impact of climate change on health

1. CGE TRAINING MATERIALS -
VULNERABILITY AND ADAPTATION
ASSESSMENT
CHAPTER 8
Human Health

2. 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

3. 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

4. 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.

5. OVERVIEW OF THE POTENTIAL
HEALTH IMPACTS OF CLIMATE
VARIABILITY AND CHANGE
1A.5

6. 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.

7. Environmental
Conditions
Social Conditions
(upstream determinants
of health
Health System
Conditions
Climate
Change
Direct
Exposures
Indirect
Exposures
(Changes in
food quality,
disease
vectors,
ecosystem
changes)
Changes in Social
Disruption
Health
Impacts
Modifying
Influence
Pathways for Weather to Affect Health

8. Health effects
Temperature-related illness
and death
Extreme weather- related
health effects
Air pollution-related health
effects
Water and food-borne
diseases
Vector-borne and rodent-
borne diseases
Effects of food and water
shortages
Effects of population
displacement
CLIMATE
CHANGE
Human exposures
Regional weather
changes
Heat waves
Extreme weather
Temperature
Precipitation
Source: based on Patz, et al., 2000
Modulating
influences
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
Contamination
pathways
Transmission
dynamics
Agro-ecosystems,
hydrology
Socioeconomics,
demographics

9. POTENTIAL HEALTH IMPACTS
FROM ENVIRONMENTAL
CHANGES

10. TEMPERATURE

11. Temperature
CSIRO 2006: Climate Change in the Asia/Pacific Region

12. Temperature

13. Temperature Extremes in Bhutan, 1800s –2010
Temperature

14. 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.

15. 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

16. 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.

17. STORMS/FLOODS

18. 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.
From: Environment Solutions: www.environmentsolutions.dk
Source: 2009 Global Assessment report on Disaster Risk Reduction

19. 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

20. 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.

21. 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

22. 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

23. DRINKING WATER

24. 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.

25. 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

26. AIR QUALITY

27. Air quality

28. China Haze 10 January 2003
Source: NASA

29. 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.

30. 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.

31. 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.

32. VECTOR-BORNE DISEASE

33. Malaria in Vanuatu
Wet season in Vanuatu is from November until April, temperatures very between 24 to 30oC

34. 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.

35. 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.

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

37. 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
+2
-2
< -2
A1
B2
A2
B1
Van Lieshout et al. 2004

38. FOOD SECURITY

39. 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

40. 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.

41. FOOD SAFETY

42. 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.

43. DIARRHOEAL DISEASES

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

45. Number of Cholera cases in Uganda 1997-2002
0
10000
20000
30000
40000
50000
1996 1997 1998 1999 2000 2001 2002 2003
Time in years
Number
of
cases
El Nino starts
El Nino stops
El Nino Events and the possible impact on diseases: Cholera

46. SOCIAL IMPACTS

47. 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

48. 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.

49. 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.

50. 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 >

51. PREDICTIVE TOOLS FOR
THE FUTURE
Assessing the Vulnerability of Human Health to Climate Change

52. 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

53. 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

54. 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

55. 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.”

56. 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.

57. 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.

58. 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.

59. 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.

60. 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.

61. USE OF THE HIA PROCESS
FOR CLIMATE CHANGE

62. SCREENING
SCOPING
RISK ASSESSMENT
RISK MANAGEMENT
• Does the situation require a HIA?
• Identify health impacts
• Set boundaries
• Population
• Vulnerable groups
• What are the risks/benefits?
• Minimize risks
• Maximize benefits.
PROFILING
The HIA Process in the Vulnerability Assessment

63. 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.

64. 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.

65. 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/>

66. 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.

67. HEALTH IMPACT ASSESSMENT
OF CLIMATE CHANGE

68. 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?

69. 1. UNDERSTANDING
POPULATIONS

70. 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>

71. Population data
Source: U.S. Census Bureau, International Data Base
Ten Largest Countries in Population (2011)
• The implications of country numbers and distribution
are important in determining health impacts and their
responses.

72. The 20 Largest Urban Areas in the World
* Demographia World Urban Areas and Population Projection. 7th Annual edition. April, 2011. www.demographia.com

73. Nauru
Source: Nauru Bureau of Statistics
• Total expenditure on
health per capita
(Intl $, 2010) 264
• Total expenditure on
health as % of GDP
(2010) 11.2

74. Bhutan

75. VULNERABILITY

76. 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:
• Need to identify and address the vulnerability
components individually and integrated for specific
sectors and communities.
Regional Economic Social Infrastructure
& Services
Overall
Vulnerability

77. 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

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

79. 2. HEALTH DATA

80. 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>

81. 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.

82. 3. ESTABLISH A CLIMATE
SCENARIO

83. 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.

84. 4. ENVIRONMENTAL CHANGES

85. 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.

86. 5. DETERMINING HEALTH
IMPACTS

87. Determine Health Impacts:- Assume only current controls
Climate
variable
Impacts to communities
and individuals
Vulnerability Evidence/
uncertainties
Environmental Health:
-direct
-indirect
Regional Economic Social Infra-
structure
Temp
increase
Rainfall
change
Sea level
increase
Extreme
events:
-Heatwaves
Droughts
-Bushfires
-Flooding
-Storms
-Tropical
cyclones

88. 6. COPING CAPACITY

89. Coping Capacity
Health
impacts
Current
controls
Limitations
Effectiveness
in 2030
Gaps for
2030
Sectors
involved
Describe what is being implemented now to minimize negative effects

90. 7. HEALTH RISK ASSESSMENT

91. 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.

92. 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).

93. 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.

94. RISK PERCEPTION

95. Risk Perception
Perception of risk is related to many factors:

96. Risk Perception

97. 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.

98. 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.

99. 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.

100. 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.

101. 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
Consequence Scale

102. 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.

103. Likelihood
Consequences
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
Consequence x Likelihood = Risk Priority Level

104. Extreme
events
Consequence Likelihood Risk
Evidence or
reason for
decision
Further
information
required
Direct
physical
injuries
from
extreme
events.
Example of Table

105. RISK PRIORITIZATION

106. 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

107. 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

108. 8. ADAPTATION MEASURES

109. 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
DECREASING
EFFECTIVENESS

110. Health Impact Pathway
Extreme rainfall and flooding
Overflow of waste from septic
tanks into flood waters
Human contact with flood water
Gastro intestinal diseases
Prevent/reduce flooding
Avoid human contact with water
Correct medical treatment
Prevent/reduce overflow of waste

111. 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.

112. 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

113. 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.

114. 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?

115. Example of Table
Possible Adaptation Measures
For each Potential Adaptation measure:
Sectors
What is our capacity in this
regard – in general and for
vulnerable regions and groups?
How can this measure
be implemented or
upgraded?
Legislative or Regulatory
A= adequate I= inadequate
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)

116. 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.

117. METHODS TO DETERMINE
THE CURRENT BURDEN OF
CLIMATE-SENSITIVE DISEASES
1A.11
7
Tools available for use for specific diseases

118. 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.
Malaria in Africa

119. MARA/ARMA Environmental Data for Malaria

120. 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.

121. 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.

122. 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

123. Relationship between Temperature and Daily Survivorship of Anopheles
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
1
6
.
1
1
8
2
0
2
2
2
4
2
6
2
8
3
0
3
2
3
4
3
6
3
8
4
0
Mean Temperature (°C)
Proportion
of
Mosquitoes
Surviving
One
Day

124. Relationship between Temperature and Time Required for Parasite Development
0
20
40
60
80
100
120
17 19 21 23 25 27 29 31 33 35 37 39
Mean Temperature (°C )
Days

125. Proportion of Vectors Surviving Time Required for Parasite Development
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
17 19 21 23 25 27 29 31 33 35 37 39
Mean Temperature (°C)
Proportion
Surviving

126. MARA/ARMA: Distribution of Endemic Malaria in Africa

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

128. Mozambique – Endemic Malaria Season Length

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

130. MARA/ARMA: Populations at Risk From Malaria in Africa

131. Mozambique – Endemic Malaria Prevalence

132. Mozambique – Endemic Malaria Prevalence by Age

133. MARA/ARMA: Possible Applications

134. Reference
• Ebi et al. Climate Suitability for Stable Malaria Transmission in Zimbabwe
Under Different Climate Change Scenarios. Geneva: WHO, 2005
Objective: to look at the range of responses in the climatic suitability
for stable falciparum malaria transmission under different climate
change scenarios in Zimbabwe

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

136. 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

137. 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

138. 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

139. 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

140. 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

141. 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

142. 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

143. Assignment of Fuzzy Logic Values to Climate Variables
Fuzzy Logic Value for Mean Temperature
0
0.2
0.4
0.6
0.8
1
1.2
17.5
19.5
21.5
23.5
25.5
27.5
29.5
31.5
33.5
35.5
37.5
39.5
Mean Temperature (°C)
Fuzzy
Value
Fuzzy Logic Value for Precipitation
0
0.2
0.4
0.6
0.8
1
1.2
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72
76
80
84
Precipitation (mm)
Fuzzy
Value
Fuzzy Logic Value for Minimum Temperature
0
0.2
0.4
0.6
0.8
1
1.2
3.5
3.7
3.9
4.1
4.3
4.5
4.7
4.9
5.1
5.3
5.5
5.7
5.9
6.1
6.3
6.5
Minimum Temperature (°C)
Fuzzy
Value

144. 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

145. 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

146. Baseline
Source: Ebi, et al., 2005

147. 2025
Source: Ebi, et al., 2005

148. 2050
Source: Ebi, et al., 2005

149. 2075
Source: Ebi, et al., 2005

150. 2100
Source: Ebi, et al., 2005

151. 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

152. 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>

153. 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.

154. Sudan – Projected Increase in Transmission Potential of Malaria in 2030

155. Sudan – Projected Increase in Transmission Potential of Malaria in 2060

156. 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.

157. ADAPTATION OPTIONS FOR
MALARIA

158. 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

159. Analysis of the Practical Range of Response Options – Malaria
Theoretical
Range of
Choice
Technically
viable?
Financial
capability?
Human skills &
institutional
capacity?
Compatible
with current
policies?
Target of
opportunity?
Improved public
health
infrastructure
Yes Low Low Yes Yes
Forecasting 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

160. GLOBAL PROJECTIONS OF
HEALTH IMPACTS

161. 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

162. 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

163. Comparative Risk Assessment
2020s
2050s
2080s
GHG emissions scenarios
Global climate modelling:
Generates series of maps
of predicted future climate
Health impact model:
Estimates the change in relative risk of
specific diseases
Source: Campbell-Lendrum et al., 2003
Time
2080s
2050s
2020s

164. 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

165. Relative Risk of Deaths and Injuries in Inland
Floods in 2030, by Region
0
1
2
3
4
5
6
7
8
Afr
D
Afr
E
Amr
A
Amr
B
Amr
D
Emr
B
Emr
D
Eur
A
Eur
B
Eur
C
Sear
B
Sear
D
Wpr
A
Wpr
B
Relative
Risk
s550
s750
UE
Projected Relative Risk of Flooding
Source: WHO, 2003

166. Relative Risk of Diarrheoa in 2030, by Region
0.94
0.96
0.98
1
1.02
1.04
1.06
1.08
1.1
Afr
D
Afr
E
Amr
A
Amr
B
Amr
D
Emr
B
Emr
D
Eur
A
Eur
B
Eur
C
Sear
B
Sear
D
Wpr
A
Wpr
B
Relative
Risk
s550
s750
UE
Source: WHO, 2003
Projected Relative Risk of Diarrheoa

167. Floods
Malaria
Diarrhea
Malnutrition
0
20
40
60
80
100
120 2 4 6 8 10
DALYs (millions)
Deaths (thousands)
2000
2020
Source: Campbell-Lendrum et al., 2003
Estimated Death and Disability Adjusted Life years Lost(DALYs)Attributable to Climate Change

168. 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>

169. Vulnerability:
Current burden of disease
Current health protection programs
Future Impacts:
Changing burden without climate change
Projected health impacts of climate change
Adaptation:
Identify, prioritize additional interventions
Identify resources & barriers to implementation
Health harms
& benefits
in other sectors
Communicate
Plan &
Implement
Frame & Scope
Assessment
Assess Manage & Monitor Risks
Defining the
geographical
region and health
outcomes of
interest;
Identifying the
questions to be
addressed and
steps to be used;
Identifying the
policy context for
the assessment;
Establishing a
project team and
a management
plan;
Establishing a
stakeholder
process;
Developing a
communications
plan.
Monitor &
evaluate
Source: WHO, et al., 2008
Additional Information: Vulnerability and Adaptation (V&A)
Framework for Health