Climate change influences on public health and infectious diseases
7250ENV Environmental Systems and Climate Change
Chani Asha (s5123214), Ashik Chacko Mathulla (s5113947), Sukhmanjeet Singh Sidhu (s5121241) and Jacinta Palmer (s2841446)
Changes in the global climate have produced rippling effects on public health and the transmission of infectious diseases. This is particular evident within South and South-East Asia, but also in the Northern and Southern hemispheric developed countries. Several infectious diseases have been identified as being primary public health risks, and can be influenced by climate changes and seasonal patterns. Since there is a particularly wide range that has been researched within the literature, this paper will focus on three key diseases dominant within the South and South-East Asia region and are lingering issues globally. These are cholera, dengue fever, and malaria. Cholera is a form of diarrheal disease, and dengue and malaria are vector-borne.
This literature review aims to address the seasonality and health implications of diseases, climatic changes influencing the frequency of transmission, the mortality toll from extreme heat, shifts in disease distribution, and the main organisations involved in mitigating these risks. The primary focus will be on rising temperatures and heat fluctuations, and the influences on cholera, dengue, malaria and mortality. Temporal fluctuations is one of several components of climate change and disease transmission, and has been identified to play a key role in vector-borne disease epidemics especially. Other climate drivers equally as influential will be discussed where relevant.
Seasonality of infectious diseases and health implications
Cholera (diarrheal), dengue fever and malaria (vector-borne) are infectious diseases that demonstrate cyclical seasonal incident peaks. Vector-borne diseases typically arise during warm and rainy periods. Whereas diarrheal sometimes occurs in one or two annual peaks during the spring, fall and winter depending on the disease and location (Altizer et al., 2006, p.469).
Emch et al. (2008) produced a unique paper, as it is one of the only to explore global seasonality of cholera. Through analysis of 32 years of data up to 2005 evaluating temporal cycles they found cholera sometimes peaks before (April) and after (September-December) monsoon seasons, or November to January and April to May in some cases. This depends on the strand of cholera and location. Cholera is endemic in South Asia, particularly Bangladesh and India (Emch et al., 2008; Baracchini et al. 2017).
The newer strain of cholera, V. cholera, resides in marine ecosystems varying from estuaries, to rivers and ponds. V. cholera is likely primarily transmitted through environmental factors, influenced by climate changes, involving but not limited to temperature, salinity, and nutrient quantities in water. The variability of cholera is recognizably connected with “upper troposphere humidity, cloud cover, atmospheric solar radiation, climate variability, seasonal drivers, and human dimensions”. Temperature related effects from climate change such as warming surface water can lead to phytoplankton blooms, which influences the occurrence and seasonality of cholera outbreaks (Pascual et al., 2000; Emch et al., 2008).
Cholera is still a global problem however not as threatening as in the past. It is still considered a leading cause of mortality, responsible for 20% of deaths in children under five years old in the Bengal region (Baracchini et al., 2017). Mortality for cholera is high due to quick dehydration, lack of early symptoms and usually unavailable fast treatment in developing countries (WHO, 2017; Ali et al., 2015).
Kneret et al. (2013) state, “WHO currently ranks dengue fever as the most important mosquito borne viral disease in the world”. Dengue can be found in more than 100 countries, with 50-100 million individuals infected annually (Pliego, Velázquez-Castro, & Collar, 2017; Kneret et al., 2013). In Thailand dengue generally peaks in June and July due to increased humidity and precipitation. Though Limkittikul et al. (2014) found outbreak peaks to occur during the rainy season, largely dominated by monsoons, between May and September and attributes the seasonal variability to climate variability and human dynamics. Similarly in Vietnam, outbreaks can peak between June and November (Do et al., 2014).
The United Nations set a goal to eliminate malaria globally by 2030. Malaria continues to be an issue within South and South-East Asia, particularly India, and sub-Saharan Africa. World Health Organisation (WHO) calculated 90-167 million cases of malaria per year for South and South-East Asia, this is approximately 30% of global incidences. 80.5% of people in India inhabit areas of malaria risks. The surrounding Himalayan Mountains keep India warmer by keeping out cold winds, and the Thar Desert draws in monsoonal winds providing rainfall. Most of India has a tropical climate. There is strong correlation between temperature, humidity, and precipitation when it comes to seasonality of malaria as demonstrated in India and sub-Saharan Africa, often occurring in the late second half of the year in these regions (Kumar et al., 2012; Ferrão et al., 2017).
Lisovski, Hoye and Klaassen (2016) evolved their understanding of infectious disease seasonality by including the processes of global day length variation, solar activity, and topography in their explanation. They explain the degree of seasonality is also determined by seasonal amplitude and duration, as well as population dynamics of immune responses and birth rates. This is aligned with studies from Altizer et al. (2006) and Jagai et al. (2012) who suggested several biological mechanisms attributable to seasonality and disease persistence, including immune responses and birth rates.
The literature shows there is not simply one underlying reason for infectious disease outbreaks to occur regularly. Seasonality is complex and highly variable depending on location, environmental, vector and human dynamics. Most are preventable through adequate sanitation, water quality, development and medical treatment availability (WHO, 2017; Altizer et al., 2006; Ali et al., 2015; Baracchini et al. 2017).
Climate induced changes and the frequency or severity of familiar health risks
Cholera, dengue fever, and malaria are the most widely studied infectious diseases influenced by climate change (Haines et al., 2006; Colon-Gonzalez et al., 2013; Purse et al., 2017; Githeko et al., 2000; Ermert, Fink & Paeth, 2013). Developing countries struggle the most to mitigate climate changes and are more prone to infectious disease outbreaks (WHO, 2018; Haines et al., 2006; Mirza, 2011; Purse et al., 2017). Haines et al. (2006) concluded in their findings that diarrheal disease might increase in exposure by 2-5% for developing countries. However WHO (2018) stated, “the estimated risk was 10% by 2030 in some regions”. This form of disease is listed by WHO (2018) as 8th out of the top 10 causes of death in the world as of 2015.
Understanding the potential risks from climate change requires climate-driving systems to be evaluated. A climate regulating system with the power to impact greatly on the transmission of disease is the El Nino Southern Oscillation Index (ENSO). ENSO is an oceanic and atmospheric cycle, known to influence malaria epidemics in South Asia as well as cholera within Bangladesh (Haines et al., 2006, p. 589; Kovats et al., 2003; Githeko et al., 2000).
Kovats et al. (2003) demonstrated in a time-series analysis of 18 countries, that there is evidence of the correlation between ENSO and disease outbreaks. ENSO causes heavy rainfall and flooding on the west coast of South America as a response to surface warming of the ocean. Besides rainfall, droughts also occur as a response. Climate change has the potential to intensify weather events of ENSO (Kovats et al., 2003; Pascual et al., 2000; Githeko et al., 2000).
In South Asia throughout the Ganges, Brahmaputra, and Meghna cholera previously ran rampant from floods and droughts. Floods and droughts cause increases in concentration and survival of cholera by also affecting salinity, pH or nutrient concentrations, human exposure and sanitation. Cholera increases when ocean surface temperatures rise, as a connection with climate change. Warmer temperatures in South Asia are likely to increase the frequency and severity of floods (Mirza, 2011).
ENSO is observed to also influence cholera in the coastal regions of Bangladesh, triggering spring outbreaks outside of typical patterns. From 1980 to 1998, cholera incidences were identified as attributable to ENSO. After the occurrence of floods, diarrheal diseases have been reported to emerge in high and low Gross Domestic Product (GDP) regions. Any other alterations in climate including temperature, humidity, rainfall, soil moisture and sea level rise can affect transmissions. These changes will only exacerbate ENSO effects (Mirza, 2011; Haines et al., 2006; Pascual et al., 2000; Githeko et al., 2000).
Githeko et al. (2000) makes reference to the WHO by affirming they state increased outbreaks of dengue fever in 1998 within Asian countries can be traced to El Nino events within the year. The dengue fever incubation period was reduced by 5 days through a 2-5 degree temperature increase above 30°C.
Do et al. (2014) and Haines et al. (2006) mention there’s a direct correlation between dengue fever epidemics and climate variability. For example in Hanoi, Vietnam dengue is prevalent during June and November during the highest rainfall and temperature period. Do et al. (2014) also points out the same can be shown when assessing outbreaks in Asia and South-East Asia, that higher temperatures, precipitation and humidity directly ties to dengue fever occurrences.
Githeko et al. (2000) suggests the expected global temperature rise in conjunction with climate changes will have the most impact on vector-borne diseases and their transmission, particularly within extreme ranges of temperature. Warmer temperatures are shown to affect the life cycles of mosquitos and vectors by shortening the processing times and biological capabilities, for example mosquito digestion and feeding behaviour. This only increases transmission possibilities.
Kovats et al. (2003) recognises climate variability to have some kind of influence on the distribution of malaria, but suggests climate change should not be referred to generally impact malaria transmission. Minor changes in climate and weather may affect malaria however the strength of public health defences is suggested to be a stronger factor of transmission. Kovats et al. (2003) demonstrated several examples of where ENSO has played a role in malaria transmission. For example in Punjab and Rajasthan rainfall is connected to ENSO, which increases malaria risk post ENSO fluctuations.
Githeko et al. (2000), Haines et al. (2006), and Huynen et al. (2013) suggest otherwise regarding the role climate change plays on vector-borne diseases such as malaria. Whilst Huynen et al. (2013) agrees climate change may have more of an indirect impact; they do not diminish its importance. Temperature, humidity and rainfall all influence the life cycle and potential of mosquitos carrying malaria. Huynen et al. (2013) mentions the combination of process-based biological models and climate change scenarios in other studies show global warming to be linked to malaria shifts in risks.
There is both disagreement and agreement within academic literature as to the influence of climate changes on malaria. This has mostly to do with models and assessments used as well as regional differentiation between studies. The Intergovernmental Panel for Climate (IPCC) (2007a) report highlights the variability of climate change effects on malaria by mentioning some regions may experience increased geographical scale of transmission and others, the opposite will be true. Any relationship climate change may have with vector-borne diseases is complicated by non-climate indicators, which interact and influence transmission as well (IPCC, 2007a).
Mortality toll of heat waves
The influence of anthropogenic effects on climate change has claimed over 150,000 lives annually over the last three decades (Patz, Campbell-Lendrum, Holloway ; Foley, 2005). The influence of climatic changes on human health range from fatalities due to heat waves to serious health concussions. Various studies conducted in medical science have found out that mortality due to high temperature is significantly high compared to non-accidental deaths (McMichael et al. 2008; Stafoggia et al. 2006). According to Luber and McGeehin (2008) heat waves kill more people in many cities around the world than any other weather-related fatalities.
The IPCC has forecasted an increase in hot weather that would also increase weather-related mortalities (IPCC 2007). Hajat, Kovats and Lachowycz (2007) state that people living in urban areas are more vulnerable to heat waves due to the higher density of population. Furthermore Smargiassi et al. (2009) assessed the combined effects of urban heat island effect, poor urban design and the interaction between air pollution and heat, which had an effect on the inhabitants in the urban areas. Those at high risk of being affected due to heat waves are the elderly who become more sensitive to climatic conditions (Semenza et al. (1996), and those with cardiovascular diseases and pre-existing medical conditions (Kovats ; Hajat, 2008).
Guest et al. (1999) states as an example, that the increased mortality rates in Australia have been associated with high temperatures. Tran, Uchihama, Ochi and Yasuoka (2006) also mentioned as an example, that urban heat island effect causes serious health impacts in some major cities of South-East Asia.
Shifts in patterns of disease distribution
Rising temperatures, increased precipitation and more extreme weather events in the South East Asia region due to climate change will create shifts in current patterns of health issues. Conditions for vector-based diseases reliant on mosquitoes for transmission and water-borne diseases will find changed conditions that allow for a greater spread.
In the literature examined, vector-based disease was identified as a key health issue where climate change, particularly rises in temperature, will likely lead to shifts in the areas where diseases like Malaria and Dengue fever occur (Harley et al., 2011; Hoberg ; Brooks, 2015; Kovats, Campbell-Lendrum, McMichel, Woodward, ; Cox, 2001; Wu, Lu, Zhou, Chen, ; Xu, 2016).
Malaria and Dengue fever are both spread via the mosquito vector (Aedes species). These species are directly affected by changes in temperature and available water for transmission. Aedes aegypti requires a temperature range of between 20°C-30°C (Ebi ; Nealon, 2016) while their eggs will freeze at below 10°C (Epstein, 2001). The virus pathogens also require specific temperatures for development and direct exposure to higher temperatures can kill them (Parham et al., 2015). The larvae of Aedes species require water to develop and can often remain dormant through dry conditions. Increased precipitation allows for better locations for distribution while droughts can conversely provide stagnant water which provides perfect breeding grounds for mosquito larvae (Altizer et al., 2006; Ebi ; Nealon, 2016; Wu et al., 2016).
Modelling shows that more of the world will be exposed to the prime conditions for these disease-vectors with climate change (Ebi ; Nealon, 2016). Evidence already exists to show that an increase in Dengue outbreaks in mountainous regions of Nepal and Bhutan has occurred due to the rise in temperature at higher altitudes providing favourable conditions for mosquito life cycles (Kumaresan, Narain, ; Sathiakumar, 2011). A mean latitude shift in mosquito presence has also been observed since the 1960s (Ebi ; Nealon, 2016). The high population in South-East Asia falls within this expanded range.
So it is reasonable to predict that changes in temperature and precipitation will lead to a shift in the locations that vector-based diseases occur. Kovats et al. (2001) questions whether causation can be declared as it other explanations can usually be found for changes in vector and disease distribution. Long term data series are rarely available to map changes in vector distribution and therefore it can be hard to conclude climate change as a factor. Economic growth can also play a part in countering the effect of the migration to new areas for these vectors. As better sewage is built or more environments are air-conditioned limiting exposure the impact of these disease may be mitigated (Ebi ; Nealon, 2016; Parham et al., 2015).
Extreme weather events and higher humidity from changes to the atmosphere are predicted with climate change. Shifts in locations of water-borne pathogens, such as Cholera outbreaks, will occur as existing infrastructure are put under pressure to deal with an increase in incidents. In both developed and developing countries outbreaks after extreme weather of water-borne diseases mostly occurs due to a contamination of existing sewage and water supply infrastructure. Storms and floods wash pathogens from animal manure and the environment into human water supplies causing diarrheal diseases. Droughts reduce the water available to dilute effluent-derived pathogens in river-systems (Cann, Thomas, Salmon, Wyn-Jones, ; Kay, 2013; Harley et al., 2011; Wu et al., 2016). Water scarcity may also lead to more diarrhea cases as scarcity leads to people using any available, possibly contaminated, water source (Wu et al., 2016).
Key organisations and their mitigation strategies
Economic development in the Asia Pacific region is becoming a big contributor to greenhouse gas emissions, which will affect the climate and can cause harmful effects to the area. Now all the attention of governments is to reduce greenhouse gas emissions and to control the instability of climate. Policies and strategies are being made for mitigation of climate change in the area of biofuels, forestry, water, waste, and market structures (Christensen et al. 2007; Vickers et al. 2010).
Organizations such as the Food and Agriculture Organization (FAO), The Intergovernmental Panel on Climate Change (IPCC), The United Nations Framework Convention on Climate Change (UNFCCC), and other Nations and Research Institutions are contributing to the environment by developing impactful, straightforward adaptation and mitigation strategies. These are organizations working on climate change aspects on a global basis. One important strategy is reducing emissions from deforestation and forest degradation, and enhancing forest carbon stocks in developing countries (REDD+), which is developed by the UNFCCC. The major purpose of this strategy is to provide incentives to forest owners for reducing emissions and increase forest area (Angelsen, 2009).
In the Asia Pacific funding bodies, such as the Collaborative Adaptation Research Initiative in Africa and Asia (CARIAA) and Future Climate For Africa (FCFA), are developing research programmes for climate adaptation. The funding bodies include UK Department for International Development (DFID) and International Development Research Centre of Canada (IDRC) (Lang et al. 2012; Mustelin et al. 2013).
In the Seventieth Session of the WHO Regional Committee for South-East Asia, on 7 September 2017, the Ministerial Roundtable organized “Building Health Systems Resilience to Climate Change” in Male, Maldives. This was all about the adoption of health and safety measures and mitigation strategies for climate change risks in the near future by different countries, as climate change has a negative effect on the livelihoods of people. Highly influential changes like fluctuation of temperature, precipitation and imbalance of gases in the atmosphere can lead towards the evolution of new diseases from harmful organisms surviving in extreme weather conditions (World Health Organisation, 2017).
There are some strategies discussed to minimize the effect of climate change (World Health Organisation, 2017):
To cooperate with other countries and collaborate for funding in the sector of climate change.
All the policies could be discussed or shared with other ministries. Some countries have agreed on Paris agreement.
There should be a proper health workforce who has proper knowledge and information of health and climate risks with useful resources.
Understanding of health risks from climate variability on the most vulnerable groups of a country and there protection policies with probable outcomes.
A prediction of upcoming hazards from climate by use of surveillance tools and preparing for them.
To start public health programmes for identification and management of environmental components like air and water quality, water availability, housing and waste systems, and reinforce the health system.
To develop a programme for identifying and monitoring the budget for all processes.
In the literature examined we found that increasing temperature, humidity and rainfall would increase the impacts of health issues across South East Asia and South Asia. Dengue and cholera were both shown to have specific seasonality for when they are more prevalent. The impacts felt during these periods has been shown to be affected by the predicted increases in temperature and humidity. ENSO and other extreme weather patterns provide conditions for cholera and malaria to thrive and changes to these existing patterns can deliver large impacts in the region. Heat mortality, heat waves and the urban heat island effect have all been shown to increase with temperature rise from climate change. The conditions for vector-borne diseases transmission, such as dengue and malaria through mosquitoes, will become more favourable across the highlands and coastal regions of SEAR/SAR leading to more cases unless managed by health organisations. Currently organisations are involved in adaptation and mitigation actions focussing on reducing the triggers of climate change and providing strategies for dealing with health impacts on the ground.
In conclusion, we found that the literature shows a relationship between temperature increases in South East Asia and South Asia and predicted health impacts. Organisations in the region are developing strategies to adapt and mitigate future health impacts.
Summary of Findings
Elements and Drivers (Climate and Other)
Mitigation and Adaptation Strategies
Future Uncertainty and Uncontrollability
Bangladesh and India
Global issue, not as severe as in past
Monsoonal seasons (April-May and Sept-Jan)
Temp (direct and indirect), salinity, nutrient density, rainfall distribution
Floods and droughts
Ocean surface temp rise
Mortality in children especially
Quick dehydration symptoms
Sanitation of environment improved
Water quality and availability improved
Health standards upgraded with food and drink contamination
Fast and adequate treatment
Extreme weather events
Climate change and global warming
Effects of ENSO
Changes in seasonal patterns and regional location of endemics
Changes in transmission
Changes in vector life cycles
Mitigated through further research, medical assistance, assistance from developed countries, finance
Mitigated through advancement in modelling technology, data collection and projections
Clean Development Mechanisms
Temps too high can kill vectors
Optimal vector range 20-30
June-No seasonality (when depends on region)
Humidity and Precipitation
Droughts and stagnant water, increased breeding
Rainfall increase distribution
Temp rise increases incubation
50-100 million annually affected
WHO ranking high importance
Improvements in infrastructure
Injections and treatment more widely available and financed
Overall standard of sanitation and cleanliness of environment and cities improved
Protection from the elements: Housing structures improved
Protection from insects: repellents
Increased funding for mitigation
Primarily in India
Public health defence ability stronger driver
Temperature, humidity and rainfall
ENSO indirect effect
Urban heat island effect
UN to eliminate by 2030
30% global incidence in South/South-East Asia
Elderly, young, those with pre-existing medical conditions easy targets
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