1A.1

Vulnerability and Adaptation Assessments Hands-On

Training WorkshopHuman Health Sector

Kristie L. Ebi, Exponent Health Group

Outline

1. Overview of the potential health impacts of climate variability and change

2. Health data to determine the current burden of climate-sensitive diseases

3. Methods and tools for V&A assessment in the health sector

4. Methods for determining a health adaptation baseline

1A.3

Overview of the Potential Health Impacts of Climate

Variability and Change

Topics

Pathways for weather to affect health Potential health impacts of climate change

Extreme weather events El Nino and disease Temperature Floods

Vector-borne diseases Diseases related to air pollution Diarrheal diseases

Corvalan et al., 2003

Pathways from Driving Forces to Potential Health Impacts

Pathways for Weather to Affect Health: Example = Diarrheal Disease

TemperatureHumidityPrecipitation

Distal Causes Proximal Causes Infection Hazards Health Outcome

Living conditions(water supply andsanitation)

Food sources andhygiene practices

Survival/ replicationof pathogens in theenvironment

Contamination ofwater sources

Rate of personto person contact

Consumption ofcontaminated water

Consumption ofcontaminated food

Contact withinfected persons

Incidence of mortality andmorbidityattributableto diarrhea

Vulnerability(e.g. age andnutrition)

Contamination of food sources

WHO

IPCC TAR–Potential Health Impacts of Climate Change

Any increase in climate extremes (storms, floods, cyclones) could increase the risk of infectious disease epidemics, particularly in low-income countries

Increase in heatwaves, often exacerbated by increased humidity & urban air pollution

Increase in the geographic range of potential transmission of malaria & other vector-borne diseases

Increase in water- and food-borne diseases

The severity of impacts will depend on the capacity to adapt & its effective deployment

Drivers of Health Issues

Population density Urbanization Public health infrastructure Economic and technologic development Environmental conditions Populations at risk

Poor Children Increasing population of elderly residents Immunocompromised

ENSO and Disease

Kovats et al., 2003

Exploring Linkages Between ENSO and Human Health

Dengue Epidemics in South Pacific 1970-1999

Number of Cholera cases in Uganda 1997-2002

0

10000

20000

30000

40000

50000

1996 1997 1998 1999 2000 2001 2002 2003

Time in years

Num

ber o

f cas

es

El Nino starts El Nino stops

Dr. Githeko, personal communication

Climate Change May Entail Changes in

Variance, as Well as Changes in

Mean

Folland et al., 2001

Temperature Extremes in

the Caribbean,1955-2000

Climate Variability and Change Impacts in the Caribbean

DATE COUNTRY EVENT DEATH ESTIMATED COSTS(US$ million, 1998)

1974 Honduras Hurricane Fifi 7,000 1,331

1982/3 Bolivia, Ecuador, Peru El Niño 0 5,661

1997/98

Bolivia, Colombia, Ecuador, Peru

El Niño 600 7,694

1998 Central America Hurricane Mitch 9,214 6,008

1998 Dominican Republic Hurricane Georges 235 2,193

  Cuba Hurricane Georges 6 N/A

1999 Venezuela Landslide 25,000 N/A

Fuente: ECLAC, América Latina y El Caribe: El Impacto de los Desastres Naturales en el Desarrollo, 1972-1999, LC/MEX/L.402; OFDA, Venezuela- Floods, Fact Sheet #10, 1/12/ 2000.

Mechanisms by Which Above Average Rainfall Can Affect Health

Event Description Potential Health Impact

Heavy precipitation

“Extreme event” Increased or decreased mosquito abundance

Flood River/stream over tops its banksProperty or crops damaged

Above plus contamination of surface water

Flood Catastrophic flood/disaster

Above plus increased risk of respiratory and diarrhoeal disease, injuries, etc.

Kovats et al., 2003

Health Impacts of Floods

Immediate deaths and injuries

Nonspecific increases in mortality

Infectious diseases – leptospirosis, hepatitis, diarrheal, respiratory, and vector-borne diseases

Exposure to toxic substances

Mental health effects Increased demands on

health systemsPhilip Wijmans, LWF/ACT Mozambique, March 2000

Mechanisms by Which Drought Can Affect Health

Description Potential Health Impact

Soil moisture decreases Changes in vector abundance

Decreased crop production Depends on socioeconomic factors

Reduction in food or water supply and quality

Food shortage, illness, malnutrition, increased risk of disease

Food shortage leading to deaths

Death, starvation, risks associated with population displacement

Kovats et al., 2003

Examples of Environmental Changes and Possible Effects on Infectious Diseases

Environmental Change

Example Disease

Pathway of Effect

Dams, canals, irrigation

Malaria Increase breeding sites for mosquitoes

Urbanization Cholera Decreased sanitation & hygiene, increased water contamination

Reforestation Lyme disease

Increase tick hosts, outdoor exposure

Ocean warming Red tide Increase toxic algal blooms

Wilson 2001Patz et al., 2003

Factors that Influence the Range and Prevalence of Infectious Diseases

Sociodemographic influences Human travel, trade, and migration Disease control efforts Drug resistance Nutrition

Environmental influences Land-use, including deforestation, agricultural

development, and urbanization Ecological influences

Temperature and Precipitation Effects on Vector- and Rodent-Borne Diseases

Survival and reproduction rate of the vector Time of year and level of vector activity,

specifically the biting rate Rate of development and reproduction of the

pathogen within the vector

Main Types of Transmission Cycles for Infectious Disease

Patz et al., 2003

Potential Transmission of Schistosomiasis, Jiangsu Province

Yang et al., 2005

Climate Change and Malaria under Different Scenarios (2080)

Increase: East Africa, Central Asia, Russian Federation Decrease: Central America, Amazon [within current vector limits]

Van Lieshout et al. 2004

C hange o f consecutive m onths

> +2

+2

-2

< -2

A1

B2

A2

B1 Van Lieshout et al. 2004

China Haze 10 January 2003

NASA

Daily Temperature

Daily Diarrhea Admissions

Diarrhea increases by 8% for each 1ºC increase in temperature

Checkley et al., 2000

Effect of Temperature Variation on Diarrheal Incidence in Lima, Peru

Resources

McMichael, A.J., D.H. Campbell-Lendrum, C.F. Corvalan, K.L. Ebi, A. Githeko, J.D. Scheraga, and A. Woodward (eds.). 2003. Climate Change and Human Health: Risks and Responses. WHO, Geneva.

Summary pdf available at http://www.who.int/globalchange/publications/cchhsummary/

Kovats, R.D., K.L Ebi, and B. Menne. 2003. Methods of Assessing Human Health Vulnerability and Public Health Adaptation to Climate Change. WHO/Health Canada/UNEP.

Pdf available at http://www.who.dk/document/E81923.pdf

1A.28

Health Data to Determine the Current Burden of Climate-

Sensitive Diseases

Questions to be Addressed

What climate-sensitive diseases are important in the country or region? What is the current burden of these diseases?

What factors other than climate should be considered? Water, sanitation, etc.

Where are data available? Are health services able to satisfy current

demands?

Health Data Sources

World Health Report provides regional-level data for all major diseases http://www.who.int/whr/en Annual data in Statistical Annex

WHO databases Malnutrition http://www.who.int/nutgrowth/db Water and sanitation

http://www.who.int/entity/water_sanitation_health/database/en

Ministry of Health Disease surveillance/reporting

branch

Health Data Sources – Other

UNICEF at http://www.unicef.org CRED-EMDAT provides data on disasters

http://www.em-dat.net Mission hospitals Government district hospitals

Indonesia

Total population = 219,883,000 Annual population growth rate = 1.4% Life expectancy at birth = 67 years Under age 5 mortality rate = 41/1,000

70% of 1-year-olds immunized with 3 doses of DTP

3.2% of gross domestic product spent on health

WHO, 2005

1A.33

Methods and Tools for V&A Assessment in the

Health Sector

Methods and Tools

Qualitative assessments Methods of assessing human health

vulnerability to climate change WHO Global Burden of Disease

Comparative Risk Assessment Environmental Burden of Disease

MIASMA Other models

Qualitative Assessments

Available data allow for qualitative assessment of vulnerability

For example, given current burden of diarrheal diseases and projected changes in precipitation, will vulnerability remain the same, increase, or decrease?

1A.36

Methods of Assessing Human Health Vulnerability and

Public Health Adaptation to Climate Change

Kovats et al., 2003

Methods for:

Estimating the current distribution and burden of climate-sensitive diseases

Estimating future health impacts attributable to climate change

Identifying current and future adaptation options to reduce the burden of disease

Kovats et al., 2003

Estimate Potential Future Health Impacts

Requires using climate scenarios Can use top-down or bottom-up approaches

Models can be complex spatial models or be based on a simple exposure-response relationship

Should include projections of how other relevant factors may change

Uncertainty must be addressed explicitly

Kovats et al., 2003

Case Study: Risk of Vector-Borne Diseases in Portugal

Four qualitative scenarios developed of changes in climate and in vector populations Vector not present Focal distribution of vector Widespread distribution of vector Change from focal to potentially regional

distribution Expert judgment determined likely risk under

each scenario for 5 vector-borne diseases

Casimiro et al., 2006

Portuguese National Assessment

Vector Parasite

  None Present Imported human cases

only

Low prevalence in

vectors/hosts

High prevalence

vectors/hosts

None Present

NegligibleRisk

NegligibleRisk

NegligibleRisk

NegligibleRisk

Focal Distribu-

tion

NegligibleRisk

Very lowRisk

LowRisk

LowRisk

Regional NegligibleRisk

Very lowRisk

LowRisk

Medium Risk

Wide-spread

NegligibleRisk

Very lowRisk

Medium Risk

High Risk

Casimiro & Calheiros 2002

Sources of Uncertainty

Data Missing data or errors in data

Models Uncertainty regarding predictability of the

system Uncertainty introduced by simplifying

relationships Other

Inappropriate spatial or temporal data Inappropriate assumptions Uncertainty about predictive ability of

scenariosKovats et al., 2003

Estimating the Global Health Impacts of Climate Change

What will be the total potential health impact caused by climate change (2000 to 2030)?

How much of this could be avoided by reducing the risk factor (i.e. stabilizing greenhouse gas (GHG) emissions)?

McMichael et al., 2004

Comparative Risk Assessment

2020s

2050s

2080s

Greenhouse gas emissions scenarios

Global climate modelling:

Generates series of maps of predicted future climate

Health impact model: Estimates the change in relative risk of specific diseases

Time

2080s2050s2020sMcMichael et al., 2004

Criteria for Selection of Health Outcomes

Sensitive to climate variation Important global health burden Quantitative model available at the global

scale

McMichael et al., 2004

Health Outcomes Considered

Outcome Class Incidence / prevalence

Outcome

Direct effects of heat and cold

Incidence Cardiovascular disease deaths

Foodborne & waterborne diseases

Incidence Diarrhea episodes

Vector-borne diseases Incidence Malaria cases

Natural disasters Incidence

Incidence

Deaths due to unintentional injuries

Other unintentional injuries

Risk of malnutrition Prevalence Non-availability of recommended daily calorie intake

McMichael et al., 2004

Exposure: Alternative Future Projections of GHG Emissions

Unmitigated current GHG emissions trends Stabilization at 750 ppm CO2-equivalent by

the year 2210 Stabilization at 550 ppm CO2-equivalent by

the year 2170 Average climate conditions for 1961-1990

(WMO climate normal baseline)Source: UK Hadley Centre models

McMichael et al., 2004

Estimated Mortality (000s) Attributable to Climate Change, 2000

Mal-nutrition

Diarrhea CVD All Causes

Deaths / Million

SEAR-B

0 1 1 2 7.9

SEAR-D

52 22 7 80 65.8

McMichael et al., 2004

Climate scenarios, as function of GHG emissions

Relative Risk of Diarrheoa in 2030, by Region

0.94

0.96

0.98

1

1.02

1.04

1.06

1.08

1.1

Afr

D

Afr

E

Am

r A

Am

r B

Am

r D

Em

r B

Em

r D

Eur

A

Eur

B

Eur

C

Sea

r B

Sea

r D

Wpr

A

Wpr

B

Rel

ativ

e R

isk

s550

s750

UE

Conclusions

Climate change may already be causing a significant burden in developing countries

Unmitigated climate change is likely to cause significant public health impacts out to 2030

Largest impacts from diarrhea, malnutrition, and malaria Uncertainties include:

Uncertainties in projections Effectiveness of interventions Changes in nonclimatic factors

McMichael et al., 2004

Environmental Burden of Disease

A. Prüss-Üstün, C. Mathers, C. Corvalan, and A. Woodward. 2003. Introduction and Methods: Assessing the Environmental Burden of Disease at National and Local Levels [pdf available at http://www.who.int/peh/burden/burdenindex.html]

Climate change document will be published soon

Climate and Stable Malaria Transmission

Climate suitability is a primary determinant of whether the conditions in a particular location are suitable for stable malaria transmission

A change in temperature may lengthen or shorten the season in which mosquitoes or parasites can survive

Changes in precipitation or temperature may result in conditions during the season of transmission that are conducive to increased or decreased parasite and vector populations

Climate and Stable Malaria Transmission (continued)

Changes in precipitation or temperature may cause previously inhospitable altitudes or ecosystems to become conducive to transmission. Higher altitudes that were formerly too cold or desert fringes that were previously too dry for mosquito populations to develop may be rendered hospitable by small changes in temperature or precipitation.

Relationship between Temperature and Daily Survivorship of Anopheles

0.000.100.200.300.400.500.600.700.800.901.00

Mean Temperature (°C)

Prop

ortio

n of

Mos

quito

es

Surv

ivin

g O

ne D

ay

Relationship between Temperature and Time Required for Parasite Development

0

20

40

60

80

100

120

Mean Temperature (°C )

Days

Proportion of Vectors Surviving Time Required for Parasite Development

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

Mean Temperature (°C)

Pro

port

ion

Sur

vivi

ng

The website [http://www.mara.org.za] contains prevalence and population data,and regional and country-level maps

MARA/ARMA Model

Biological model that defines a set of decision rules based on minimum and mean temperature constraints on the development of the Plasmodium falciparum parasite and the Anopheles vector, and on precipitation constraints on the survival and breeding capacity of the mosquito

CD-ROM $5 for developing countries or can download components from website: www.mara.org.za

MIASMA

Modeling Framework for the Health Impact Assessment of Man-Induced Atmospheric Changes

MIASA was written by Dr. Pim Martens (p.martens@icis.unimaas.nl). A fee of US$ 5 is required for a self-extracting CD

Includes modules for thermal stress, malaria, dengue, and schistosomiasis

Select IPCC scenario and GCM

Other Models

CiMSiM and DENSim for dengue Weather and habitat-driven entomological

simulation model that links with a simulation model of human population dynamics to project disease outbreaks

http://daac.gsfc.nasa.gov/IDP/models/index.html

India’s Initial National Communication: Goals

To identify, analyze, and evaluate the impacts of climate variability and change on natural ecosystems, socioeconomic systems, and human health

To assess the vulnerabilities, which also depend on the institutional and financial capacities of the affected communities

To assess the potential adaptation responses To develop technical, institutional, and financial

strategies to reduce vulnerability

India’s Initial National Communication

Temperature-related mortality Vector-borne diseases

Changing patterns of diseases – malaria, filaria, kala-azar, Japanese encephalitis, dengue

Health effects of extreme weather Diarrhea, cholera, and poisoning caused by biological and

chemical contaminants in water Damaged public health infrastructure due to cyclones/floods Social and mental health stress due to disasters and

displacements Health effects due to insecurity in food production

Malaria in India 1976-2001

Projected Changes in Number of Months Malaria Can Be Transmitted

Factors Affecting Malaria Distribution and Prevalence in India

Climate Urban settlements Poverty Irrigation Agricultural practices Land-use change

1A.67

Methods for Determining a Health Adaptation Baseline

Questions for Designing Adaptation Policies and Measures

Adaptation to what? Is additional intervention needed? What are the future projections for the

outcome? Who is vulnerable? On scale relevant for adaptation

Who adapts? How does adaptation occur? When should interventions be implemented? How good or likely is the adaptation?

Current and Future Adaptation Options

What is being done now to reduce the burden of disease? How effective are these policies and measures?

What measures should begin to be implemented to increase the range of possible future interventions?

When and where should new policies be implemented? Identify strengths and weaknesses, as well as

threats and opportunities to implementation

Kovats et al., 2003

Public Health Adaptation

Existing risks Modifying existing prevention strategies Reinstitute effective prevention programs that

have been neglected or abandoned Apply win/win or no-regrets strategies

New risks

Options for Adaptations to Reduce the Health Impacts of Climate Change

Health Outcome Legislative Technical Educational-advisory Cultural & Behavioral

Thermal stress Building guidelines Housing, public buildings, urban planning, air conditioning

Early warning systems Clothing, siesta

Extreme weather events

Planning laws, economic incentives for building

Urban planning, storm shelters

Early warning systems Use of storm shelters

Vector-borne diseases Vector control, vaccination, impregnated bednets, sustainable surveillance, prevention & control programmes

Health education Water storage practices

Water-borne diseases Watershed protection laws, water quality regulation

Screening for pathogens, improved water treatment & sanitation

Boil water alerts Washing hands and other behavior, use of pit latrines

McMichael et al. 2001

Screening the Theoretical Range of Response Options – Malaria

Theoretical Range of Choice

Technically feasible?

Effective? Environmentally acceptable?

Financially

Feasible?

Socially and Legally Acceptable?

Closed/Open (Practical Range of Choice)

Improved public health infrastructure

Yes Low Yes Sometimes Yes Open

Forecasting & early warning systems

Yes Medium Yes Often Yes Open

Public information & education

Yes Low Yes Yes Yes Open

Control of vector breeding sites

Yes Yes Spraying - no Yes Sometimes Open

Impregnated bed nets

Yes Yes Yes Yes Yes Open

Prophylaxis Yes Yes Yes Only for the few

Yes Closed for many

Vaccination No Closed

Ebi and Burton, submitted

Analysis of the Practical Range of Response Options – Malaria

Theoretical Range of Choice

Technically viable?

Financial

capability?

Human skills & institutional capacity?

Compatible with current policies?

Target of opportunity?

Improved public health infrastructure

Yes Low Low Yes Yes

Forecasting & early warning systems

Yes Yes Yes Yes Yes

Public information & education

Yes Yes Sometimes Yes Yes

Control of vector breeding sites

Yes Sometimes Sometimes Yes Yes

Impregnated bed nets

Yes Sometimes Yes Yes Yes

Prophylaxis Yes Sometimes Yes Yes Yes

Ebi and Burton, submitted

1A.74

Thank you