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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary 2 Climate, Ecology, and Infectious Disease OVERVIEW As depicted in the convergence model of infectious disease emergence, illustrated in Figure SA-4, climate interacts with, and can alter, the complex ecological relationships underlying infectious disease transmission patterns. This chapter examines such interactions from several perspectives: Their consequences throughout the aquatic-marine food web, which defines ecological relationships for water-dwelling animals In patterns of distribution and transmission dynamics of individual infectious diseases (cholera, Rift Valley fever, chikungunya, and plague) Their effects on the dynamics of plant diseases, and their effects on agriculture and natural ecosystems As manifested in the public health challenges posed by climate change to human populations in the Arctic Research on the effects of climate variation on infectious disease incidence and geographic range in these diverse contexts is providing the basis for developing climate-based early warning systems for disease risk. Such studies also represent a necessary first step toward anticipating how climate change may alter infectious disease dynamics in various ecological frameworks. In her workshop presentation, Leslie Dierauf, director of the U.S. Geological Survey’s National Wildlife Health Center in Madison, Wisconsin, described the apparent and predicted effects of climate on a broad cross-section of animal species that inhabit fresh- and saltwater ecosystems, as well as the intertidal
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary zones that unite aquatic and marine environments. Ecological connections among these environments are illustrated in Figure SA-8, which depicts the marine food web. Dierauf also emphasized the physical connectedness of aquatic and marine environments, which makes it possible for infectious diseases of fish and wildlife to move from freshwater sources to intertidal zones to marine environments, affecting species that may not have encountered these disease agents before. Salmon, for example, hatch in small freshwater streams, travel hundreds of kilometers downstream to the ocean where they live for several years, only to return to the same streams where they hatched to spawn and die shortly thereafter. Thus, she observed, “if the temperature of the streams changes or the fish themselves pick up novel disease agents, because a vector, or an intermediate host, or a disease agent thrives in the new warmer environment, infectious disease may result.” Evidence-based studies of the effects of climate change on the health of aquatic and marine wildlife are few, Dierauf reported; therefore, current understanding of this topic derives from such sources as historical comparisons (of climatic conditions and of animal health and behaviors), long-term ecological research, correlation studies, and recognition of the physical, chemical, and biological processes governing climate change. Following the flow of water from inland streams to estuaries and into the open ocean, Dierauf considered the possible impacts of climate change in each of the three main elements of the aquatic continuum and how these changes may affect the health of their animal inhabitants. In freshwater ecosystems, extreme weather events that produce flooding can trigger overwhelming influxes of nutrients into ecosystems. Storms can cause a range of environmental disturbances; Dierauf described the release of Nile tilapia into Mississippi streams from aquaculture facilities damaged by Hurricane Katrina. Several emerging diseases of inland aquatic animals, described and depicted in Box SA-2 in the Summary and Assessment, may also be influenced by climate change. Intertidal areas, such as salt marshes and estuaries, are essential for maintaining a delicate balance among many complex and interactive variables (such as temperature, light, salinity, wave action, sea level rise, erosion, and sediment deposition) that characterize the transition from freshwater to saltwater environments, Dierauf explained. Storms, such as hurricanes, greatly affect intertidal zones. Heavy inland rainfall increases the speed and volume of the run-off that reaches estuaries, while marine storms drive saltwater and its contents past the intertidal buffer, affecting inland ecosystem health. Climate change is expected to produce a range of important effects on oceans (as well as on large, deep-water lakes such as the Great Lakes), according to Dierauf. These include increased wave intensity, increased nutrient turnover, changes in nutrients, and changes in the food web. In addition, she noted, higher
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary concentrations of atmospheric carbon dioxide are dramatically increasing the acidity of ocean waters, which in turn is weakening the carbonate shells and skeletons of many marine species that comprise coral reef systems. She also noted the effects of harmful algal blooms (HABs), which are thought to result from nutrient influxes to the ocean (see Summary and Assessment). HABs appear to be increasing in both frequency and size as the climate warms, she said; this could result from increased upwelling of nutrients within the ocean or changes in ocean currents, as well as from the effects of extreme weather events inland. “What we do know is that HABs are affecting and often killing living things in the food web, like zooplankton, shellfish, fish, birds, and marine mammals, like manatees,” she said. Ocean warming, which is reducing the availability of food and sea ice for marine mammals, may also be compromising their resistance to infectious disease, Dierauf said. “Already, climate change and thinning of sea ice has reduced the time mother polar bears have to build the fat stores they need to sustain themselves over winter and to feed their young come spring when they emerge from their dens,” she noted. Faced with shortages of food in their native waters, some marine mammals move to new territories where they both encounter and introduce novel disease agents (see Summary and Assessment). “Climate change and climate variability will affect aquatic and marine species worldwide,” Dierauf concluded. “We must act now at personal, professional, local, and global levels to protect vulnerable ecosystems and the aquatic and marine species that depend on these habitats for survival.” In contrast to the broad perspective on the effect of climate change on aquatic ecosystems offered by Dierauf, this chapter’s first paper, by Rita Colwell of the University of Maryland, focuses on the specific and well-characterized effects of climate on cholera, a water-borne disease that affects an estimated 100,000 people per year, resulting in 10,000 deaths. The incidence and distribution of cholera are controlled by water temperature, precipitation patterns, and water salinity—all of which are influenced by global climate—and conducted through a complex web of ecological relationships. Sanitation and infrastructure also play a role in the incidence and distribution of cholera. Colwell noted, however, that “by simply educating women to filter drinking water through several layers of ‘sari cloth,’ we were able to reduce cholera incidence by 50 percent.” Colwell described how, over the course of decades, she and coworkers deduced the circumstances under which the causal agent of cholera, the bacterium Vibrio cholerae, is transmitted to humans by the plankton species with which the bacterium associates. This knowledge led to the development of remote sensing systems capable of predicting the onset of cholera epidemics in the Ganges delta, known as the “home of cholera,” because of its long history of epidemic disease. This chapter’s second paper also describes the use of remote sensing to monitor the effects of climate variation on specific infectious diseases. Speaker Jean-Paul Chretien, of the Department of Defense Global Emerging Infections
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary Surveillance and Response System (DOD-GEIS), and coauthors describe the use of satellite and epidemiological data to examine connections between the El Niño/Southern Oscillation (ENSO) and recent epidemics of two mosquito-borne viral diseases: Rift Valley fever (RVF) and chikungunya fever. In the first case, the association of RVF outbreaks in East Africa with periods of heavy rainfall, which occur during the El Niño phase of ENSO, led researchers to develop a model to forecast RVF risk in that region based on vegetation density (a marker for rainfall), as measured by satellite (Linthicum et al., 1999). The authors describe the operation of this model in the El Niño season of 2006-2007, when its prediction of elevated risk of disease prompted intensified surveillance for RVF in Kenya and, ultimately, to an international effort to stem a pending epidemic. Chikungunya fever caused a series of outbreaks along the Kenyan coast in 2004, from which it apparently spread to several western Indian Ocean islands and India, resulting in the largest chikungunya fever epidemic on record (Chretien et al., 2007). At the time of the initial outbreaks in Kenya, a regional drought—corresponding to the La Niña phase of ENSO—had gripped the region. Chretien and coauthors discuss several possible, nonexclusive mechanisms connecting the epidemic with the drought, some of which may have also have influenced the first appearance of chikungunya fever in Europe in 2007. In the chapter’s third paper, speaker Nils Stenseth of the University of Oslo provides a much longer view of climate variation and its effects on infectious disease dynamics. Throughout recorded history, the various forms of plague, caused by the bacterium Yersinia pestis and transmitted by fleas among a wide range of hosts, are known to have caused both endemic and epidemic disease. Stenseth examines the dynamic ecology and epidemiology of plague in its ancient reservoir in Central Asia, and compares these patterns with local climate variation over the course of decades (as recorded in regular measurements of temperature and rainfall) and centuries (as reflected in tree-ring data for the past 1,000 years). Using data collected twice annually between 1949 and 1995 in Kazakhstan, a focal region for plague where human cases are regularly reported, Stenseth and colleagues determined that Y. pestis prevalence increases dramatically in its primary host, the great gerbil (Rhombomys opimus), during warmer springs and wetter summers (Stenseth et al., 2006). Rodent populations also tend to increase under these conditions and, along with them, the possibility that plague will be transmitted to humans. Analyses of historical climate variation, as reflected in tree-ring patterns, suggest that similar warm, wet conditions existed in Central Asia during the onset of the Black Death in the fourteenth century, as well as in the years preceding a mid-nineteenth-century plague pandemic. As Earth’s climate warms, warmer springs and wetter summers are expected to become more common in Central Asia (as well as in North America) therefore raising the possibility that plague activity—and therefore the potential for epidemic disease—will increase. “Although the number of human cases of plague is relatively low, it would
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary be a mistake to overlook its threat to humanity, because of the disease’s inherent communicability, rapid spread, rapid clinical course, and high mortality if left untreated,” Stenseth notes. Moreover, he adds, even a minor plague outbreak can result in panic, with severe economic repercussions; a 1994 plague outbreak in India that caused 50 deaths also led to a nationwide collapse in tourism and trade, costing the nation an estimated $600 million (Fritz et al., 1996). “Plague remains a fairly poorly understood threat that we cannot afford to ignore,” Stenseth concludes. “Only by knowing more about how the eco-epidemiological plague systems in the different parts of the world will respond to given climate scenarios can we take the necessary precautionary measures to reduce the risks of human infections.” While climate-based early warning systems for human disease are in an early stage of development, plant disease forecasting systems based on variables such as temperature and precipitation have been used for many years, according to speaker Karen Garrett of Kansas State University. However, she adds, these well-established models will need to be adapted (based on sound science) to account for climate change, as will plant disease management policies that flow from climate-based forecasts. In her contribution to this chapter, Garrett establishes a framework for this critical effort. She describes standard methods for managing plant disease, reviews observed effects of climate variation on plant diseases and their implications given projected future climatic conditions, and discusses research and policy needs for plant disease management in response to climate change. In considering the consequences of climate change for plant health, Garrett emphasizes threshold effects: environmental perturbations that produce disproportionate ecological upheaval. Examples of such thresholds include longer growing seasons; pathogen introductions and range shifts; pathogen overwintering; and the removal of constraints on pathogen reproduction at a critical population size. Much as it has been argued that the most effective available protective measures against the adverse human health effects of climate change are basic public health interventions (see Campbell-Lendrum in Chapter 4), Garrett observes that “the good news for formulation of strategies for plant disease management under changing climate conditions is that much of what needs to be done is the same with or without climate change.” Thus, she advocates research to advance our understanding of plants’ adaptive capacities and mechanisms, and policies to encourage the development of “diverse, flexible, and resilient agricultural systems that can adapt more readily to new climatic conditions.” The chapter’s final paper, by Alan Parkinson of the Centers for Disease Control and Prevention’s (CDC’s) Arctic Investigations Program in Anchorage, Alaska, presents a panoramic view of the public health challenges faced by people living in the Arctic, where the physical effects of climate change are dramatically apparent. Temperatures in this region have increased at nearly twice the global average over the past century, causing widespread melting of land and
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary sea ice (see Figure SA-13; Borgerson, 2008; IPCC, 2007). These conditions are exposing the Arctic’s human inhabitants, many of whom have limited access to public health and/or sanitation services, to an increasingly broad range of infectious disease threats (among other health challenges). Parkinson describes the observed and projected effects of climate change in the Arctic environment, discusses the direct effects of higher ambient temperatures on the health of Arctic inhabitants, and catalogs the many ways in which climate change may increase the risk of infectious disease for Arctic residents. Indeed, Parkinson observes, infectious disease risks are already increasing in the Arctic through the indirect influence of climate change on the populations and ranges of disease vector species (e.g., mosquitoes, ticks) and the population density and range of reservoir hosts that can transmit disease (e.g., rodents, foxes). Flooding and the loss of permafrost are also damaging the sanitation infrastructure of Arctic communities, thereby increasing the risk of water-borne infectious diseases, respiratory diseases, and skin infections. Meanwhile, increasing mean ambient temperatures raise the risk of food-borne diseases, particularly for Arctic residents who rely on traditional methods of subsistence and food preservation (e.g., fermentation, air-drying, burying). In the face of these public health challenges, Parkinson recommends a range of public health responses, including monitoring of high-risk, climate-sensitive infectious diseases with potentially large public health impacts (e.g., water-borne diseases such as giardiasis), prompt investigation of infectious disease outbreaks that may be related to climate change, and research on the relationship between climate and infectious disease emergence to guide early detection and public health interventions. He also encourages the creation of infectious disease monitoring networks to connect typically small, isolated Arctic communities and link them to regional, national, and international health organizations. Such networks would encourage the standardization of monitoring methods, the sharing of data, and the detection of infectious disease trends over a larger geographic area. THE MARINE ENVIRONMENT AND HUMAN HEALTH: THE CHOLERA MODEL Rita Colwell, Ph.D.1 University of Maryland Cholera, a disease I have studied for more than 30 years, is a model of the complex interactions between climate, ecology, environment, and weather related to epidemics of infectious diseases. Revealing cholera’s secrets has required inter- 1 Chairman, Canon U.S. Life Sciences, Inc., and Distinguished University Professor at both the University of Maryland at College Park and at the Johns Hopkins University Bloomberg School of Public Health.
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary disciplinary research examining all of these influences, as well as a point of view that I call biocomplexity: recognizing that infectious diseases operate on a wide range of time and space scales. Thus, we employ gene probes, environmental measurements (ground truth), and other precise techniques for pathogen detection, but at the same time, we take a holistic approach that integrates information from the atomic to the atmospheric—and perhaps, in some cases, even the cosmic—in order to build a predictive model for cholera outbreaks. Cholera is a significant, global public health problem, as shown in Table 2-1. Annually, it results in approximately 100,000 hospitalizations and approximately 10,000 deaths, varying from year to year. A few cases of cholera appear each year in the United States, usually associated with seafood harvested from closed beds near sewage outfalls in the Gulf of Mexico. Most of my group’s research on cholera has focused on the Ganges delta, which feeds into the Bay of Bengal. This area is known as the home of cholera due to spring and fall epidemics, of varying but predictable intensity, that have recurred there for hundreds of years (see Figure 2-1). During the monsoon season, flooding rains wash nutrients down from the Himalayas, while winds drive water from the Bay of Bengal up into the Ganges and its tributaries, creating ideal conditions (discussed later) for cholera outbreaks. The fall 2007 epidemic, which followed massive flooding, was catastrophic. The Center for Diarrheal Disease TABLE 2-1 Cholera Cases Officially Reported to WHO, 2004—Selected Countries Country Number of Cases Imported Deaths Mortality Rate (%) Benin 642 9 1.40 Burundi 819 14 1.71 Cameroon 8,005 137 1.71 Comoros 1 0 0.00 Côte d’Ivoire 105 9 8.57 DROC (Congo) 7,665 228 2.97 Niger 2,178 57 2.62 Nigeria 3,186 185 5.81 Somalia 4,490 26 0.58 Uganda 3,380 91 2.69 Tanzania 10,319 272 2.64 Zambia 12,149 373 3.07 Zimbabwe 119 9 7.56 India 4,695 7 0.15 Japan 66 55 0 0.00 Singapore 11 1 1 9.09 Total 57,830 56 1,418 2.45 SOURCE: WHO (2005).
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary FIGURE 2-1 Bangladesh border, barrier islands, and location of Dacca, Matlab, Mathbaria, and Bakerganj. SOURCE: Printed with permission from Google. Research in Dacca admitted about a thousand new cases per day for almost 30 days and had to use temporary space to house cholera victims. We are working to create predictive models to provide advance warning of conditions that produce severe epidemics in this region of the world. However, V. cholerae, the bacterium, is a natural inhabitant of rivers, estuaries, and coastal waters throughout the world. Currently, we are sequencing approximately 50 different strains of Vibrio cholerae, the causative agent of cholera collected from many geographic locations to examine their genetic relationships. Preliminary sequencing studies of V. cholerae collected at a depth of 2,000 m at a site located off the coast of Oregon indicate that those isolates may represent ancestral strains; interestingly, one strain studied in detail has genes in common with other Vibrio pathogens, as well, including Vibrio vulnificus and Vibrio parahaemolyticus, the latter being the most common food-borne pathogen in Asian countries, where raw seafood is consumed.
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary The Ecology of Cholera My laboratory accomplished the first isolation of Vibrio cholerae from the Chesapeake Bay more than two decades ago, and we now know that this bacterium is found in estuaries of similar salinity, (ca. 15 parts per thousand), where the water temperature rises seasonally to 15°C or higher and where an influx of nutrients encourages plankton blooms (Colwell, 1996). Other species of Vibrio, including V. parahaemolyticus and V. vulnificus, also thrive under these conditions. One of my current graduate students, Brad Haley, has just returned from Iceland, where he was able to isolate V. cholerae at locations where geothermal effluent flows into bays. Clearly, water temperature is critical to the growth of this pathogen. Vibrio cholerae also has a dormant state, which it assumes between epidemics and during which it cannot be cultured but can be detected with probes (fluorescent antibodies and gene signature sequences). Only during the peak of the zooplankton bloom, in the spring and the fall, is V. cholerae easily culturable. We were able to show that by adding nalidixic acid and nutrient (yeast extract) to water containing the quiescent bacterium, we can stimulate cell elongation and metabolism. Another important discovery was that cholera is transmitted by plankton. Thus, it is not enough to say that its growth correlates with sea surface temperature and salinity; it is important to recognize the ecological interactions that produce these correlations. There is a commensal relationship—which may prove to be symbiosis—between Vibrio bacteria and zooplankton. Vibrios are chitinolytic (i.e., capable of breaking down chitin, the material that forms the carapaces of zooplankton and crustaceans (e.g., crabs, shrimp). V. cholerae also produces a powerful proteolytic enzyme that the bacterium apparently uses to perform an additional function for zooplankton: breaking down its egg sac, enabling the eggs to disperse into the water column. We are discovering that interactions between V. cholerae and various zooplankton species are quite intricate; for example, certain strains of the bacterium attach preferentially to certain species of zooplankton (Rawlings et al., 2007). All of this leads to the conclusion that V. cholerae is integral to marine ecosystems, and therefore cannot be eradicated. The Epidemiology of Cholera We have determined in earlier studies that between 10,000 and 50,000 Vibrio cholerae bacteria may be attached to an individual copepod (the zooplankton favored by V. cholerae). A liter of water drawn by a villager from a pond in Bangladesh between epidemics may contain 10 copepods. However, during a zooplankton bloom, that concentration can increase a hundredfold or more per liter, carrying a dose of cholera bacteria sufficient to cause cholera. The severity of the disease is dose dependent: a low concentration of bacterial cells will pro-
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary duce mild diarrhea; hospitalized cases—which represent about 25 percent of all infections—require more since one million bacteria per milliliter has been shown to be required to produce the disease. Thus, it has been estimated that only 25 percent of those with cholera end up in hospitals and many more may have been infected (Colwell and Huq, 2004). Cholera is a disease with rapid onset. Within 24 to 48 hours, the typical patient can lose up to 18 liters of fluid. If that fluid can be replenished quickly, either intravenously or through oral rehydration (using a simple mixture of bicarbonate of soda, table salt, and sugar), recovery is fairly rapid. From years of study in Bangladesh, we have determined several factors that interact and are associated with the massive annual biennial (spring and fall) cholera epidemics, so that we can predict the onset and severity of epidemics. Our recent research focuses on the communities of Mathbaria and Bakerganj, which are located in the barrier islands region of the Ganges delta (see Figure 2-1). Mangrove-based ecosystems are abundant in copepods. Thus, the Vibrio population is also abundant, and during the zooplankton/Vibrio bloom, cholera results from drinking untreated water. In Bakerganj and Mathbaria, copepods comprise the majority of zooplankton species. We now have evidence that the severity of a given local cholera epidemic can be determined by copepod population dynamics, with intense epidemics occurring during times of abundance of those copepod species to which epidemic strains of V. cholera preferentially attach. We are currently conducting a seasonal study of zooplankton species in an attempt to determine which species carry V. cholera and to identify factors that influence population size; we will use this information, with other environmental data, to build a predictive capacity for cholera epidemics. We are also using our knowledge of cholera epidemiology to help the people of Bangladesh to avoid contracting cholera. In one study, for example, we found that by simply educating women to filter drinking water through several layers of sari cloth, we were able to reduce cholera incidence by 50 percent. This result supported our hypothesis that plankton and particulates—to which the bacteria are attracted—transmit cholera and when removed by simple filtration, the incidence of the disease is significantly reduced. Predictive Models of Cholera Currently, the spring bloom of phytoplankton in the Bay of Bengal can be measured by satellite sensors that measure chlorophyll intensity and, therefore, the phytoplankton population. Phytoplankton blooms are followed by zooplankton blooms, but the latter cannot yet be measured directly by satellite sensors. However, the zooplankton peak can be inferred using a series of calculations from measurements of the phytoplankton populations that precede the zooplankton
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary population peak. This information taken together with salinity, temperature, and other environmental factors, provides a more complete picture. We have also gathered ground truth data over the past 10 years in the Bakerganj area, including conductivity of the water, presence of inorganic nutrients, temperature, and salinity. With these data, we are able to improve our prediction of the timing and, possibly, the severity of cholera epidemics. In our original work, we were able to use satellite imagery to measure sea surface temperature and sea surface height in the Bay of Bengal. As shown in Figure 2-2, the correlation of chlorophyll and temperature data, measured by satellite sensors, provides a predictive capacity for conditions conducive to cholera outbreaks. We are currently working on a predictive model that takes into account ocean currents to monitor the movement of plankton into the Bay of Bengal estuaries from the southern tip of India. This could provide as much as a 3-month warning prior to an impending cholera outbreak. In Latin America, the 1991-1992 El Niño event corresponded with a cholera epidemic that was initially attributed to the dumping of ballast water by a ship in the harbor of Lima, Peru (Gil et al., 2004). We were able to disprove this hypothesis by demonstrating that cholera outbreaks had occurred in three different cities along the coast of Peru, starting before the peak of the 1991-1992 El Niño event. The epidemic more likely resulted from the effect of increased sea surface temperatures on existing plankton and V. cholerae populations. Our most sophisticated predictive model for cholera incorporates chlorophyll, sea surface height, temperature, and extensive ground truth data. Within a few years, the National Oceanic and Atmospheric Administration (NOAA) will launch a satellite that may provide salinity data. We are also refining our model, based on the 40 years of data accumulated on cholera in Bangladesh and in India, which we are presently analyzing. Nevertheless, with the analyses we have performed to date—sea surface temperature and sea surface height from satellite sensors; measurements of chlorophyll intensity (corrected for the time lag from chlorophyll-phytoplankton bloom to the zooplankton bloom that feeds on the phytoplankton); and measurements of vibrio dispersion in the water—we are able to determine significant correlations and, thus, a foundation from which to predict cholera epidemics. Conclusion Climate change is likely to increase the burden of cholera in Bangladesh, but even greater suffering will occur if sea levels rise to predicted levels, displacing millions of people. However, our interdisciplinary, international (as demonstrated by our large number of collaborators from many countries), and biocomplexity approach to studying cholera extends well beyond Bangladesh and even beyond the disease itself. By gaining an understanding of the complex interactions between infectious disease, ecology, and the physical environment, we can
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Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence - Workshop Summary standardization, data-sharing, and the detection of infectious disease trends over a larger geographic area. This capacity is essential for the development of strategies to minimize the negative effects of climate change on the health of Arctic residents in the future. REFERENCES Overview References Borgerson, S. G. 2008. Arctic meltdown: the economic and security implications of global warming. Foreign Affairs 87(2):63-77. Chretien, J. P., A. Anyamba, S. A. Bedno, R. F. Breiman, R. Sang, K. Sergon, A. M. Powers, C. O. Onyango, J. Small, C. J. Tucker, and K. J. Linthicum. 2007. Drought-associated chikungunya emergence along coastal East Africa. American Journal of Tropical Medicine and Hygiene 76(3):405-407. Fritz, C. L., D. T. Dennis, M. A. Tipple, G. L. Campbell, C. R. McCance, and D. J. Gubler. 1996. Surveillance for pneumonic plague in the United States during an international emergency: a model for control of imported emerging diseases. Emerging Infectious Diseases 2(1):30-36. IPCC (Intergovernmental Panel on Climate Change). 2007. Climate change 2007: the physical science basis. Contribution of Working Group I to the fourth assessment report of the IPCC. Cambridge, UK: Cambridge University Press. Linthicum, K. J., A. Anyamba, C. J. Tucker, P. W. Kelley, M. F. Myers, and C. J. Peters. 1999. Climate and satellite indicators to forecast Rift Valley fever epidemics in Kenya. Science 285(5426):397-400. Stenseth, N. C., N. I. Samia, H. Viljugrein, K. L. Kausrud, M. Begon, S. Davis, H. Leirs, V. M. Dubyanskiy, J. Esper, V. S. Ageyev, N. L. Klassovskiy, S. B. Pole, and C. Kung-Sik. 2006. Plague dynamics are driven by climate variation. Proceedings of the National Academy of Sciences 103(35):13110-13115. Colwell References Colwell, R. R. 1996. Global climate and infectious disease: the cholera paradigm. Science 274(5295):2025-2031. Colwell, R. R., and A. Huq. 1994. Vibrios in the environment: viable but nonculturable Vibrio cholerae. In: Vibrio cholerae and cholera: molecular to global perspectives, edited by I. K. Wachsmuth, O. Olsvik, and P. A. Blake. Washington, DC: American Society for Microbiology. Pp. 117-133. Gil, A. I., V. R. Louis, I. N. Rivera, E. Lipp, A. Huq, C. F. Lanata, D. N. Taylor, E. Russek-Cohen, N. Choopun, R. B. Sack, R. R. Colwell. 2004.Occurrence and distribution of Vibrio cholerae in the coastal environment of Peru. Environmental Microbiology 6(7):699-706. Rawlings, T., G. M. Ruiz, and R. R. Colwell. 2007. Association of Vibrio cholerae O1 El Tor and O139 Bengal with the copepods Acartia tonsa and Eurytemora affinis. Applied Environmental Microbiology 73(24):7926-7933. WHO (World Health Organization). 2005. Weekly epidemiological record 80(31):261-268, http://www.who.int/wer/2005/wer8031.pdf (accessed May 1, 2008).
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