CGE TRAINING MATERIALS VULNERABILITY AND ADAPTATION ASSESSMENT CHAPTER 8

Human Health

Objectives and Expectations

• Having read this presentation, in conjunction with the related handbook, the reader should: a) Have an

overview of drivers and their potential impacts

on human health b) Be familiar with commonly used

methods and tools

for assessing impacts of climate change on human health c) Also be familiar with methods for

determining appropriate

adaptive responses.

2

Outline

• Overview of the potential health impacts of climate variability and change • Predictive tools for the future a) Health impact assessment (HIA) of climate change • Methods and tools for vulnerability and adaptation (V&A) assessment in the health sector • Methods for determining a health adaptation baseline • The following sections provide additional information that can be used during the V&A assessment: • Health data to determine the current burden of climate-sensitive diseases • Global projections of health impacts

Topics

• Climate change and health • Pathways for weather to affect health • Potential health impacts of climate change a) Extreme weather events • Temperature • Storms/floods b) Drinking water supply c) Air quality d) Food production and security e) Vector-borne diseases f) Food and water borne disease • Diarrhoeal diseases g) Other indirect impacts.

OVERVIEW OF THE POTENTIAL HEALTH IMPACTS OF CLIMATE VARIABILITY AND CHANGE

1A.5

Climate Change and Health

• There is consideration worldwide on the potential health impacts from global climate change. • Three kinds of health impacts have been identified [1] : a) Relatively direct impacts, usually caused by weather extremes b) Consequences of environmental change and ecological disruption in response to climatic change c) Consequences that occur when populations are demoralised and displaced by the following climate change induced factors: • economic dislocation, • environmental decline and conflict situations including traumatic, infectious, nutritional, psychological and other health consequences.

[1] World Health Organisation (WHO). 2003. Climate change and human health: risks and responses.

Pathways for Weather to Affect Health

Env ironmental Conditions Climate Change Social Conditions (upstream determinants of health Direct Exposures Indirect Exposures (Changes in food quality, disease vectors, ecosystem changes) Changes in Social Disruption Health System Condition s Health Impacts Modifying Influence

Mapping Links Between Climate Change and Health

• Most expected impacts will be adverse but some will be beneficial.

• Expectations are not for new health risks , but rather changes in frequency or severity of familiar health risks

CLIMATE CHANGE Human exposures Regional weather changes Heat waves Extreme weather Temperature Precipitation

Modulating influences

Contamination pathways Transmission dynamics Agro-ecosystems, hydrology Socioeconomics, demographics Health effects Temperature-related illness and death Extreme weather- related health effects Air pollution-related health effects Water and food-borne diseases Vector-borne and rodent borne diseases Effects of food and water shortages Effects of population displacement

Source: based on Patz, et al., 2000

POTENTIAL HEALTH IMPACTS FROM ENVIRONMENTAL CHANGES

TEMPERATURE

Temperature

CSIRO 2006: Climate Change in the Asia/Pacific Region

Temperature

Temperature

Temperature Extremes in Bhutan, 1800s –2010

Direct Impacts to Health from Heat

• The human body maintains body temperature in ambient temperatures not exceeding 32 degrees C • Above this temperature, heat lost through the skin and sweating • Heat-related illness occurs when the body unable to adequately cool • Minimum ambient temperatures are also important: a) Difficulties cooling when minimum temperature is greater than 22 degrees C • High humidity reduces effectiveness of sweating and increases the risk of heat-related illness at any given temperature.

Relative Atmospheric Temperature (

°

C)

Humidity(%) and Temperature

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

26

25 25 26 26 26 27 27 27 28 28 28

28

27 27 27 27 28 28 29 31 32 34 36

30

28 28 28 29 30 31 33 35 38 41 44

32

30 30 30 31 32 34 37 40 44 49 56

34

32 32 32 33 35 38 42 47 52 58

36

33 33 34 36 39 43 48 54

61 38

35 35 37 39 43 49 55 63 At an apparent temperature, (T a ) of:

32 – 40

°

C

Heat cramps or heat exhaustion possible

41 – 54

°

C

Heat cramps or heat exhaustion likely, heat stroke possible

54

°

C<

Heat stroke highly likely Exposure to full sunshine can increase the heat index value by up to 8 o C

40

36 37 39 43 48 55 62

42

37 39 42 47 54 62

44

38 41 46 52 60

Impacts to Health from Increased Temperatures

• Direct impacts to health:

a) Heat cramps

– muscular pains and spasms

b) Heat exhaustion

– body fluids are lost through heavy sweating

c) Heat stroke

– is life threatening. • Indirect impacts: a) Range of areas that can potentially be affected with gradual and extreme temperature increases b) Includes impacts on ecosystems, water, food, disease-carrying vectors, lifestyle, community resilience.

STORMS/FLOODS

Storms/Flooding

Flooding is heavily concentrated in Asia

Most human exposure to flood is in Asia. The top ten countries – in absolute and relative terms - are in south and south east Asia.

Source: 2009 Global Assessment report on Disaster Risk Reduction From: Environment Solutions: www.environmentsolutions.dk

2012 Flood in Pakistan (September)

• Monsoon floods in Pakistan during September, killed more than 400 people and affected more than 4.5 million others: a) b) Tens of thousands have been made homeless by heavy flooding in the provinces of Balochistan and Sindh – where 2.8 million were affected.

Pakistan has suffered devastating floods in the past two years. c) The worst floods were in 2010, when almost 1,800 people were killed and 21 million were affected.

• During 2011, many Asian countries experienced flooding, including Bangladesh, China, India, Japan, Laos, North Korea, Pakistan, Thailand, the Philippines and Singapore.

BBC news: 28 Sept 2012

Health Impacts of Floods

• Immediate deaths and injuries • Non-specific increases in mortality • Infectious diseases – leptospirosis, hepatitis, diarrhoeal, respiratory, and vector-borne diseases • Exposure to toxic substances • Mental health effects • Indirect effects • Increased demands on health systems.

Flooding: Direct Health Effects

Causes

Stream flow velocity; topographic land features; absence of warning; rapid speed of flood onset; deep floodwaters; landslides; risk behaviour; fast flowing waters carrying boulders and fallen trees Contact with water Drowning Injuries Contact with polluted water Increase of physical and emotional stress

Health Implications

Respiratory diseases; shock; hypothermia; cardiac arrest Wound infections; dermatitis; conjunctivitis; gastrointestinal illness; ear, nose and throat infections; possible serious waterborne diseases Increase of susceptibility to psychosocial disturbances and cardiovascular incidents

Flooding: Indirect Health Effects

Causes

Damage to water supply systems; sewage and sewage disposal damage; insufficient supply of drinking water; insufficient water supply for washing Disruption of transport systems Disruption of social networks; loss of property, jobs and family members and friends Clean-up activities following floods

Health Implications

Possible waterborne infections (enterogenic

E.coli

, shigella, hepatitis A, Leptospirosis, giardiasis, camplylobacter) dermatitis, and conjunctivitis Food shortage; disruption of emergency response Potential acute or chronic effects of chemical pollution Underground pipe disruption; dislodgement of storage tanks; overflow of toxic waste sites; release of chemicals; rupture of gasoline storage tanks may lead to fires Standing waters; heavy rainfalls; expanded range of vector habitats Rodent and other pest migration Vector-borne diseases Possible diseases caused by rodents or other pests Possible psychosocial disturbances Destruction of primary food products Damage to health services; disruption of “normal” health service activities Electrocutions; injuries; lacerations; skin punctures Food shortage Decrease of “normal” health care services, insufficient access to medical care

DRINKING WATER

Climatic Change: Drinking Water Supply

• Drying climate causes: a) Changes to land cover and run-off patterns (erosion) b) Increased bushfire risk c) Increased sediment, nutrient and debris.

• Flooding can also affect drinking water supplies: a) b) Coastal intrusion Contamination.

Climatic Change: Drinking Water Supply

• Reduction in flows to dams and groundwater aquifers • Increased evaporation from surface water storages • Salt water intrusion into coastal aquifers • Acidification of susceptible inland aquifers • Increased risk from the: a) b) Concentration of nutrient and chemical contaminants Formation of toxic algal bloom

AIR QUALITY

Air quality

China Haze 10 January 2003

Source: NASA

Climatic Change: Air Quality

• Weather has a major role in the development, transport, dispersion and deposition of air pollutants • Air pollution episodes are often associated with stationary or slowly moving air masses • Air pollutants and fine particulate matter may change in response to climate change.

Climatic Change: Air Quality

• Airflow on edges of a high pressure system can transport ozone precursors. Ozone levels are increasing in many areas • An increase in fire events will mean increased toxic gases and particulates • Changes in wind pattern may increase long-range transport of air pollutants • Weather patterns can enhance urban “heat islands” which can lead to elevated pollution levels.

Potential health Impacts

• Ozone – pneumonia, COPD, asthma, allergic rhinitis and others – premature mortality • Particulate matter (PM) – known to affect morbidity and mortality • Toxic gases and PM from fires contribute to acute and chronic respiratory illness. Evidence from 1997 Indonesia fires – transboundary impacts • Wind blown dust (respirable particles, trace elements) from desert regions can affect populations in remote areas. Evidence that mortality is increased in the days after a dust storm.

VECTOR-BORNE DISEASE

Malaria in Vanuatu

Wet season in Vanuatu is from November until April, temperatures very between 24 to 30 o C

Mosquito-borne-disease: Environmental Changes

Distribution of vectors will change arising from: • Increasing temperature • Changing rainfall: a) Increase or decrease b) Seasonality • Cyclones, flooding • Changes in animal host/reservoir populations • Rising sea levels • Extreme tides • Loss of coastal margins.

Mosquito-borne-disease: Human Factors

Location of population: • Geographic location • Proximity to water bodies Urban environment: • Peri-domestic breeding Mobility of population • Arrival of infected people a) International b) Interstate c) Intrastate Living standards: • Insect screens, air conditioning • Social/political breakdown.

Mosquito-borne-disease: Water Management Breeding is also influenced by: • Water hoarding/storage: a) Rainwater tanks b) Uncovered containers • Dams • Irrigation • Groundwater recharge.

Climate Change and Malaria under Different Scenarios (2080) • Increase: East Africa, Central Asia, Russian Federation • Decrease: Central America, Amazon [within current vector limits.

A1 B1 Change of consecutive months > +2 A2 +2 -2 < -2 B2

Van Lieshout et al. 2004

FOOD SECURITY

Food Production: Land

Land based agriculture: • Food production, loss of soil fertility, erosion and salinization: a) Changes in crop yields and protein levels (+/-) b) Effects on feed intakes and animal reproduction c) Changes to pests, weeds and diseases d) Changes to use of agrochemicals • Dietary and nutritional changes

Food Production: Fisheries

Oceanic and coastal fisheries: • A change in coastal circulation patterns can affect: a) Nutrient supply b) Lagoon flushing c) Coastal erosion d) Ocean acidity and coral bleaching e) Decline in productivity.

FOOD SAFETY

Food Safety

• Food borne disease may cause food poisoning: a) May increase the proliferation of bacterial pathogens including Salmonella, Campylobacter and Listeria spp.

b) May increase mycotoxins and aflatoxins in seafood.

DIARRHOEAL DISEASES

Effect of Temperature Variation on Diarrheal Incidence in Lima, Peru Daily diarrhoea admissions Daily temperature Diarrhoea increases by 8% for each 1ºC increase in temperature Source: Checkley, et al., 2000

El Nino Events and the possible impact on diseases: Cholera

Number of Cholera cases in Uganda 1997-2002

50000 40000 30000 20000 10000 0 1996 El Nino starts 1997 1998

El Nino stops

1999 2000

Time in years

2001 2002 2003

SOCIAL IMPACTS

Social Impacts

Lifestyle and behaviour are likely to be affected in the following ways: • Increased temperatures: a) Increases in crime - particularly involving aggression b) Accidents - workplace and traffic c) Decline in physical health d) Hot nights may cause sleep deprivation e) Recreational opportunities - changes to exercise patterns f) Changes in alcohol consumption g) Stress h) Lack of cold water- reduced ability to cool down

Social Impacts

• Mental Health can be impacted as follows: a) Anxiety and depression b) Post traumatic stress disorder c) Insecurity d) Grief e) Stress, self harm and possible suicide f) Drug and alcohol misuse g) Impacts on individuals, communities h) Loss of social cohesion i) j) Dislocation Specific impacts on children, women and elderly.

Social Impacts

Economic impacts may be as follows: • Loss of income and/or assets • Reduction of goods and services • Higher costs of insurance, food, water and energy • Financial strain for Governments and others • Impacts on provision of health services.

Resources

• McMichael AJ, Campbell-Lendrum DH, Corvalan CF, Ebi KL, Githeko A, Scheraga JD, and Woodward A. (eds.). 2003.

Climate Change and Human Health: Risks and Responses.

Geneva, WHO.

a) Summary PDF available at < http://www.who.int/globalchange/publications/cchhsummary/ > • Kovats RD, Ebi KL, and Menne B. 2003.

Methods of Assessing Human Health Vulnerability and Public Health Adaptation to Climate Change.

WHO/Health Canada/UNEP.

a) PDF available at < http://www.who.dk/document/E81923.pdf

> • PAHO and WHO. 2011.

Protecting Health from Climate Change: Vulnerability and Adaptation Assessment

. a) PDF available at <

www.who.int/entity/globalchange/VA_Guidance_Discussion.pdf

>

PREDICTIVE TOOLS FOR THE FUTURE

Assessing the Vulnerability of Human Health to Climate Change

Methods Required to Assess the Vulnerability of Human Health • 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.

Source: Kovats, et al., 2003

Issues to be Considered

• 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: a) Largest impacts may come from existing conditions such as diarrhoea, malnutrition, and vector-borne diseases • Uncertainties need to be considered and include: a) Uncertainties in projections b) Effectiveness of interventions c) Changes in non-climatic factors.

Source: Campbell-Lendrum, et al., 2003

Health Impact Assessment (HIA)

• The World Health Organization (WHO) defines a Health Impact Assessment (HIA) as: “A

combination of procedures or methods by which a policy, programme or project may be judged as to the effects it may have on the health of a population.”

a) The HIA was initiated worldwide to facilitate the assessment of health issues in new proposals

The Aim of the HIA

“ To enhance the potentially

beneficial

health effects of a policy, programme or proposal and to mitigate potentially

negative

health risks and costs.

”

The Benefits of the Health Impact Assessment (HIA)

• It facilitates a comprehensive assessment of the impact of climate change on human health • The ability to forecast the potential health impacts of new developments, policies and plans • It is a process incorporating

predictive evaluative

elements and • This tool can be easily incorporated into current impact assessment procedures.

The Health Impact Assessment Process

• The strength of the process comes from its underlying principles and values: a) Sustainability b) Equity c) Democracy d) Ethical use of evidence e) Promotion of health • The process can be applied to a wide range of activities such as new policies, projects, plans etc.

HIA: the Health Determinants

• Health is more than the absence of illness or disease; it includes the physical, mental, social and spiritual well-being of people.

• It is affected by social, economic and environmental factors, as well as individual behaviours and heredity.

HIA: the Health Determinants

• Individual/family: a) Biological factors b) Lifestyle c) Personal circumstances • Environment: a) Physical b) Social c) Economic/financial • Institutional access: a) Health and other services b) Economic conditions c) Public policy.

The Steps in the Process of a HIA

• The HIA, like other forms of impact assessment, is a formalized collaborative process used to consider potential impacts (positive and negative) from activities during their planning stages • The process includes the following: a) Screening b) Scoping c) Profiling d) Risk assessment e) Risk management f) Decision-making g) Evaluation.

USE OF THE HIA PROCESS FOR CLIMATE CHANGE

The HIA Process in the Vulnerability Assessment

SCREENING • Does the situation require a HIA? SCOPING PROFILING • • Identify health impacts Set boundaries • • Population Vulnerable groups RISK ASSESSMENT • What are the risks/benefits?

RISK MANAGEMENT • • Minimize risks Maximize benefits.

Project Elements Requires: • Identification of potential direct and indirect health impacts from environmental change, assuming current controls and 2030 projections of climate variables • Understanding of the key current controls or coping strategies: a) Assessment of their effectiveness in terms of general population, vulnerable groups and vulnerable regions • • • Determination of current knowledge and gaps Identification of linkages with other sectors Identification of opportunities for adaptation.

Climate Change and Health V&A Project Components

• Identify key stakeholders and project range • Determine sectors and data requirements • Establish climate change scenario • Provide background information for participants • Undertake workshops: a) Scope of impacts: • Environmental changes • • General population Vulnerability: groups, services and regions b) Current activities (coping capacity) c) Risk assessment d) Adaptation responses.

Climate Change and Health V&A Project

• A step by step guidance to undertaking climate change and health vulnerability assessments has been developed:

a) Climate Change, Vulnerability and Health: A Guide to assessing and addressing health impacts.

b) This document can be obtained from <

http://ehia.curtin.edu.au/ >

Consultative Approach

• Consult stakeholders representing as many sectors as possible • Important to recognize that most activities that impact on health are not actually addressed by the health sector • Need to establish integrative processes.

HEALTH IMPACT ASSESSMENT OF CLIMATE CHANGE

Questions That Will be Addressed

• What is the current population profile of the country or region?

• What diseases are important in the country or region including climate-sensitive disease?

a) What is the current burden of these diseases?

• What factors other than climate should be considered?

a) Water, sanitation, etc.

• Where are data available?

• Are health services able to satisfy current demands?

1. UNDERSTANDING POPULATIONS

Population Data Sources

• United Nations: Thematic Area - Population, provides population statistics for every country.

a) < http://www.un.org/en/development/progareas/population .shtml

> • Economic Commission for Africa, provides specific population data.

a) < http://www.uneca.org/popia/ > • Both provide extensive demographic information which can be used to assess vulnerability.

• Others: a) US AID: < http://www.measuredhs.com/ > b) City Population: < http://www.citypopulation.de/Africa.html

>

Population data

• The implications of country numbers and distribution are important in determining health impacts and their responses.

Ten Largest Countries in Population (2011) Source: U.S. Census Bureau, International Data Base

The 20 Largest Urban Areas in the World

* Demographia World Urban Areas and Population Projection. 7th Annual edition. April, 2011. www.demographia.com

Nauru

• Total expenditure on health per capita (Intl $, 2010)

264

• Total expenditure on health as % of GDP (2010)

11.2

Source: Nauru Bureau of Statistics

Bhutan

VULNERABILITY

Vulnerability

• Degree to which individuals and systems are susceptible to, or unable to cope with, the adverse effects of climate change, including climate variability and extremes • Integration of:

Regional Economic Social Infrastructure & Services Overall Vulnerability

• Need to identify and address the vulnerability components individually and integrated for specific sectors and communities.

Vulnerable populations

• Elderly • Children (immature immune response) • Socio-economically disadvantaged • Women, especially pregnant and breastfeeding women • The obese • Those who are not acclimatized, e.g. new arrivals • Those who have underlying medical conditions or immuno-compromised especially cardiovascular disease • Athletes and other participants in outdoor recreational activities • Manual labourers, outdoor workers • Mentally ill, disabled and homeless • Physically unfit – reduced vital capacity

Other Drivers of Vulnerability

• Population density • Urbanization • Public health infrastructure • Other infrastructure: a) Energy b) Water c) Transport • Economic and technological development.

2. HEALTH DATA

Health Data Sources

• World Health Organization Office for the region: a) < http://www.afro.who.int/ >

b) Health Situation Analysis in the African Region: Atlas of Health Statistics, 2011

• World Health Report provides regional-level data for all major diseases: a) < http://www.who.int/whr/en > b) Annual data in Statistical Annex • WHO databases: a) Malnutrition < http://www.who.int/nutgrowth/db > b) Water and sanitation < http://www.who.int/entity/water_sanitation_health/data base/en >

Health Data Sources – Other

• Ministry of Health: a) Disease surveillance/reporting branch • UNICEF at < http://www.unicef.org

> • CRED-EMDAT provides data on disasters a) < http://www.em-dat.net

> • Mission hospitals • Government district hospitals.

3. ESTABLISH A CLIMATE SCENARIO

Establish Scenario of Potential Climate Projection:

• Obtain climate data from a range of sources including the IPCC: a) Use 2030 as a starting point for health impacts

Example:

• Expected average temperature increases: (e.g. 1 0 to 3 0 C) • Increases in the number of days over 35 0 C (heatwave temp)

a) Choose regions if necessary

• Rainfall changes in:

a) Seasonal changes across regions

• Sea-level increases by

x

cm by 2030 and

y

• Extreme weather events such as: cm by 2100 a) b) c) d) e) f) Heatwaves – more per year Droughts – more frequent and severe Bushfires – increased risk Flooding – increased intensity Storms – increased intensity Tropical cyclones – increased intensity.

4. ENVIRONMENTAL CHANGES

Local Changes Affecting Health

• • • • It is important to have a good understanding of local predicted changes in relation to: Biophysical environment : a) Encompassing major impacts related to physical environment, including temperature, water quality, air quality and biodiversity Social environment : a) Encompassing the wide range of social impacts, population displacement and mental health impacts Service and infrastructure : a) The range of impacts as it relates to services, infrastructure and economics, including resource availability and access to a range of health, emergency and other services Environmental diseases : a) Impacts related to production of food, vector-borne and food borne disease and other environmental diseases.

5. DETERMINING HEALTH IMPACTS

Determine Health Impacts:- Assume only current controls

Climate variable Impacts to communities and individuals Environmental Health:

-

direct

-

indirect Vulnerability Regional Economic Social Infra structure Evidence/ uncertainties Temp increase Rainfall change Sea level increase Extreme events:

-

Heatwaves Droughts

-

Bushfires

-

Flooding

-

Storms

-

Tropical cyclones

6. COPING CAPACITY

Coping Capacity Describe what is being implemented now to minimize negative effects

Health impacts Current controls Limitations Effectiveness in 2030 Gaps for 2030 Sectors involved

7. HEALTH RISK ASSESSMENT

Understanding Risk

Risk is: • The potential for realization of unwanted negative consequences of an event • The probability of an adverse outcome • The downside of a gamble (the total gamble must be considered).

Safe means “without risk”: • There is usually no such thing as zero risk.

Risk Analysis Activities:

• Risk assessment: a) The systematic characterization of potential adverse health effects resulting from human exposure to hazardous agents • Risk management: a) The process of weighing policy alternatives and selecting the most appropriate regulatory action based on the results of risk assessment and social, economic, and political concerns • Risk communication: a) The process of making risk assessment and risk management information comprehensible to lawyers, politicians, judges, business and labour, environmentalist and community groups (public).

Risk Assessments

Usually consider the relationship between the consequences that might arise from a particular activity and the likelihood of the activity actually occurring.

Risk = Consequence x Likelihood

The rankings may be of the form: •

Consequences catastrophic, major, moderate, minor, insignificant

•

Likelihood - almost certain, likely, possible, unlikely, rare.

RISK PERCEPTION

Risk Perception

Perception of risk is related to many factors:

Risk Perception

Risk Assessment Aims

• To carry out a

qualitative

risk assessment of the identified potential health impacts • To identify information that may still be required to improve or enable assessment of potential health impacts • To provide a comparison of the risks of health impacts to assist in prioritizing in decision-making processes.

Health Risk Assessment Process

• The potential health impacts of climate change have been identified • A risk assessment of each impact is carried out to determine level and likelihood of risk: a) This should be undertaken by experts in each of the areas of impacts (see next slides) • Sufficient detail should be obtained to progress to health risk management responses: a) These will be either adaptation responses or the need for further information.

Health Impacts -Less Complex

• These health impacts have clear climate-health relationships and supporting empirical observations: a) Extreme events b) Temperature related impacts c) Water-borne d) Vector-borne e) Air quality f) Food-borne.

Health Impacts - Indirect, Complex Impacts

• These health impacts have complex relationships with other factors that must be taken into consideration: a) Food production b) Biodiversity and others c) Infrastructure d) Social • Dislocation • Mental health • Community impacts • Lifestyle/behavioural.

Consequence Scale

Consequence

Catastrophic Major Moderate Minor Insignificant

Examples

Large numbers of serious injuries, illnesses or loss of life Severe and widespread disruption to communities Long term inability to deliver essential goods and services Severe long-term reductions in quality of life Huge economic costs Small numbers of serious injuries, illnesses or loss of life Significant, widespread disruption to communities Significant decline in delivery of essential goods and services Significant long-term decline in quality of life Small number of minor injuries or illnesses Significant disruption to some communities Significant decline in delivery of essential goods and services Significant short-term or minor long-term reduction in quality of life Serious near misses or minor injuries Isolated short-term disruption to some communities Isolated but significant reductions in essential goods and services Minor reductions in quality of life Appearance of a threat but no actual harm Very minor disruption to small section of community Isolated, minor reduction in delivery of essential goods and services Insignificant impacts on quality of life

Likelihood Scale

Likelihood

Almost certain Likely Possible Unlikely Rare

Description

Is expected to occur in most circumstances Will probably occur in most circumstances Might occur at some time Could occur at some time May occur only in exceptional circumstances.

Consequence x Likelihood = Risk Priority Level

Likelihood Almost Certain Likely Possible Unlikely Rare Insignificant Medium Low Low Low Low Minor Consequences Moderate Medium Medium High High Medium Low Low Medium Medium Low Major Extreme High High Medium Low Catastrophic Extreme Extreme High Medium Medium

Example of Table

Extreme events Consequence Likelihood Risk Evidence or reason for decision Further information required

Direct physical injuries from extreme events.

RISK PRIORITIZATION

Risk Prioritization

• The risk levels are ranked from highest to lowest once the levels for each impact have been determined • The resultant list provides direction on priorities for action: a) Provides clarity for decision makers.

Risk Level

Extreme High Medium Low

Health Impact examples

Drinking water Physical Impacts from Extreme events Malaria Mental Health Impacts Food Poisoning Pesticide Levels in Food

Management Actions

Risk Levels for Health

Extreme High Medium Low

Description of Management Action

Risks require urgent attention at the most senior level and cannot be simply accepted by the community Risks are the most severe that can be accepted by the community Risks can be expected to be part of normal circumstances but maintained under review by appropriate sectors Risks will be maintained under review but it is expected that existing controls will be sufficient and no further action will be required to treat them unless they become more severe

8. ADAPTATION MEASURES

Stages of Adaptation

• Primary – prevent onset of health impact • Secondary – preventative measures taken in response to early evidence of impact • Tertiary – actions to lessen the health effects

Health Impact Pathway

Extreme rainfall and flooding

Prevent/reduce flooding

Overflow of waste from septic tanks into flood waters

Prevent/reduce overflow of waste

Human contact with flood water

Avoid human contact with water

Gastro intestinal diseases

Correct medical treatment

Health Impact Pathway

• Each link in the chain is: a) A potential for vulnerability b) An opportunity for adaptation.

• In terms of adaptation: a) The higher up the chain the better b) The more links we weaken the better.

Types of Adaptation

Adaptation responses may be of the form: • Legislative or regulatory • Public education or communication • Surveillance and monitoring • Ecosystem intervention • Infrastructure development • Technological/engineering • Health intervention • Research/ further information

Categories

The adaptation responses for health will fall into the following categories: • Direct impacts of extreme events • Direct impacts of heat events and temperature • Water related • Vector-borne • Air quality • Food-borne • Food production • Social • Generic.

Exercise Format

A series of

possible

adaptation measures have been provided.

A number of questions need to be addressed: • Are these adaptation measures relevant?

• What is our current status of each relevant adaptation measure, particularly with reference to vulnerable regions or groups?

a) b) Inadequate Adequate c) b) Being developed d) Not in place.

• For each adaptation measure: a) How can these be implemented?

• Adjustment of existing measures • Development of new measures b) Who should be involved in implementation?

• Lead agency/sector • Supporting agencies/sectors • What other adaptations are needed?

a) Current status?

How and who to implement?

Example of Table

Possible Adaptation Measures Legislative or Regulatory

 Cost sharing mechanisms for compensation and adaptation initiatives  Regulations for minimum building standards to withstand extreme events in vulnerable regions  Regulations regarding fire management, property management to reduce risk of injuries  Mid to long-term strategies for land use planning that accounts for likely impacts

Public Education and Communication

 Improvement in communicating risks of extreme events to vulnerable regions and groups  Education of measures to reduce risk of damage or injuries  Evaluation of the effectiveness of educational material.

What is our capacity in this regard For each Potential Adaptation measure: – in general and for vulnerable regions and groups?

A= adequate I= inadequate D= developing N = not in place How can this measure be implemented or upgraded?

Surveillance and Monitoring

 Standardization of information collected after disasters to more accurately measure morbidity and mortality  Evaluation of responses and health outcomes of extreme event.

 Monitoring of appropriate management measures to reduce risk (fire breaks, trees near power lines)

Sectors

Health Report and Action Plan

• Compilation of the outcomes from each of the eight stages of the V&A assessment.

• The Report should include: a) Documentation of the methodology which provides enough details to enable readers to understand the process used b) Acknowledgement of all participants/stakeholders during consultation c) Text to explain the content of each section d) Development of an action plan to progress the identified adaptations.

METHODS TO DETERMINE THE CURRENT BURDEN OF CLIMATE-SENSITIVE DISEASES

Tools available for use for specific diseases 1A.11

7

Malaria in Africa

The Mapping Malaria Risk in Africa (MARA/ARMA) website contains prevalence and population data, and regional and country-level maps.

MARA/ARMA Environmental Data for Malaria

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.

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

Relationship between Temperature and Daily Survivorship of Anopheles 1.00

0.90

0.80

0.70

0.60

0.50

0.40

0.30

0.20

0.10

0.00

16 .1

18 20 22 24 26 28 30 32

M ean Temperature (°C)

34 36 38 40

Relationship between Temperature and Time Required for Parasite Development 120 100 80 60 40 20 0 17 19 21 23 25 27 29 31

Mean Temperature (°C )

33 35 37 39

Proportion of Vectors Surviving Time Required for Parasite Development 0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00

17 19 21 23 25 27 29 31

Mean Temperature (°C)

33 35 37 39

MARA/ARMA: Distribution of Endemic Malaria in Africa

MARA/ARMA: Duration of the Malaria Transmission Season in Africa

Mozambique – Endemic Malaria Season Length

MARA/ARMA: predicted Prevalence Rates of Malaria in West Africa

MARA/ARMA: Populations at Risk From Malaria in Africa

Mozambique – Endemic Malaria Prevalence

Mozambique – Endemic Malaria Prevalence by Age

MARA/ARMA: Possible Applications

Reference

Objective

: to look at the range of responses in the climatic suitability for stable

falciparum

malaria transmission under different climate change scenarios in Zimbabwe • Ebi et al.

Climate Suitability for Stable Malaria Transmission in Zimbabwe Under Different Climate Change Scenarios

. Geneva: WHO, 2005

Malaria in Zimbabwe

Cases by Month

Source: South African Malaria Research Programme • Patterns of stable transmission follow pattern of precipitation and elevation (which in turn influences temperature) • > 9,500 deaths and 6.4 million cases between 1989 and 1996 • Recent high-altitude outbreaks Source: Ebi, et al., 2005

Methods

• Baseline climatology determined • COSMIC was used to generate Zimbabwe-specific scenarios of climate change; changes were added to baseline climatology • Outputs from COSMIC were used as inputs for the MARA/ARMA (

Mapping Malaria Risk in Africa

) model of climate suitability for stable

Plasmodium falciparum

malaria transmission.

Source: Ebi, et al., 2005

Data Inputs

• Climate data: a) Mean 60 year climatology of Zimbabwe on a 0.05

° lat/long grid (1920–1980) b) Monthly minimum and maximum temperature and total precipitation • COSMIC output: a) Projected mean monthly temperature and precipitation (1990 –2100).

Source: Ebi, et al., 2005

Climate in Zimbabwe

• Rainy warm austral summer October-April • Dry and cold May-September • Heterogeneous elevation-dictated temperature range • Strong inter-annual and decadal variability in precipitation • Decrease in precipitation in the last 100 years (about 1% per decade) • Temperature changes 1933–1993: a) Increase in maximum temperatures +0.6

°C b) Decrease in minimum temperatures -0.2 °C.

Source: Ebi, et al., 2005

Global Climate Models

• Canadian Centre for Climate Research (CCC) • United Kingdom Meteorological Office (UKMO) • Goddard Institute for Space Studies (GISS) • Henderson-Sellers model using the CCM1 at NCAR (HEND).

Source: Ebi, et al., 2005

Scenarios

• Climate sensitivity: a) High = 4.5

°C b) Low = 1.4

°C • Equivalent carbon dioxide (ECD) analogues to the 350 ppmv and 750 ppmv greenhouse gas (GHG) emission stabilization scenarios of the IPCC second assessment report (SAR) Source: Ebi, et al., 2005

Assumptions

• No change in the monthly range in minimum and maximum temperatures • Permanent water bodies do not meet the precipitation requirements • Climate did not change between the baseline (1920– 1980) and 1990 Source: Ebi, et al., 2005

Fuzzy Logic Value

• Fuzzy logic boundaries established for minimum, mean temperature, and precipitation a) 0 = unsuitable b) 1 = suitable for seasonal endemic malaria .

Source: Ebi, et al., 2005

1.2

1 0.8

0.6

0.4

0.2

0

Assignment of Fuzzy Logic Values to Climate Variables

Fuzzy Logic Value for Mean Temperature

1.2

1 0.8

0.6

0.4

0.2

0

Mean Temperature (°C) Fuzzy Logic Value for Precipitation Fuzzy Logic Value for M inimum Temperature

1.2

1 0.8

0.6

0.4

0.2

0

Precipitation (mm) Minimum Temperature (°C)

Climate Suitability Criteria

• Fuzzy values assigned to each grid: a) For each month, determined the lowest fuzzy value for precipitation and mean temperature • Determined moving 5-month minimum fuzzy values • Compared these with the fuzzy value for the lowest monthly average of daily minimum temperature • Assigned the lowest fuzzy value.

Source: Ebi, et al., 2005

United Kingdom Met Office (UKMO)

• S750 ECD stabilization scenario with 4.5˚C climate sensitivity • Model output : a) Precipitation: • Rainy season (ONDJFMA) increase in precipitation of 8.5% from 1990 to 2100 b) Temperature: • Annual mean temperature increase by 3.5°C from 1990 to 2100, with October temperatures increasing more than July temperatures.

Source: Ebi, et al., 2005

Baseline

Source: Ebi, et al., 2005

2025

Source: Ebi, et al., 2005

2050

Source: Ebi, et al., 2005

2075

Source: Ebi, et al., 2005

2100

Source: Ebi, et al., 2005

Conclusions

• Assuming no future human-imposed constraints on malaria transmission, changes in temperature and precipitation could alter the geographic distribution of stable malaria transmission in Zimbabwe • Among all scenarios, the highlands become more suitable for transmission • The low-veld and areas currently limited by precipitation show varying degrees of change • The results illustrate the importance of using several climate scenarios.

Source: Ebi, et al., 2005

Other Models

• MIASMA: a) Global malaria model • CiMSiM and DENSim for dengue: a) Weather and habitat-driven entomological simulation model that links with a simulation model of human population dynamics to project disease outbreaks b) < http://daac.gsfc.nasa.gov/IDP/models/index.html

>

Sudan National Communication

• Using an Excel spreadsheet, modelled malaria based on relationships described in MIASMA • Calculated monthly changes in transmission potential for the Kordofan Region for the years 2030-2060, relative to the period 1961 –1990 using the IPCC IS92A scenario, simulation results of HADCM2, GFDL, and BMRC, and MAGICC/SCENGEN.

Sudan – Projected Increase in Transmission Potential of Malaria in 2030

Sudan – Projected Increase in Transmission Potential of Malaria in 2060

Sudan – Malaria Projections

• Malaria in Kordofan Region could increase significantly during the winter months in the absence of effective adaptation measures: a) The transmission potential during these months is 75 per cent higher than without climate change • Under HADCM2, the transmission potential in 2060 is more than double the baseline • Transmission potential is projected to decrease during May-August due to increased temperature.

ADAPTATION OPTIONS FOR MALARIA

Screening the Theoretical Range of Response Options – Malaria

Theoretical Range of Choice

Improved public health infrastructure Forecasting & early warning systems Public information & education Control of vector breeding sites Impregnated bed nets Prophylaxis

Technically feasible? Effective?

Yes Yes Yes Yes Yes Yes Low Medium Low Yes Yes Yes Vaccination No

Environmentally acceptable?

Yes Yes Yes Spraying - no Yes Yes

Financially Feasible?

Sometimes Often Yes Yes Yes Only for the few

Socially and Legally Acceptable?

Yes

Closed/Open (Practical Range of Choice)

Open Yes Yes Sometimes Yes Yes Open Open Open Open Closed for many Closed Source: Ebi and Burton, 2008

Analysis of the Practical Range of Response Options – Malaria

Theoretical Range of Choice

Improved public health infrastructure Forecasting and early warning systems Public information and education Control of vector breeding sites Impregnated bed nets Prophylaxis

Technically viable? Financial capability? Human skills & institutional capacity?

Yes Low Low Yes Yes Yes Yes Yes Yes Yes Yes Sometimes Sometimes Sometimes Sometimes Yes Sometimes Yes

Compatible with current policies?

Yes

Target of opportunity?

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Source: Ebi and Burton, 2008

GLOBAL PROJECTIONS OF HEALTH IMPACTS

Estimating Potential Future Health Impacts

• Requires using climate scenarios • Can use top-down or bottom-up approaches: a) 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.

Source: Kovats et al., 2003

Example: 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 GHG emissions)?

Source: Campbell-Lendrum et al., 2003

Comparative Risk Assessment

GHG emissions scenarios Time Global climate modelling:

Generates series of maps of predicted future climate

2020s 2050s 2080s Health impact model:

Estimates the change in relative risk of specific diseases

2020s 2050s 2080s

Source: Campbell-Lendrum et al., 2003

Selection of Health Outcomes

Criteria used can include diseases that are: • Sensitive to climate variation • Important global health burden.

Quantitative models are available at the global scale: a) Malnutrition (prevalence) b) Diarrhoeal disease (incidence) c) Vector-borne diseases – dengue and

falciparum malaria

d) Inland and coastal floods (mortality) e) Heat and cold-related cardiovascular disease mortality Source: Campbell-Lendrum et al., 2003

Projected Relative Risk of Flooding

3 2 1 0 8 5 4 7 6

Relative Risk of Deaths and Injuries in Inland Floods in 2030, by Region

s550 s750 UE Source: WHO, 2003

Projected Relative Risk of Diarrheoa

Relative Risk of Diarrheoa in 2030, by Region

1.1

1.08

1.06

1.04

1.02

1 0.98

0.96

0.94

s550 s750 UE Source: WHO, 2003

Estimated Death and Disability Adjusted Life years Lost(DALYs) Attributable to Climate Change

2000 2020 Floods Malaria Diarrhea Malnutrition 120 100 80 60 40 20 Deaths (thousands) 0 2 4 6 DALYs (millions) 8 10

Source: Campbell-Lendrum et al., 2003

Environmental Burden of Disease

• Prüss-Üstün A, Mathers C, Corvalan C, and Woodward A. 2003.

Introduction and Methods: Assessing the Environmental Burden of Disease at National and Local Levels.

available at < http://www.who.int/peh/burden/burdenindex.html

>

Additional Information: Vulnerability and Adaptation (V&A) Framework for Health

Frame & Scope Assessment Assess Manage & Monitor Risks Defining the geographical region and health outcomes of interest; Identifying the questions to be addressed and steps to be used; Identifying the policy context for the assessment; Establishing a project team and a management plan; Establishing a stakeholder process; Developing a communications plan.

Vulnerability: Current burden of disease Current health protection programs Future Impacts: Changing burden without climate change Projected health impacts of climate change Adaptation: Identify, prioritize additional interventions Identify resources & barriers to implementation Health harms & benefits in other sectors Communicate Plan & Implement Monitor & evaluate Source: WHO, et al., 2008