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
Environmental
Social Conditions
(upstream determinants
of health
Health System
Conditions
Conditions
Direct
Exposures
Climate
Change
Indirect
Exposures
(Changes in
food quality,
disease
vectors,
ecosystem
changes)
Changes in Social
Disruption
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
Modulating
influences
Human exposures
CLIMATE
CHANGE
Regional weather
changes
Heat waves
Extreme weather
Temperature
Precipitation
Contamination
pathways
Transmission
dynamics
Agro-ecosystems,
hydrology
Socioeconomics,
demographics
Source: based on Patz, et al., 2000
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 rodentborne diseases
Effects of food and water
shortages
Effects of population
displacement
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
26
28
30
32
34
36
38
40
42
44
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 8oC
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
features; absence of warning; rapid speed
of flood onset; deep floodwaters; landslides;
risk behaviour; fast flowing waters carrying
boulders and fallen trees
Drowning
Injuries
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
and sewage disposal damage; insufficient
supply of drinking water; insufficient water
supply for washing
Possible waterborne infections (enterogenic
E.coli, shigella, hepatitis A, Leptospirosis,
giardiasis, camplylobacter) dermatitis, and
conjunctivitis
Disruption of transport systems
Food shortage; disruption of emergency
response
Underground pipe disruption; dislodgement
of storage tanks; overflow of toxic waste
sites; release of chemicals; rupture of
gasoline storage tanks may lead to fires
Potential acute or chronic effects of
chemical pollution
Standing waters; heavy rainfalls; expanded
range of vector habitats
Vector-borne diseases
Rodent and other pest migration
Possible diseases caused by rodents or
other pests
Disruption of social networks; loss of
property, jobs and family members and
friends
Possible psychosocial disturbances
Clean-up activities following floods
Electrocutions; injuries; lacerations; skin
punctures
Destruction of primary food products
Food shortage
Damage to health services; disruption of
“normal” health service activities
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)
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 highpressure 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 30oC
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.
Change of consecutive months
> +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
Number of cases
El Nino starts
40000
El Nino stops
30000
20000
10000
0
1996
1997
1998
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) 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 climatesensitive 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:
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. 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 foodborne disease and other environmental diseases.
5. DETERMINING HEALTH
IMPACTS
Determine Health Impacts:- Assume only current controls
Climate
variable
Impacts to communities
and individuals
Environmental
Temp
increase
Rainfall
change
Sea level
increase
Extreme
events:
-Heatwaves
Droughts
-Bushfires
-Flooding
-Storms
-Tropical
cyclones
Health:
-direct
-indirect
Vulnerability
Regional
Economic
Social
Evidence/
uncertainties
Infrastructure
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
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
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
Almost Certain
Example of Table
Extreme
events
Direct
physical
injuries
from
extreme
events.
Consequence
Likelihood
Risk
Evidence or
reason for
decision
Further
information
required
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
Health Impact examples
Extreme
Drinking water
Physical Impacts from
Extreme events
High
Malaria
Mental Health Impacts
Medium
Food Poisoning
Low
Pesticide Levels in Food
Management Actions
Risk Levels for
Health
Description of Management Action
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
DECREASING EFFECTIVENESS
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) 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
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.
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)
What is our capacity in this
regard – 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?
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 <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
Mean Temperature (°C)
40
38
36
34
32
30
28
26
24
22
20
18
.1
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
16
Proportion of Mosquitoes
Surviving One Day
Relationship between Temperature and Daily Survivorship of Anopheles
Relationship between Temperature and Time Required for Parasite Development
120
100
Days
80
60
40
20
0
17
19
21
23
25
27
29
31
Mean Temperature (°C )
33
35
37
39
Mean Temperature (°C)
39
37
35
33
31
29
27
25
23
21
19
0.40
0.35
0.30
0.25
0.20
0.15
0.10
0.05
0.00
17
Proportion Surviving
Proportion of Vectors Surviving Time Required for Parasite Development
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
Fuzzy Value
1
0.8
0.6
0.4
0.2
39.5
37.5
35.5
33.5
31.5
29.5
27.5
25.5
23.5
21.5
19.5
17.5
0
Mean Temperature (°C)
Fuzzy Logic Value for Minimum Temperature
1.2
1
1
Precipitation (mm)
Minimum Temperature (°C)
6.5
6.3
6.1
5.9
5.7
5.5
5.3
5.1
4.9
4.7
4.5
84
80
76
72
68
64
60
56
52
48
44
40
36
32
28
24
20
16
0
8
0
12
0.2
4
0.2
4.3
0.4
4.1
0.4
0.6
3.9
0.6
0.8
3.7
0.8
3.5
Fuzzy Value
1.2
0
Fuzzy Value
Fuzzy Logic Value for Precipitation
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
Technically
feasible?
Effective?
Environmentally
acceptable?
Financially
Feasible?
Socially and
Legally
Acceptable?
Closed/Open
(Practical Range
of Choice)
Improved public
health
infrastructure
Yes
Low
Yes
Sometimes
Yes
Open
Forecasting &
early warning
systems
Yes
Medium
Yes
Often
Yes
Open
Public
information &
education
Yes
Low
Yes
Yes
Yes
Open
Control of vector
breeding sites
Yes
Yes
Spraying - no
Yes
Sometimes
Open
Impregnated bed
nets
Yes
Yes
Yes
Yes
Yes
Open
Prophylaxis
Yes
Yes
Yes
Only for the
few
Yes
Closed for many
Vaccination
No
Closed
Source: Ebi and Burton, 2008
Analysis of the Practical Range of Response Options – Malaria
Theoretical
Range of
Choice
Technically
viable?
Financial
Human skills &
capability? institutional
capacity?
Compatible
with current
policies?
Target of
opportunity?
Improved public
health
infrastructure
Yes
Low
Low
Yes
Yes
Forecasting and
early warning
systems
Yes
Yes
Yes
Yes
Yes
Public
information and
education
Yes
Yes
Sometimes
Yes
Yes
Control of vector
breeding sites
Yes
Sometimes Sometimes
Yes
Yes
Impregnated bed
nets
Yes
Sometimes Yes
Yes
Yes
Prophylaxis
Yes
Sometimes Yes
Yes
Yes
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:
Generates series of maps
of predicted future climate
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
8
Relative Risk of Deaths and Injuries in Inland
Floods in 2030, by Region
7
s550
s750
UE
5
4
3
2
1
Wpr B
Wpr A
Sear D
Sear B
Eur C
Eur B
Eur A
Emr D
Emr B
Amr D
Amr B
Amr A
Afr E
0
Afr D
Relative Risk
6
Source: WHO, 2003
Projected Relative Risk of Diarrheoa
Relative Risk of Diarrheoa in 2030, by Region
1.1
s550
1.08
s750
UE
1.04
1.02
1
0.98
0.96
Wpr B
Wpr A
Sear D
Sear B
Eur C
Eur B
Eur A
Emr D
Emr B
Amr D
Amr B
Amr A
Afr E
0.94
Afr D
Relative Risk
1.06
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
8
10
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
Assessment
Assess
Vulnerability:
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.
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
Manage & Monitor Risks
Health harms
& benefits
in other sectors
Communicate
Plan &
Implement
Monitor &
evaluate
Source: WHO, et al., 2008