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Executive Summary

Health and climate have been linked since antiquity. In the fifth century B.C., Hippocrates observed that epidemics were associated with natural phenomena rather than deities or demons. In modern times, our increasing capabilities to detect and predict climate variations such as the El Niño/Southern Oscillation (ENSO) cycle, coupled with mounting evidence for global climate change, have fueled a growing interest in understanding the impacts of climate on human health, particularly the emergence and transmission of infectious disease agents.

Simple logic suggests that climate can affect infectious disease patterns because disease agents (viruses, bacteria, and other parasites) and their vectors (such as insects or rodents) are clearly sensitive to temperature, moisture, and other ambient environmental conditions. The best evidence for this sensitivity is the characteristic geographic distribution and seasonal variation of many infectious diseases. Weather and climate affect different diseases in different ways. For example, mosquito-borne diseases such as dengue, malaria, and yellow fever are associated with warm weather; influenza becomes epidemic primarily during cool weather; meningitis is associated with dry environments; and cryptosporidiosis outbreaks are associated with heavy rainfall. Other diseases, particularly those transmitted by direct interpersonal contact such as HIV/AIDS, show no clear relationship to climate. By carefully studying these associations and their underlying mechanisms, we hope to gain insights into the factors that drive the emergence and seasonal/interannual variations in contemporary epidemic diseases and, possibly, to understand the potential future disease impacts of long-term climate change.

The U.S. federal agencies entrusted with guarding the nation's health and the environment, along with other concerned institutions, requested the forma-



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Page 1 Executive Summary Health and climate have been linked since antiquity. In the fifth century B.C., Hippocrates observed that epidemics were associated with natural phenomena rather than deities or demons. In modern times, our increasing capabilities to detect and predict climate variations such as the El Niño/Southern Oscillation (ENSO) cycle, coupled with mounting evidence for global climate change, have fueled a growing interest in understanding the impacts of climate on human health, particularly the emergence and transmission of infectious disease agents. Simple logic suggests that climate can affect infectious disease patterns because disease agents (viruses, bacteria, and other parasites) and their vectors (such as insects or rodents) are clearly sensitive to temperature, moisture, and other ambient environmental conditions. The best evidence for this sensitivity is the characteristic geographic distribution and seasonal variation of many infectious diseases. Weather and climate affect different diseases in different ways. For example, mosquito-borne diseases such as dengue, malaria, and yellow fever are associated with warm weather; influenza becomes epidemic primarily during cool weather; meningitis is associated with dry environments; and cryptosporidiosis outbreaks are associated with heavy rainfall. Other diseases, particularly those transmitted by direct interpersonal contact such as HIV/AIDS, show no clear relationship to climate. By carefully studying these associations and their underlying mechanisms, we hope to gain insights into the factors that drive the emergence and seasonal/interannual variations in contemporary epidemic diseases and, possibly, to understand the potential future disease impacts of long-term climate change. The U.S. federal agencies entrusted with guarding the nation's health and the environment, along with other concerned institutions, requested the forma-

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Page 2 tion of a National Research Council committee to evaluate this issue. Specifically, the committee was asked to undertake the following three tasks: 1. Conduct an in-depth, critical review of the linkages between temporal and spatial variations of climate and the transmission of infectious disease agents; 2. Examine the potential for establishing useful health-oriented climate early-warning and surveillance systems, and for developing effective societal responses to any such early warnings; 3. Identify future research activities that could further clarify and quantify possible connections between climate variability, ecosystems, and the transmission of infectious disease agents, and their consequences for human health. There are many substantial research challenges associated with studying linkages among climate, ecosystems, and infectious diseases. For instance, climate-related impacts must be understood in the context of numerous other forces that drive infectious disease dynamics, such as rapid evolution of drug- and pesticide-resistant pathogens, swift global dissemination of microbes and vectors through expanding transportation networks, and deterioration of public health programs in some regions. Also, the ecology and transmission dynamics of different infectious diseases vary widely from one context to the next, thus making it difficult to draw general conclusions or compare results from individual studies. Finally, the highly interdisciplinary nature of this issue necessitates sustained collaboration among disciplines that normally share few underlying scientific principles and research methods, and among scientists that may have little understanding of the capabilities and limitations of each other's fields. In light of these challenges, the scientific community is only beginning to develop the solid scientific base needed to answer many important questions, and accordingly, in this report the committee did not attempt to make specific predictions about the likelihood or magnitude of future disease threats. Instead, the focus is on elucidating the current state of our understanding and the factors that, at present, may limit the feasibility of predictive models and effective early warning systems. The following is a summary of the committee's key findings and recommendations: KEY FINDINGS: LINKAGES BETWEEN CLIMATE AND INFECTIOUS DISEASES Weather fluctuations and seasonal-to-interannual climate variability influence many infectious diseases. The characteristic geographic distributions and seasonal variations of many infectious diseases are prima facie evidence of linkages with weather and climate. Studies have shown that factors such as temperature, precipitation, and humidity affect the lifecycle of many disease pathogens and vectors (both directly, and indirectly through ecological changes) and thus

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Page 3 can potentially affect the timing and intensity of disease outbreaks. However, disease incidence is also affected by factors such as sanitation and public health services, population density and demographics, land use changes, and travel patterns. The importance of climate relative to these other variables must be evaluated in the context of each situation. Observational and modeling studies must be interpreted cautiously. There have been numerous studies showing an association between climatic variations and disease incidence, but such studies are not able to fully account for the complex web of causation that underlies disease dynamics and thus may not be reliable indicators of future changes. Likewise, a variety of models have been developed to simulate the effects of climatic changes on incidence of diseases such as malaria, dengue, and cholera. These models are useful heuristic tools for testing hypotheses and carrying out sensitivity analyses, but they are not necessarily intended to serve as predictive tools, and often do not include processes such as physical/biological feedbacks and human adaptation. Caution must be exercised then in using these models to create scenarios of future disease incidence, and to provide a basis for early warnings and policy decisions. The potential disease impacts of global climate change remain highly uncertain. Changes in regional climate patterns caused by long-term global warming could affect the potential geographic range of many infectious diseases. However, if the climate of some regions becomes more suitable for transmission of disease agents, human behavioral adaptations and public health interventions could serve to mitigate many adverse impacts. Basic public health protections such as adequate housing and sanitation, as well as new vaccines and drugs, may limit the future distribution and impact of some infectious diseases, regardless of climate-associated changes. These protections, however, depend upon maintaining strong public health programs and assuring vaccine and drug access in the poorer countries of the world. Climate change may affect the evolution and emergence of infectious diseases. Another important but highly uncertain risk of climate change are the potential impacts on the evolution and emergence of infectious disease agents. Ecosystem instabilities brought about by climate change and concurrent stresses such as land use changes, species dislocation, and increasing global travel could potentially influence the genetics of pathogenic microbes through mutation and horizontal gene transfer, and could give rise to new interactions among hosts and disease agents. Such changes may foster the emergence of new infectious disease threats. There are potential pitfalls in extrapolating climate and disease relationships from one spatial/temporal scale to another. The relationships between

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Page 4 climate and infectious disease are often highly dependent upon local-scale parameters, and it is not always possible to extrapolate these relationships meaningfully to broader spatial scales. Likewise, disease impacts of seasonal to interannual climate variability may not always provide a useful analog for the impacts of long-term climate change. Ecological responses on the timescale of an El Niño event, for example, may be significantly different from the ecological responses and social adaptations expected under long-term climate change. Also, long-term climate change may influence regional climate variability patterns, hence limiting the predictive power of current observations. Recent technological advances will aid efforts to improve modeling of infectious disease epidemiology. Rapid advances being made in several disparate scientific disciplines may spawn radically new techniques for modeling of infectious disease epidemiology. These include advances in sequencing of microbial genes, satellite-based remote sensing of ecological conditions, the development of Geographic Information System (GIS) analytical techniques, and increases in inexpensive computational power. Such technologies will make it possible to analyze the evolution and distribution of microbes and their relationship to different ecological niches, and may dramatically improve our abilities to quantify the disease impacts of climatic and ecological changes. KEY FINDINGS: THE POTENTIAL FOR DISEASE EARLY WARNING SYSTEMS As our understanding of climate/disease linkages is strengthened, epidemic control strategies should aim towards complementing “surveillance and response” with “prediction and prevention.” Current strategies for controlling infectious disease epidemics depend largely on surveillance for new outbreaks followed by a rapid response to control the epidemic. In some contexts, however, climate forecasts and environmental observations could potentially be used to identify areas at high risk for disease outbreaks and thus aid efforts to limit the extent of epidemics or even prevent them from occurring. Operational disease early warning systems are not yet generally feasible, due to our limited understanding of most climate/disease relationships and limited climate forecasting capabilities. But establishing this goal will help foster the needed analytical, observational, and computational developments. The potential effectiveness of disease early warning systems will depend upon the context in which they are used. In cases where there are relatively simple, low-cost strategies available for mitigating risk of epidemics, it may be feasible to establish early warning systems based only on a general understanding of climate/disease associations. But in cases where the costs of mitigation actions are significant, a precise and accurate prediction may be necessary, re-

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Page 5 quiring a more thorough mechanistic understanding of underlying climate/disease relationships. Also, the accuracy and value of climate forecasts will vary significantly depending on the disease agent and the locale. For instance, it will be possible to issue sufficiently reliable ENSO-related disease warnings only in regions where there are clear, consistent ENSO-related climate anomalies. Finally, investment in sophisticated warning systems will be an effective use of resources only if a country has the capacity to take meaningful actions in response to such warnings, and if the population is significantly vulnerable to the hazards being forecast. Disease early warning systems cannot be based on climate forecasts alone. Climate forecasts must be complemented by an appropriate suite of indicators from ongoing meteorological, ecological, and epidemiological surveillance systems. Together, this information could be used to issue a “watch” for regions at risk and subsequent “warnings” as surveillance data confirm earlier projections. Development of disease early warning systems should also include vulnerability and risk analysis, feasible response plans, and strategies for effective public communication. Climate-based early warning systems being developed for other applications, such as agricultural planning and famine prevention, provide many useful lessons for the development of disease early warning systems. Development of early warning systems should involve active participation of the system's end users. The input of stakeholders such as public health officials and local policymakers is needed in the development of disease early warning systems, to help ensure that forecast information is provided in a useful manner and that effective response measures are developed. The probabilistic nature of climate forecasts must be clearly explained to the communities using these forecasts, so that response plans can be developed with realistic expectations for the range of possible outcomes. RECOMMENDATIONS FOR FUTURE RESEARCH AND SURVEILLANCE Research on the linkages between climate and infectious diseases must be strengthened. In most cases, these linkages are poorly understood and research to understand the causal relationships is in its infancy. Methodologically rigorous studies and analyses will likely improve our nascent understanding of these linkages and provide a stronger scientific foundation for predicting future changes. This can best be accomplished with investigations that utilize a variety of analytical methods (including analysis of observational data, experimental manipulation studies, and computational modeling), and that examine the consistency of climate/disease relationships in different societal contexts and across a variety of temporal and spatial scales. Progress in defining climate and infec-

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Page 6 tious disease linkages can be greatly aided by focused efforts to apply recent technological advances such as remote sensing of ecological changes, high-speed computational modeling, and molecular techniques to track the geographic distribution and transport of specific pathogens. Further development of disease transmission models is needed to assess the risks posed by climatic and ecological changes. The most appropriate modeling tools for studying climate/disease linkages depend upon the scientific information available. In cases where there is limited understanding of the ecology and transmission biology of a particular disease, but sufficient historical data on disease incidence and related factors, statistical-empirical models may be most useful. In cases where there are insufficient surveillance data, “first principle” mechanistic models that can integrate existing knowledge about climate/disease linkages may have the most heuristic value. Models that have useful predictive value will likely need to incorporate elements of both these approaches. Integrated assessment models can be especially useful for studying the relationships among the multiple variables that contribute to disease outbreaks, for looking at long-term trends, and for identifying gaps in our understanding. Epidemiological surveillance programs should be strengthened. The lack of high-quality epidemiological data for most diseases is a serious obstacle to improving our understanding of climate and disease linkages. These data are necessary to establish an empirical basis for assessing climate influences, for establishing a baseline against which one can detect anomalous changes, and for developing and validating models. A concerted effort, in the United States and internationally, should be made to collect long-term, spatially resolved disease surveillance data, along with the appropriate suite of meteorological and ecological observations. Centralized, electronic databases should be developed to facilitate rapid, standardized reporting and sharing of epidemiological data among researchers. Observational, experimental, and modeling activities are all highly interdependent and must progress in a coordinated fashion. Experimental and observational studies provide data necessary for the development and testing of models; and in turn, models can provide guidance on what types of data are most needed to further our understanding. The committee encourages the establishment of research centers dedicated to fostering meaningful interaction among the scientists involved in these different research activities through long-term collaborative studies, short-term information-sharing projects, and interdisciplinary training programs. The National Center for Ecological Analysis and Synthesis provides a good model for the type of institution that would be most useful in this context.

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Page 7 Research on climate and infectious disease linkages inherently requires interdisciplinary collaboration. Studies that consider the disease host, the disease agent, the environment, and society as an interactive system will require more interdisciplinary collaboration among climate modelers, meteorologists, ecologists, social scientists, and a wide array of medical and public health professionals. Encouraging such efforts requires strengthening the infrastructure within universities and funding agencies for supporting interdisciplinary research and scientific training. In addition, educational programs in the medical and public health fields need to include interdisciplinary programs that explore the environmental and socioeconomic factors underlying the incidence of infectious diseases. Numerous U.S. federal agencies have important roles to play in furthering our understanding of the linkages among climate, ecosystems, and infectious disease. There have been a few programs established in recent years to foster interdisciplinary work in applying remote-sensing and GIS technologies to epidemiological investigations. The committee applauds these efforts and encourages all of the relevant federal agencies to support interdisciplinary research programs on climate and infectious disease, along with an interagency working group to help ensure effective coordination among these different programs. The U.S. Global Change Research Program (USGCRP) may provide an appropriate forum for this type of coordinating body. This will require, however, that organizations such as the Centers for Disease Control and Prevention, and the National Institute of Allergy and Infectious Diseases become actively involved with the USGCRP. Finally, the committee wishes to emphasize that even if we are able to develop a strong understanding of the linkages among climate, ecosystems, and infectious diseases, and in turn, are able to create effective disease early warning systems, there will always be some element of unpredictability in climate variations and infectious disease outbreaks. Therefore, a prudent strategy is to set a high priority on reducing people's overall vulnerability to infectious disease through strong public health measures such as vector control efforts, water treatment systems, and vaccination programs.