Meeting Summary
Climate Change and Impact on Zoonotic and Parasitic Diseases in the North: A strategy to
monitor change in disease prevalence.
Danish Polar Centre, Copenhagen, Denmark, September 23-24, 2010
Objectives
The objectives of this meeting will be to 1) review the state of knowledge of zoonotic and parasitic
infections that impact the health of peoples of the North, 2) explore the potential impact on climate
change on the distribution and prevalence of disease 3) identify those diseases of concern which require
additional evaluation, research, monitoring and intervention, 4) develop a strategy to monitoring those
diseases have the potential to spread in a warming Arctic.
Agenda
Thursday September 23
10:00 Introductions
10:15 Overview: Climate Change and Infectious Diseases in the North
Alan Parkinson
11:00 Report from a meeting on Zoonotic and Parasitic Diseases in Alaska
Jim Berner
11:30 State of knowledge zoonotic and parasitic infections of concern: Impact of Climate Change
Puumalavirus
Magnus Evander
Francella tularensis
Anders Sjostedt
Tick-borne encephalitis
Birgitta Evengard
12:30 Lunch
1:30 State of knowledge zoonotic and parasitic infections of concern: Impact of Climate Change (cont)
Pregnant Women as an indicator group
Jon Oyvind Odland
Echinococcus
Eskild Petersen
Q, fever
Eskild Petersen
Toxoplasma
Babill Stray-Petersen
Brucella
Jacques Godfroid
Borrelliosis (Lyme Disease)
Birgitta Evengard
2:50 Break
3:00 New surveillance methods (population based, indicator populations or species).
ICS
Alan Parkinson
Qualitative Assessments
Maria Furberg
Serosurveys
Alan Parkinson
Arctic Network (ArNe)
Birgitta Evengard
PROMIS
Barbara Schumann
ECDC
Jan Semenza
WHO
David Mercer/ Bettina Mene
5:00 Adjourn for the day
7:00 Dinner
Friday September 24
9:00 am Discussion on the development of a strategy to monitor the spread of diseases of concern.
1.
2.
3.
4.
5.
What are the main pathogens of concern?
For these pathogens what are the gaps in research, monitoring, intervention
How can we address these gaps?
Who would be responsible for addressing these gaps?
How do we maintain or enhance coordination/cooperation between responsible
agencies/organizations
Discussion on the formation of an ICS Climate Change and Infectious Disease working group.
12:00 Adjourn
Attendees
CDC Arctic Investigations Program, Anchorage Alaska, USA
Alan Parkinson ajp1@cdc.gov
Mike Bruce zwa8@cdc.gov
Tom Hennessy tbh0@cdc.gov
Alaska Native Tribal Health Consortium, Anchorage Alaska USA
Jim Berner jberner@anmc.org
Brian McMahon bdm9@cdc.gov
Steve Livingston slivings@anmc.org
University of Umea, Umea, Sweden
Birgitta Evengard birgitta.evengard@climi.umu.se
Magnus Evander magnus.evander@climi.umu.se
Christina Hedlund Christina.hedlund@climi.umu.se
Maria Furburg maria.furberg@climi.umu.se
Barbara Schumann barbara.schumann@epiph.umu.se
Anders Sjostedt anders.sjostedt@climi.umu.se
ECDC, Stockholm, Sweden
Jan Semenza jan.semenza@ecdc.europa.se
University of Oslo, Oslo Norway
Babil Stray-Pederson babill.stray-pedersen@medisin.uio.no
University of Tromso Norway
Jon Oyvind Odland jon.oyvind.odland@uit.no
Jacques Godfroid Jacques.godfroid@nvh.no
WHO Euro Copenhagen Denmark
David Mercer mercer@who.int
Mikhal Ejov mej@euro.who.int
Statens Serum Institute, Copenhagen Denmark
Anders Koch ako@ssi.dk
Malene Borresen mlb@ssi.dk
Johan Navre johannavne@gmail.com
Nuuk Greenland
Gert Mulvad gm@peqqik.gl
Flemming Stenz flst@peqqik.gl
Karin Ladefoged kala@peqqik.gl
Aarhus University, Denmark
Eskil Petersen eskildp@dadlnet.dk
Prophylactic Center Khanty Mansiysk, Russian Federation
Alexander Vladimirov vladimirov-av@mail.ru
Pasteur University, St Petersburg, Russian Federation
Liudmila Lyalina lyalina@pasteurorg.ru
Andrey Tulisov andrey_tulisov@mail.ru
Presentations (available at www.arcticinfdis.com )
Overview: Climate Change and Infectious Diseases in the North
Alan Parkinson
The Arctic, like most other parts of the world, has warmed substantially over last few decades. This is
already impacting local communities who have observed profound changes in their local environments,
and is leading to significant economic and cultural upheaval particularly for the indigenous peoples of
the. Resident indigenous populations of the Arctic are uniquely vulnerable to climate change because of
their close relationship with, and dependence on, the land, sea and natural resources for their well
being. Direct health threats from climate change include morbidity and mortality resulting from
increasing extreme events (storms, floods, increased heat and cold) and an increased incidence of injury
and mortality associated with unpredictable ice and storm conditions. Indirect effects include increased
mental and social stress related to changes in environment and loss of traditional lifestyle; potential
changes in bacterial and viral diseases; and decreased access to quality water sources.
Some regions are at risk for increasing illness due to failing sanitation infrastructure resulting from
changes in permafrost and storm surge. The impact of climate on the incidence of these existing
infectious disease challenges is unknown. However it is known that inadequate housing and sanitation
are already important determinants of infectious disease transmission in many Arctic regions. Damage
to the sanitation infrastructure by melting permafrost or flooding may therefore result in increased
rates of hospitalization rates among children for respiratory infections, as well as an increased rate of
skin infections, and diarrheal diseases caused by bacterial, viral, and parasitic. Some infectious diseases
are unique to the Arctic and lifestyles of the indigenous populations, and may increase in a warming
Arctic. For example, many Arctic residents depend on subsistence hunting, fishing and gathering for
food and a predictable climate for food storage. Food storage methods often include above ground airdrying of fish and meat at ambient temperature, below ground cold storage on or near the permafrost,
and fermentation. Changes in climate may prevent the drying of fish or meat, resulting in spoilage.
Similarly loss of the permafrost may result in spoilage of food stored below ground. Warmer
temperatures may allow an infected host animal species to survive winters in larger numbers, increase
in population and expand their range of habitation and thus increase the opportunity to pass infections
to humans. Climate change may influence the density and distribution of animal hosts and mosquito
vectors which could result in an increase in human illness or a shift in the geographical range of disease
caused by these agents.
The public health response to these emerging microbial threats should include enhancing the public
health capacity to monitor diseases with potentially large public health impacts, including respiratory
diseases in children, skin infections, and diarrheal diseases particularly in communities with failing
sanitation systems. Because Arctic populations are relatively small and widely dispersed over a large
area, region-specific detection of significant trends in emerging climate related infectious diseases may
be delayed. This difficulty may be overcome by linking regional monitoring systems for the purposes of
sharing standardized information on climate sensitive infectious diseases of mutual concern. Efforts
should be made to harmonize notifiable disease registries, laboratory methods and clinical surveillance
definitions across administrative jurisdictions to allow comparable disease reporting and analysis. The
public health capacity should be enhanced to promptly respond to infectious disease food-borne
outbreaks. Public health research is needed to determine the baseline prevalence of potential climate
sensitive infectious diseases in both human and animal hosts in regions where emergence may be
expected. Such studies can be used to accumulate additional evidence of the effect of climate change or
weather on infectious disease emergence, to guide early detection and public health intervention
strategies, and to provide science based support for public health actions on climate change.
Report from a meeting on Zoonotic and Parasitic Diseases in Alaska
Jim Berner
A meeting was held August 11-12, 2010, University of Alaska, Fairbanks, to review historical data on
zoonoses in Alaska, review climate changes, predictions, review current knowledge of zoonoses in
Alaska, and to develop plan for human/wildlife surveillance and collaboration within Alaska and other
Arctic countries. Organisms reviewed included: Brucella, Arboviruses (Snowshoe hare, Jamestown
Canyon, WHV), Trichinella, Rabies, Q-fever, Echinococcus, Francisella tularensis, Avian influenza,
Giardiasis, Toxoplasma , Cryptosporidia. Priority data and research needs that emerged from this
meeting included: For Brucella, a need for serologic/PCR tests for marine brucella, an understanding of
the cross-reactivity between B.suis/marine brucella, the need for baseline seroprevalence in important
food species, an understanding of marine/freshwater ecology of marine brucella, and potential for
human co-infection. For Toxoplasma there is a need for baseline seroprevalence in humans in rural
Alaska, and subsistence species and an understanding of the asexual ecology in rural Alaska. For
Trichinella a need for baseline prevalence in humans, subsistence wildlife, and protocol standardization
for sampling, testing. For Francisella tularensis , both types A & B exist in Alaska, and with movement
of beavers and muskrat north with the warming trend, raises threat of local waterborne outbreaks .
Baseline seroprevalence studies in humans, and animals are needed. Next steps included: (1) the
establishment of a Alaska Zoonotic Disease Committee, to plan collaborative efforts with multiple
federal agencies to address data and research needs, (2) to establish a village-based capacity for hunters
to gather specimens to begin zoonotic disease surveillance, (3) to create education products for
residents, medical providers in rural Alaska and (4) to participate in circumpolar planning to create
international zoonotic disease research and surveillance.
Puumalavirus
Magnus Evander
Milder winters in Northern Scandinavia may contribute to larger outbreaks of hemorrhagic fever virus.
A combination of a mild climate at the beginning of winter, loss of protective snow cover and high
rodent reservoir numbers likely caused the sudden and dramatic increase of NE cases in the winter
2006/2007 in northern Sweden. Rodent-borne hantaviruses should be regarded as an increasing threat
to health in the North since future climate change scenarios predict higher temperatures. These events
should alert public health officials to the need for preparedness for epidemics of hantavirus, as well as
other viral zoonotic diseases e.g. mosquito-borne, and the need to increase the capacity for
rodent/vector surveillance, virus detection and climate studies to improve knowledge of the
pathogenesis and natural history of these diseases.
Francella tularensis
Anders Sjostedt
A model to assess effects of climate change on infections
Francella tularensis is the causative agent of tularemia. It is highly infectious – infectious dose <10
bacteria- Is spread by rodents, hares, mosquitoes, ticks etc. Infects through the skin, mucous
membranes, gastrointestinal tract, or lungs. There are two clinically important subspecies, F. tularensis
(Type A) only North America, F. holarctica (Type B) Northern hemisphere. The infectious cycle is
normally dependent in ticks, but in Scandinavia most cases are related to mosquito-bites. Infections
commonly occur between July and October each year. Environmental factors that can affect outbreaks
include: Temperature, precipitation, humidity, snow cover, water flow, Summer precipitation and
humidity and winter temperature. There is a temporal relationship that support a causative relationship
between mosquito density and outbreaks of tularemia. The predicted future warming will significantly
increase the risk of tularemia outbreaks. There is quantative correlation of mosquito abundance in late
summer and tularemia in humans. The tools are generally applicable for forecasting outbreaks and their
relationship to arthropod distribution.
Tick-borne encephalitis
Birgitta Evengard
TBE is caused by an arbovirus transmitted by ticks that act as both vector and reservoir. Temperature
accelerates tick development, egg production, population density and distribution. It is likely that
climate change has already contributed to changes in the distribution of ticks (and TBE) in Europe. TBE is
a notifiable disease in Sweden and represents a substantial part of the viral encephalitis disease burden
in the country. In the four-year period leading up to 2009, an average of 177 TBE cases were reported
annually, and the number of TBE cases increased by 71% from 131 cases in 2005 to 224 cases in 2008.
TBE occurs from April to December in Sweden, with the peak incidence between May and July. Climate
models with warmer and dryer summers project that TBE will move to higher altitudes and latitudes,
however it is unlikely that these factors alone explain the surge in incidence over the last 30 years.
Echinococcus in the Arctic
Eskild Petersen
E. Granulosis cycles in dogs and other canids . The definative host and sheep, goats, swine etc
(Intermediate host –get disease) accidental host man. In Finland the sylvatic cycle involves wolves and
reindeer (prevalence in reindeer 0.1%). In Norway and Sweden there is a dog reindeer cycle. Incidence
has decreased due to treatment of dogs. Greenland and Iceland (not reported). In Greenland absence is
due to the absence of suitable local rodent host. Russia, reported in 25-70% of domesticated reindeer in
north eastern Siberia (Chulotka). In Alaska is found in 30% of wolves, common in moose, caribou. E.
multilocularis commonly cycles in fox and rodent. There is a high prevalence in Northern Canada,
Alaska, Russia, China, Japan. Found in mice in Svalbard. The impact of climate is uncertain. E. granulosis
and E. multilocularis are already present in the Arctic, and the distribution seems to be dependent on
proper host and exchange between hosts and not climate. The distribution of hosts (dogs/foxes) may be
climate dependent, but both are adapted to all climate zones.
Q, fever
Eskild Petersen
Caused by Coxiella burnetii a spore forming intracellular, small gr. negative rod, found in reservoir
animals ( Sheep, cows, goats, rodents and other mammals, birds). Transmission airborne (dust),
placenta, amniotic fluid, urine, feces. Can survive in the environment at least 1 year probably
longer dependent on temperature and humidity. Incubation time 14 – 45 days. Symptoms , include
fever, muscle pains, cough, headacke, rash. Most people clear the infection without treatment, although
about 5% of persons develops chronic endocarditis, hepatitis, osteomyelitis , meningoencephalitis. Case
identifed in Greenland. Possible source dogs, seals. Q fever diagnosed in northwestern Russia resulting
from contact with liquidated cattle complexes. Also in other parts of northern Russia. May be
underdiagnosed (lack of diagnostics). Also found in northern Canada, Sweden and Finland. Impact of
climate change uncertain. Coxiella burnetii are already present in the arctic and indeed in most of the
rest of the world. The distribution seem to be ubiqitous in all climatic zoones. Spores are very resistant.
More research are needed on the presence or absence of C. bunetii . Predictions: Coxiella burnetii will be
found in the Arctic if looked for, climatic changes with influence on spore survival may cause changes in
the epidemiology, but the infections is already widespread in wild mammals and birds.
Toxoplasma
Babill Stray-Petersen
Parasite causes congenital infections in newborn. Uninfected women at risk. Definitive host is the cat.
Parasite replicated in cat intestine, Oocysts survive in environment months to years and infect
secondary animal and avian hosts ( pigs, cattle waterfowl). Humans become infected by ingesting
Oocysts eating raw or undercooked meat, water, other soil contaminated food items. Common dogma
is that infection is via cat. However ingestion of undercooked food items most common source of
infection. While there are few cats in many Arctic environments, the traditional food supply may be an
increasingly source of infection for indigenous peoples. Migratory birds may be seeding the Arctic
environment resulting in increasing prevalence of infection in Arctic foxes, marine mammal, land
mammals. As waterfowl, marine and land mammal migratory patterns change with global warming,
infection may spread to new regions with increased infection in indigenous populations that depend on
these species for food.
Brucella in the Arctic
Jacques Godfroid
Brucella is a widespread infection of terrestrial mammals in most parts of the world and presents a
substantial risk of infection to human populations who depend on these animals for food. Common
pathogens for humans are Br. melintensis (biovar 1-3 from sheep,goats), Br abortis (biovar 1-6,9 in
cattle), Br Suis (biovar 1-3 in pigs),and Br suis biovar 4 found in in reindeer and caribou. Br cetis and Br
pinnipedialis have recently been isolated from marine mammals raising questions regarding the
significance of these agents and in particular the zoonotic potential. Serosurveys using terrestrial
mammal brucella antigens suggest widespread infections in many marine mammal species used for food
by indigenous populations of the Arctic.
Borrelliosis (Lyme Disease)
Birgitta Evengard
Borrelliosis is a tick-transmitted bacterial infection caused by some members of the spirochete group
Borrelia burgdorferi. It is the most prevalent tick-transmitted infection in temperate areas of Europe,
North America and Asia, and its geographic distribution is ever-increasing. In Europe Lyme borrellosisis
the most common tick borne disease resulting in 85,000 cases per year and has increased in incidence in
several European countries including Finland, Sweden and the Russian Federation. The shift toward
milder winter temperatures due to climate change may enable expansion of Lyme disease into higher
latitudes and altitudes but only if all of the vector host species required by tick vectors are equally able
to shift their population distribution. In contrast, droughts, and flooding with increased precipitation
will negatively impact their distribution alter their seasonal activity and shift exposure patterns.
New surveillance methods (population based, indicator populations or species).
Pregnant Women as an indicator group
Jon Oyvind Odland
The use of special population groups in climate change research, Murmansk County Birth Registry
(MCBR). This is a collaborative project started in 2006 together with University of Tromso, and
Murmansk County Health Department and Delivery Centers, and closely connected to Norwegian and
Finnish Birth registries. Total population of Murmansk County is 860,000. Such registries can be used to
gather information on health status of pregnant women and children look for trends in morbidity and
mortality, birth weight, birth defects, prevalence of maternal diseases, lifestyles, living conditions.
Registries are used for Public Health research (levels of environmental contaminants). Blood is
collected at first visit and postpartum. Sera banked could be used for serological surveillance of climate
sensitive (or other) infectious diseases.
International Circumpolar Surveillance
Alan Parkinson
Is a network of public health laboratories, institutes and academic centers located in the US Arctic
(Alaska), northern Canada, Greenland, Denmark, Iceland, Norway Finland and northern Sweden that
share standardized quality controlled surveillance data on invasive bacterial diseases, and tuberculosis
for the purposes of cross border comparison, the monitoring trends and impact of interventions. Such a
network could also be used to monitor trends in the spread or emergence of climate sensitive infectious
diseases.
Arctic Network (ArNe)
Birgitta Evengard
Led by the University of Umea, is a scientific network on climate change and infectious diseases in the
Arctic consisting of a series of independent nodes which will perform studies allowing data to be
compared between different Arctic regions. Collaborating institutes (nodes) currently include The
University of Tromso, Tromso Norway, The University of Umea, Umea Sweden, The Center for Arctic
Medicine, Thule Institute, University of Oulu Finland, Russian Academy of Science Moscow Institute of
Forecasting, The CDC’s Arctic Investigations Program, Anchorage Alaska USA.
Qualitative Assessments
Maria Furberg
In Sweden a pilot qualitative assessment has been initiated examining the perceptions of climate change
among the Sami reindeer herders. In-depth interviews were conducted among 11 male and 3 female
reindeer herders geographically distributed throughout the Swedish Sami regions. By studying how
indigenous peoples handle climate change we can understand what is happening in these communities,
the consequences and provide feedback and suggest adaptive actions to the communities. The study
could be expand to include the Sami of Norway, Finland, and Russian Federation to better understand
how different regions from the same culture adapt to climate change.
Serosurveys
Alan Parkinson
The CDC’s Arctic Investigations Program, houses a large specimen bank consisting of some 300,000 left
over serum specimens, collected from studies conducted as far back as the 1960s, although most sera
have been added since 1980. The majority of sera are from studies conducted on Alaska Native peoples.
This bank is co managed together with the Alaska Native Tribal Health Consortium to ensure studies are
conducted on health issues of importance and benefit to the Alaska Native peoples. Studies using sera
from this specimen bank are being planned to determine the prevalence of several zoonotic and
parasitic infections in the Alaska Native population. This presentation stimulated discussion on the use
of other specimen banks for this purpose. It was suggested that an inventory of circumpolar specimen
banks (both human and wildlife) be made.
PROMIS
Barbara Schumann
Patient Reported Outcome Measures Information System is a web based patient interview instrument
designed to standardize reported outcomes. Can be adapted to research studies. Managed through
central Assessment CenterSM: A online research management tool that will allow researchers to
centralize research activities. Contains a library of interview instruments that focus on health-related
quality of life issues and allow assessment of disease outcomes reported by patients or study
participants. Can be administered online or electronically or optionally as apaper version. The University
of Umea plans to use this to examine the long term sequallae of Puumalavirus infection. Such a study
could be extended to include other regions in Northern Europe.
ECDC
Jan Semenza
The predicament of climate change calls for concerted public health action. In Europe the incidence,
prevalence, and distribution of vector-, rodent-, water-, and food-borne infections are expected to shift
in a changing environment. Due to the high level of uncertainty on the rate and speed of climate change
and its impact on infectious diseases, the European Centre for Disease Prevention and Control (ECDC), a
new public health agency in Europe, has mounted a proactive public health response by building an
integrated network for environmental and epidemiological data. The blueprint of such a European
Environment and Epidemiology (E3) Network has been designed and integrated into the IT landscape of
ECDC. It will be connected with the mandatory surveillance system of 49 diseases and with epidemic
intelligence that monitors threats and outbreaks in Europe and beyond. The E3 Network will have the
capacity to connect epidemic intelligence and infectious disease surveillance with meteorological,
entomological, water quality, remote sensing, or other data, for multivariate analyses and long-term
projections. . It would have to be pilot-tested and validated but could be a distributed, secure, webbased network that would provide timely access to climatic/environmental and infectious disease
surveillance data that are collected by a variety sources. The hub could serve as a repository and would
support data exchanges and sustained collaborations between member states, researchers, and other
authorized users across geographic and political boundaries. Merging, integrating, and analyzing such
environmental and epidemiological data will advance our understanding of the relationship between
climate change and infectious diseases in Europe and inform public health action.
WHO
David Mercer; Bettina Mene
Protecting health in an environment challenged by climate change.
In 1997 a working group was set up to provide input on the early human health effects of climate
change. After the severe heat events in 2002 and 2003 climate change was newly put on the agenda of
the 4th Ministerial Conference, with the developments of a paper on public health responses to extreme
weather events and a background paper on energy and health. Between 2000 and 2010 WHO Euro
coordinated 3 large multidisciplinary research projects – three public health projects; a number of
ministerial working groups and inputs into policy processes (including the Intergovernmental Panel on
Climate Change); contributed to thirteen national assessments. The office has a large history of
partnerships with UN agencies, EU agencies and institutions, which contributed between many others to
the BMJ public health award winning book on protecting health from climate change. After many years
of action on climate change and health in the WHO European Region, European Member States, the
European Commission and a variety of agencies have collaborated in developing this European Regional
Framework for Action, recognizing that the WHO European environment and health process provides a
unique platform and opportunity where the environment and health sectors can closely cooperate with
other sectors and partners. The overall goal of this framework is to protect health, promote health
equity and security, and provide healthy environments in a changing climate in the WHO European
Region. Activities of the WHO European Office include support on heat-health action plans and disaster
preparedness and programmes to combat infectious disease, improve water and sanitation services and
respond to natural disasters, as well as information to the public on how to avoid risks.
Discussion on the development of a strategy to monitor the spread of diseases of concern.
1) What are the main pathogens of concern?
Based on the presentations and discussion these included:
Circumpolar Interest
Brucella
Toxoplasma
Francella
Trichinella
Botulism
WNV
Hepatitis E
Regional Interest
Puumalavirus (Sweden, Norway, Finland Russian Federation)
TBE/Borrelliosis (Sweden, Norway, Finland Russian Federation)
Echinococcus (Alaska)
Some of these can be monitored using existing reporting systems (reportable diseases). A project
suggested was an assessment of reportable human diseases by country. A similar assessment should
also be possible for wildlife diseases. This would give us an idea of what to monitor in humans (ie high
risk groups etc)
There was discussion on which diseases would be most likely to be affected by climate change.
TBE/Lyme disease has already been shown to be affected by weather patterns . However there is no
clear criteria to prioritize diseases by climate sensitivity. Therefore it is more important to determine
baseline prevalence (in humans and wildlife indicator species) so that changes can be monitored and
linked to climate variables.
1.
2.
3.
4.
Determine what is notifiable
Determine diagnostic capacity
Determine disease baseline
Lobby states to make climate sensitive diseases notifiable
An alternative approach might be Syndromic Surveillance. Monitor discharge diagnosis for diarrheal
diseases, skin infections, respiratory diseases, FUOs. Use computerized system using ICD9 codes. (Jan to
send reference to French INVS system?)
Recruit Ph.D student in each country to work on same project?
Summary of potential Projects
1. Catalog available human and wildlife specimen banks by country. (Malene volunteered to draft a
specimen bank evaluation form and circulate)
2. Catalog reportable diseases by country. Evaluate diagnostic adequacy
3. Catalog available electronic databases country by country
4. Evaluate WHO data resources
5. Consider a joint circumpolar meeting on zoonotic and parasitic diseases with wildlife people.
Discussion on how do we maintain or enhance coordination/cooperation between countries.
It was decided that the attendees (and other key people would form an ICS Climate Change and
Infectious Disease Working Group. Alan and Birgitta would temporarily co-chair the group, until a terms
of reference document is produced. The next meeting could be together with the other ICS working
group meetings scheduled for September 2011, in Copenhagen. With a potential 2012 meeting in
Fairbanks, Alaska in conjunction with the 15th ICCH meeting August 5-12. In the mean time
communication will be via email.
A final item discussed was the drafting of the meeting summary and distribution. Alan will draft the
meeting summary for circulation. Presentations and other working group documents could be posted on
the website Anders created at www.arcticinfdis.com.