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:
• Have an overview of drivers and their potential impacts on human
health
• Be familiar with commonly used methods and tools for assessing
impacts of climate change on human health
• 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]:
• Relatively direct impacts, usually caused by weather extremes
• Consequences of environmental change and ecological disruption
in response to climatic change
• 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
Health System
Social Conditions Conditions
(upstream determinants
of health
Environmental
Conditions
Direct
Exposures

Indirect
Exposures
Climate (Changes in Health
Change food quality,
disease
Impacts
vectors,
ecosystem
changes)
Changes in Social Modifying
Disruption 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
Health effects
Temperature-related illness
and death
Modulating Extreme weather- related
influences health effects
Air pollution-related health
Human exposures effects
Contamination Water and food-borne
Regional weather diseases
pathways
changes
CLIMATE Heat waves
Transmission Vector-borne and rodent-
CHANGE dynamics borne diseases
Extreme weather
Agro-ecosystems,
Temperature Effects of food and water
hydrology
Precipitation
Socioeconomics, shortages
demographics 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
26 28 30 32 34 36 38 40 42 44
Temperature
0% 25 27 28 30 32 33 35 36 37 38
10% 25 27 28 30 32 33 35 37 39 41
20% 26 27 28 30 32 34 37 39 42 46
30% 26 27 29 31 33 36 39 43 47 52
40% 26 28 30 32 35 39 43 48 54 60
50% 27 28 31 34 38 43 49 55 62
60% 27 29 33 37 42 48 55 62
70% 27 31 35 40 47 54 63
80% 28 32 38 44 52 61
90% 28 34 41 49 58
100% 28 36 44 56

At an apparent temperature, (Ta) 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 oC
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) Tens of thousands have been made
homeless by heavy flooding in the
provinces of Balochistan and Sindh –
where 2.8 million were affected.
b) 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 Health Implications

Stream flow velocity; topographic land Drowning
features; absence of warning; rapid speed Injuries
of flood onset; deep floodwaters; landslides;
risk behaviour; fast flowing waters carrying
boulders and fallen trees
Contact with water Respiratory diseases; shock; hypothermia;
cardiac arrest
Contact with polluted water Wound infections; dermatitis; conjunctivitis;
gastrointestinal illness; ear, nose and throat
infections; possible serious waterborne
diseases
Increase of physical and emotional stress Increase of susceptibility to psychosocial
disturbances and cardiovascular incidents
Flooding: Indirect Health Effects
Causes Health Implications
Damage to water supply systems; sewage Possible waterborne infections (enterogenic
and sewage disposal damage; insufficient E.coli, shigella, hepatitis A, Leptospirosis,
supply of drinking water; insufficient water giardiasis, camplylobacter) dermatitis, and
supply for washing conjunctivitis
Disruption of transport systems Food shortage; disruption of emergency
response
Underground pipe disruption; dislodgement Potential acute or chronic effects of
of storage tanks; overflow of toxic waste chemical pollution
sites; release of chemicals; rupture of
gasoline storage tanks may lead to fires
Standing waters; heavy rainfalls; expanded Vector-borne diseases
range of vector habitats
Rodent and other pest migration Possible diseases caused by rodents or
other pests
Disruption of social networks; loss of Possible psychosocial disturbances
property, jobs and family members and
friends
Clean-up activities following floods Electrocutions; injuries; lacerations; skin
punctures
Destruction of primary food products Food shortage
Damage to health services; disruption of Decrease of “normal” health care services,
“normal” health service activities 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) Coastal intrusion
b) 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) Concentration of nutrient and chemical
contaminants
b) 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 oC
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.

C h a n g e o f c o n s e c u t iv e m o n th s

> +2
A1 +2 A2
-2

< -2

B1 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
El Nino starts
40000
Number of cases

El Nino stops
30000

20000

10000

0
1996 1997 1998 1999 2000 2001 2002 2003
Time in years
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) Dislocation
j) 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 and
evaluative elements
• 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 • Identify health impacts

• Set boundaries

PROFILING • 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:
• Climate Change, Vulnerability and Health: A Guide to assessing and
addressing health impacts.
• 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. 10 to 30C)
• Increases in the number of days over 350C (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 cm by 2100
• Extreme weather events such as:
a) Heatwaves – more per year
b) Droughts – more frequent and severe
c) Bushfires – increased risk
d) Flooding – increased intensity
e) Storms – increased intensity
f) 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 Impacts to communities Vulnerability Evidence/

variable and individuals uncertainties
Environmental Health: Regional Economic Social Infra-
-direct structure
-indirect

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 Current Effectiveness Gaps for Sectors

Limitations
impacts controls in 2030 2030 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 Examples
Catastrophic 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

Major 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

Moderate 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

Minor 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

Insignificant 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 Description

Almost certain Is expected to occur in most circumstances

Likely Will probably occur in most circumstances

Possible Might occur at some time

Unlikely Could occur at some time

Rare May occur only in exceptional circumstances.

 Consequence x Likelihood = Risk Priority Level

Consequences
Likelihood
Insignificant Minor Moderate Major Catastrophic

Almost Certain Medium Medium High Extreme Extreme

Likely Low Medium High High Extreme

Possible Low Medium Medium High High

Unlikely Low Low Medium Medium Medium

Rare Low Low Low Low Medium

Example of Table

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

Direct
physical
injuries
from
extreme
events.
RISK PRIORITIZATION
Risk Prioritization

• The risk levels are ranked

Risk Level Health Impact examples
from highest to lowest
once the levels for each Extreme Drinking water
impact have been Physical Impacts from
Extreme events
determined
High Malaria
Mental Health Impacts
• The resultant list provides
direction on priorities for Medium Food Poisoning
action:
a) Provides clarity for Low Pesticide Levels in Food
decision makers.
Management Actions

Risk Levels for

Description of Management Action
Health
Extreme Risks require urgent attention at the most senior level and cannot
be simply accepted by the community
High Risks are the most severe that can be accepted by the community
Medium Risks can be expected to be part of normal circumstances but
maintained under review by appropriate sectors
Low 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

DECREASING EFFECTIVENESS
• 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) Inadequate
b) Adequate
c) 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?
b) How and who to implement?
 Example of Table
For each Potential Adaptation measure:

Possible Adaptation Measures What is our capacity in this How can this measure Sectors
regard – in general and for be implemented or
vulnerable regions and groups? upgraded?
A= adequate I= inadequate
Legislative or Regulatory
D= developing N = not in place
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.

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)
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.
117
Malaria in Africa

The Mapping Malaria Risk in Africa (MARA/ARMA) website <http://www.mara.org.za> 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
Proportion of Mosquitoes

1.00
0.90
Surviving One Day

0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00

Mean Temperature (°C)

Relationship between Temperature and Time Required for Parasite Development

120

100

80
Days

60

40

20

Mean Temperature (°C )

Proportion of Vectors Surviving Time Required for Parasite Development

0.40
Proportion Surviving

0.35
0.30
0.25
0.20
0.15
0.10
0.05
0.00

Mean Temperature (°C)

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 • 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
Source: South African Malaria Research Programme • 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

 Assignment of Fuzzy Logic Values to Climate Variables
Fuzzy Logic Value for Mean Temperature

1.2

0.8

Fuzzy Value
0.6

0.4

0.2

19.5

21.5

27.5

33.5

37.5
17.5

23.5

25.5

29.5

31.5

35.5

39.5
Mean Temperature (°C)

Fuzzy Logic Value for Precipitation Fuzzy Logic Value for M inimum Temperature

1.2 1.2

1 1

0.8

Fuzzy Value
0.8
Fuzzy Value

0.6 0.6

0.4 0.4

0.2 0.2

0 0
3.9

4.3

4.5

4.9

5.1

5.5

5.7

6.3
3.5

3.7

4.1

4.7

5.3

5.9

6.1

6.5
0
4
8
12
16
20
24
28

36
40

48
52

60
64

76

84
32

44

56

68
72

80

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 Technically Effective? Environmentally Financially Socially and Closed/Open

Range of feasible? acceptable? Feasible? Legally (Practical Range
Choice Acceptable? of Choice)
Improved public Yes Low Yes Sometimes Yes Open
health
infrastructure
Forecasting & Yes Medium Yes Often Yes Open
early warning
systems
Public Yes Low Yes Yes Yes Open
information &
education
Control of vector Yes Yes Spraying - no Yes Sometimes Open
breeding sites
Impregnated bed Yes Yes Yes Yes Yes Open
nets
Prophylaxis Yes Yes Yes Only for the Yes Closed for many
few
Vaccination No Closed

Source: Ebi and Burton, 2008

Analysis of the Practical Range of Response Options – Malaria

Theoretical Technically Financial Human skills & Compatible Target of

Range of viable? capability? institutional with current opportunity?
Choice capacity? policies?
Improved public Yes Low Low Yes Yes
health
infrastructure
Forecasting and Yes Yes Yes Yes Yes
early warning
systems
Public Yes Yes Sometimes Yes Yes
information and
education
Control of vector Yes Sometimes Sometimes Yes Yes
breeding sites
Impregnated bed Yes Sometimes Yes Yes Yes
nets
Prophylaxis Yes Sometimes 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

2020s
Global climate modelling: 2050s
Generates series of maps
2080s
of predicted future climate

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

Relative Risk of Deaths and Injuries in Inland

8
Floods in 2030, by Region

7 s550
s750
6
UE
Re la tiv e Ris k

Sear D
Sear B
Eur C
A fr D

Eur B
A mr D

E mr D
A fr E

A mr B

E mr B

Wp r B
Eur A
A mr A

Wp r A
Source: WHO, 2003
Projected Relative Risk of Diarrheoa

Relative Risk of Diarrheoa in 2030, by Region

1.1

1.08 s550
s750
1.06
UE
Relative Risk

1.04

1.02

0.98

0.96

0.94

Sear D
Sear B
Eur C
Afr D

Eur B
Afr E

Amr D

Emr D
Emr B

Wpr B
Amr B

Eur A
Amr A

Wpr A
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 0 2 4 6 8 10
Deaths (thousands) DALYs (millions)

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 Assess Manage & Monitor Risks
Assessment
Health harms
Vulnerability: & benefits
Defining the Current burden of disease in other sectors
geographical Current health protection programs
region and health
outcomes of
interest;
Identifying the
questions to be
addressed and Communicate
steps to be used; Future Impacts:
Identifying the Changing burden without climate change Plan &
policy context for Projected health impacts of climate change Implement
the assessment;
Establishing a
project team and
a management
plan;
Establishing a
stakeholder Adaptation:
process; Identify, prioritize additional interventions Monitor &
Developing a Identify resources & barriers to implementation
communications evaluate
plan.

Source: WHO, et al., 2008