. But demographic and sociologic factors also play a critical role in determining disease incidence, and it is unlikely that these diseases will cause major epidemics in the United States if the public health infrastructure is maintained and improved.

Immunology, climate change and vector-borne diseases.

Global climate change might expand the distribution of vector-borne pathogens in both time and space, thereby exposing host populations to longer transmission seasons, and immunologically naive populations to newly introduced pathogens. In the African highlands, where cool temperatures limit malaria parasite development, increases in temperature might enhance malaria transmission. St Louis encephalitis viral replication and the length of the transmission season depend upon ambient temperature. Warming temperatures in the American southwest might place at risk migratory, non-immune elderly persons that arrive in early fall to spend the winter. Warm temperatures might intensify or extend the transmission season for dengue fever. Immunologists should examine this interplay between human immunocompetence and vector-borne disease risks in a warmer world.

Effects of environmental change on emerging parasitic diseases.

Ecological disturbances exert an influence on the emergence and proliferation of malaria and zoonotic parasitic diseases, including, Leishmaniasis, cryptosporidiosis, giardiasis, trypanosomiasis, schistosomiasis, filariasis, onchocerciasis, and loiasis. Each environmental change, whether occurring as a natural phenomenon or through human intervention, changes the ecological balance and context within which disease hosts or vectors and parasites breed, develop, and transmit disease. Each species occupies a particular ecological niche and vector species sub-populations are distinct behaviourally and genetically as they adapt to man-made environments. Most zoonotic parasites display three distinct life cycles: sylvatic, zoonotic, and anthroponotic. In adapting to changed environmental conditions, including reduced non-human population and increased human population, some vectors display conversion from a primarily zoophyllic to primarily anthrophyllic orientation. Deforestation and ensuing changes in landuse, human settlement, commercial development, road construction, water control systems (dams, canals, irrigation systems, reservoirs), and climate, singly, and in combination have been accompanied by global increases in morbidity and mortality from emergent parasitic disease. The replacement of forests with crop farming, ranching, and raising small animals can create supportive habitats for parasites and their host vectors. When the land use of deforested areas changes, the pattern of human settlement is altered and habitat fragmentation may provide opportunities for exchange and transmission of parasites to the heretofore uninfected humans. Construction of water control projects can lead to shifts in such vector populations as snails and mosquitoes and their parasites. Construction of roads in previously inaccessible forested areas can lead to erosion, and stagnant ponds by blocking the flow of streams when the water rises during the rainy season. The combined effects of environmentally detrimental changes in local land use and alterations in global climate disrupt the natural ecosystem and can increase the risk of transmission of parasitic diseases to the human population.

Climate change and vector-borne diseases: a regional analysis.

Current evidence suggests that inter-annual and inter-decadal climate variability have a direct influence on the epidemiology of vector-borne diseases. This evidence has been assessed at the continental level in order to determine the possible consequences of the expected future climate change. By 2100 it is estimated that average global temperatures will have risen by 1.0-3.5 degrees C, increasing the likelihood of many vector-borne diseases in new areas. The greatest effect of climate change on transmission is likely to be observed at the extremes of the range of temperatures at which transmission occurs. For many diseases these lie in the range 14-18 degrees C at the lower end and about 35-40 degrees C at the upper end. Malaria and dengue fever are among the most important vector-borne diseases in the tropics and subtropics; Lyme disease is the most common vector-borne disease in the USA and Europe. Encephalitis is also becoming a public health concern. Health risks due to climatic changes will differ between countries that have developed health infrastructures and those that do not. Human settlement patterns in the different regions will influence disease trends. While 70% of the population in South America is urbanized, the proportion in sub-Saharan Africa is less than 45%. Climatic anomalies associated with the El Niño-Southern Oscillation phenomenon and resulting in drought and floods are expected to increase in frequency and intensity. They have been linked to outbreaks of malaria in Africa, Asia and South America. Climate change has far-reaching consequences and touches on all life-support systems. It is therefore a factor that should be placed high among those that affect human health and survival.

The effects of changing weather on public health.

Many diseases are influenced by weather conditions or display strong seasonality, suggestive of a possible climatic contribution. Projections of future climate change have, therefore, compelled health scientists to re-examine weather/disease relationships. There are three projected physical consequences of climate change: temperature rise, sea level rise, and extremes in the hydrologic cycle. This century, the Earth has warmed by about 0.5 degrees centigrade, and the mid-range estimates of future temperature change and sea level rise are 2.0 degrees centigrade and 49 centimeters, respectively, by the year 2100. Extreme weather variability associated with climate change may especially add an important new stress to developing nations that are already vulnerable as a result of environmental degradation, resource depletion, overpopulation, or location (e.g. low-lying coastal deltas). The regional impacts of climate change will vary widely depending on existing population vulnerability. Health outcomes of climate change can be grouped into those of: (a) direct physical consequences, e.g. heat mortality or drowning; (b) physical/chemical sequelae, e.g. atmospheric transport and formation of air pollutants; (c) physical/biological consequences, e.g. response of vector- and waterborne diseases, and food production; and (d) sociodemographic impacts, e.g. climate or environmentally induced migration or population dislocation. Better understanding of the linkages between climate variability as a determinant of disease will be important, among other key factors, in constructing predictive models to guide public health prevention.

Effect of El Niño and ambient temperature on hospital admissions for diarrhoeal diseases in Peruvian children.

INTRODUCTION: To investigate whether the El Niño phenomenon and ambient temperature had an effect on the epidemiology of childhood diarrhoea, we analysed data on daily number of admissions of children with diarrhoea to the Oral Rehydration Unit of the Instituto de Salud del Niño in Lima, Peru, between January, 1993, and November, 1998. METHODS: We obtained daily data on hospital admissions from the Oral Rehydration Unit, and meteorological data from the Peruvian Weather Service, and used time-series linear regression models to assess the effects of the 1997-98 El Niño event on admissions for diarrhoea. FINDINGS: 57,331 children under 10 years old were admitted to the unit during the study. During the 1997-98 El Niño episode, mean ambient temperature in Lima increased up to 5 degrees C above normal, and the number of daily admissions for diarrhoea increased to 200% of the previous rate. 6225 excess admissions were attributable to El Niño, and these cost US$277,000. During the period before the El Niño episode, admissions for diarrhoea increased by 8% per 1 degree C increase in mean ambient temperature. The effects of El Niño and ambient temperature on the number of admissions for diarrhoea were greatest during the winter months. INTERPRETATION: El Niño had an effect on hospital admissions greater than that explained by the regular seasonal variability in ambient temperature. The excess increase in ambient temperature was the main environmental variable affecting admissions. If our findings are reproducible in other regions, diarrhoeal diseases may increase by millions of cases worldwide with each degree of increase in ambient temperature above normal.

Using remotely sensed data to identify areas at risk for hantavirus pulmonary syndrome.

The 1993 U.S. hantavirus pulmonary syndrome (HPS) outbreak was attributed to environmental conditions and increased rodent populations caused by unusual weather in 1991- 92. In a case-control study to test this hypothesis, we estimated precipitation at 28 HPS and 170 control sites during the springs of 1992 and 1993 and compared it with precipitation during the previous 6 years by using rainfall patterns at 196 weather stations. We also used elevation data and Landsat Thematic Mapper satellite imagery collected the year before the outbreak to estimate HPS risk by logistic regression analysis. Rainfall at case sites was not higher during 1992-93 than in previous years. However, elevation, as well as satellite data, showed association between environmental conditions and HPS risk the following year. Repeated analysis using satellite imagery from 1995 showed substantial decrease in medium- to high-risk areas. Only one case of HPS was identified in 1996.

The potential health impacts of climate variability and change for the United States: executive summary of the report of the health sector of the U.S. National Assessment.

We examined the potential impacts of climate variability and change on human health as part of a congressionally mandated study of climate change in the United States. Our author team, comprising experts from academia, government, and the private sector, was selected by the federal interagency U.S. Global Change Research Program, and this report stems from our first 18 months of work. For this assessment we used a set of assumptions and/or projections of future climates developed for all participants in the National Assessment of the Potential Consequences of Climate Variability and Change. We identified five categories of health outcomes that are most likely to be affected by climate change because they are associated with weather and/or climate variables: temperature-related morbidity and mortality; health effects of extreme weather events (storms, tornadoes, hurricanes, and precipitation extremes); air-pollution-related health effects; water- and foodborne diseases; and vector- and rodent-borne diseases. We concluded that the levels of uncertainty preclude any definitive statement on the direction of potential future change for each of these health outcomes, although we developed some hypotheses. Although we mainly addressed adverse health outcomes, we identified some positive health outcomes, notably reduced cold-weather mortality, which has not been extensively examined. We found that at present most of the U.S. population is protected against adverse health outcomes associated with weather and/or climate, although certain demographic and geographic populations are at increased risk. We concluded that vigilance in the maintenance and improvement of public health systems and their responsiveness to changing climate conditions and to identified vulnerable subpopulations should help to protect the U.S. population from any adverse health outcomes of projected climate change.

Environmental and geographical factors contributing to watershed contamination with Cryptosporidium parvum oocysts.

Cryptosporidium parvum is a waterborne parasite which infects cattle and produces life-threatening zoonosis in people with impaired immune systems. Digital maps of 100-year floodplain boundaries, land use/cover, and livestock operations were used to select and characterize cattle farms in the floodplain area in Lancaster County, Pennsylvania, U.S.A. Over 21% of the cattle farms were located within 100-year floodplain boundaries. On average, a single farm comprised 12.8 ha of pasture (including buildings and farmyard) at risk of inundation. In all farms cattle had unlimited access to the creek. Manure samples collected from closed-in calf pens, cow/heifer yard runoff, and cattle paths through the creek were tested for C. parvum. On 64% of the farms (n=50) at least one sample was positive for C. parvum, and 44% of the farms had oocysts in all manure samples. Concentration varied from 90 to 371 oocysts/g and was significantly higher (P<0.02) in calf samples than in manure from cow and cow/heifer.

Predicting key malaria transmission factors, biting and entomological inoculation rates, using modelled soil moisture in Kenya.

While malaria transmission varies seasonally, large inter-annual heterogeneity of malaria incidence occurs. Variability in entomological parameters, biting rates and entomological inoculation rates (EIR) have been strongly associated with attack rates in children. The goal of this study was to assess the weather's impact on weekly biting and EIR in the endemic area of Kisian, Kenya. Entomological data collected by the U.S. Army from March 1986 through June 1988 at Kisian, Kenya was analysed with concurrent weather data from nearby Kisumu airport. A soil moisture model of surface-water availability was used to combine multiple weather parameters with landcover and soil features to improve disease prediction. Modelling soil moisture substantially improved prediction of biting rates compared to rainfall; soil moisture lagged two weeks explained up to 45% of An. gambiae biting variability, compared to 8% for raw precipitation. For An. funestus, soil moisture explained 32% variability, peaking after a 4-week lag. The interspecies difference in response to soil moisture was significant (P < 0.00001). A satellite normalized differential vegetation index (NDVI) of the study site yielded a similar correlation (r = 0.42 An. gambiae). Modelled soil moisture accounted for up to 56% variability of An. gambiae EIR, peaking at a lag of six weeks. The relationship between temperature and An. gambiae biting rates was less robust; maximum temperature r2 = -0.20, and minimum temperature r2 = 0.12 after lagging one week. Benefits of hydrological modelling are compared to raw weather parameters and to satellite NDVI. These findings can improve both current malaria risk assessments and those based on El Niño forecasts or global climate change model projections.

Dengue fever epidemic potential as projected by general circulation models of global climate change.

Climate factors influence the transmission of dengue fever, the world's most widespread vector-borne virus. We examined the potential added risk posed by global climate change on dengue transmission using computer-based simulation analysis to link temperature output from three climate general circulation models (GCMs) to a dengue vectorial capacity equation. Our outcome measure, epidemic potential, is the reciprocal of the critical mosquito density threshold of the vectorial capacity equation. An increase in epidemic potential indicates that a smaller number of mosquitoes can maintain a state of endemicity of disease where dengue virus is introduced. Baseline climate data for comparison are from 1931 to 1980. Among the three GCMs, the average projected temperature elevation was 1.16 degrees C, expected by the year 2050. All three GCMs projected a temperature-related increase in potential seasonal transmission in five selected cities, as well as an increase in global epidemic potential, with the largest area change occurring in temperate regions. For regions already at risk, the aggregate epidemic potential across the three scenarios rose on average between 31 and 47% (range, 24-74%). If climate change occurs, as many climatologists believe, this will increase the epidemic potential of dengue-carrying mosquitoes, given viral introduction and susceptible human populations. Our risk assessment suggests that increased incidence may first occur in regions bordering endemic zones in latitude or altitude. Endemic locations may be at higher risk from hemorrhagic dengue if transmission intensity increases.