A Human Health Perspective On Climate Change Full Report

Transcript

1 A Human Health Perspective On Climate Change A Report Outlining the Research Needs on the Human Health Effects of Climate Change APRIL 22, 2010 Published by Environmental Health Perspectives and the National Institute of Environmental Health Sciences 1

2

3 A Human Health Perspective On Climate Change A Report Outlining the Research Needs on the Human Health Effects of nge Climate Cha 1 The Interagency Working Group on Climate Change and Health APRIL 2010 and Published by Environmental Health Perspectives the National Institute of Environmental Health Sciences is an open-access monthly journal of peer-reviewed EHP (ISSN 0091-6765) is a publication of the Public Health Service, U.S. Department of Health and Human Services. Environmental Health Perspectives (ISSN 1542-6351) and occasional special issues. The Secretary of Health and Human Services Chinese Edition also publishes a quarterly EHP research and news on the impact of the environment on human health. has deemed EHP to be necessary in the transaction of the public business required by law of this department. was not involved in the peer review of this report. EHP Send all correspondence to Dr. Christopher J. Portier, Senior Advisor to the Director, Principle Investigator, Environmental Systems Biology, PO Box 12233, MD B2-08, National Institute of CorrespondenCe: Environmental Health Sciences, Research Triangle Park, NC 27709 USA, E-mail: [email protected], Telephone: 919-541-3484, Fax: 919-541-1994. Copyright And reproduCtion: A Human Health Perspective On Climate Change: A Report Outlining the Research Needs on the Human Health Effects of Climate Change is a publication of the government. Publication of this report lies in the public domain and is therefore without copyright. Some photographs or figures contained in this report are copyrighted by commercial organizations or U.S. individuals that may not be used without obtaining prior approval from the holder of the copyright. The publication of this document does not mean that the National Institute of Environmental Health Sciences (NIEHS) condones, endorses, approves, or recommends the use of any products, disClAimer: services, materials, methodology, or policies stated therein. Conclusions and opinions are those of the individual authors and do not reflect the policies or views of the NIEHS. Under the provisions of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, disCriminAtion prohibited: handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity (or, on the basis of sex, with respect to any educational program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Therefore, the NIEHS must be operated in compliance with these laws and executive orders. suggested CitAtion: Portier CJ, Thigpen Tart K, Carter SR, Dilworth CH, Grambsch AE, Gohlke J, Hess J, Howard SN, Luber G, Lutz JT, Maslak T, Prudent N, Radtke M, Rosenthal JP, Rowles T, Sandifer PA, Scheraga J, Schramm PJ, Strickman D, Trtanj JM, Whung P-Y. 2010. A Human Health Perspective On Climate Change: A Report Outlining the Research Needs on the Human Health Effects of Climate Available: www.niehs.nih.gov/climatereport . Research Triangle Park, NC:Environmental Health Perspectives/National Institute of Environmental Health Sciences. doi:10.1289/ehp.1002272 Change ... Disclaimer 1 : The interagency Working Group on climate change and Health (iWGccH) is an ad hoc group formed by participating federal agencies and organizations at the invitation of the National institute of environmental Health sciences (NieHs), National Oceanic and atmospheric administration (NOaa), centers for Disease control and Prevention (cDc), and environmental Protection agency (ePa) following the January 2009 “Workshop on a research agenda for managing the Health risks of climate change,” sponsored by the institute of medicine roundtable on environmental Health sciences, research, and medicine. This report identifies gaps in knowledge of the consequences for human health of climate change, and suggests research to address them. The content, views, and perspectives presented in this report are solely those of the authors, and do not reflect the official views, policies, or implied endorsement of any of the individual participating federal agencies or organizations. i

4 Table of Working Group iii Contents Executive Summary iv Introduction 2 9 Crosscutting Issues for Climate Change and Health 8 Susceptible, Vulnerable, and Displaced Populations Public Health and Health Care Infrastructure 9 Capacities and Skills Needed 9 1 0 Communication and Education 13 Asthma, Respiratory Allergies, and Airway Diseases 17 Cancer 21 Cardiovascular Disease and Stroke 25 Foodborne Diseases and Nutrition 29 Heat-Related Morbidity and Mortality 33 Human Developmental Effects 37 Mental Health and Stress-Related Disorders 41 Neurological Diseases and Disorders 45 Vectorborne and Zoonotic Diseases 51 Waterborne Diseases 57 Weather-Related Morbidity and Mortality 60 Synthesis and Recommendations 64 Summary Statement www.niehs.nih.gov/climatereport ii

5 A Human Health Perspective ON CLIMATE CHANGE The Interagency Working Group on Participating Agencies Climate Change and Health In addition to the working group, many scientists and staff from the following agencies contributed to the development (COOrdINATING LEAd AuTHOr) PhD Christopher J. Portier, and review of this white paper. Staff of the u.S. Global Change National Institute of Environmental Health Sciences research Program provided logistical and technical support, but did not conduct a formal review. (COOrdINATING EdITOr) JD Kimberly Thigpen Tart, National Institute of Environmental Health Sciences C enters for Disease Control and Prevention National Center for Environmental Health • PhD Sarah R. Carter, AAAS Fellow , U.S. Environmental Protection Agency National Institutes of Health PhD Caroline H. Dilworth, National Institute of Environmental Health Sciences National Institute of Environmental Health Sciences • Anne E. Grambsch U.S. Environmental Protection Agency • Fogarty International Center PhD Julia Gohlke, Trans-NIH Working Group on Climate Change and Healt • h National Institute of Environmental Health Sciences (LEAd AuTHOr) MD, MPH Jeremy Hess, National Oceanic and Atmospheric Administration Centers for Disease Control and Prevention Sandra N. Howard Office of the Secretary, Department of Health and Department of Health and Human Services Human Services George Luber, PhD (LEAd AuTHOr) Centers for Disease Control and Prevention U.S. Environmental Protection Agency Jeffrey T. Lutz, PhD National Oceanic and Atmospheric Administration U.S. Department of Agriculture MPH Tanya Maslak, (LEAd AuTHOr) U.S. Global Change Research Program, U.S. Department of State University Corporation for Atmospheric Research MPH Natasha Prudent, Centers for Disease Control and Prevention Meghan Radtke, PhD (LEAd AuTHOr) AAAS Fellow, U.S. Environmental Protection Agency Joshua P. Rosenthal, PhD Fogarty International Center DVM, PhD Teri Rowles, National Oceanic and Atmospheric Administration PhD Paul A. Sandifer, National Oceanic and Atmospheric Administration PhD Joel Scheraga, U.S. Environmental Protection Agency MS, MPH Paul J. Schramm, Centers for Disease Control and Prevention Daniel Strickman, PhD (LEAd AuTHOr) Department of Agriculture, Agricultural Research Service U.S. (LEAd AuTHOr) Juli M. Trtanj, MES National Oceanic and Atmospheric Administration PhD Pai-Yei Whung, Environmental Protection Agency U.S. www.niehs.nih.gov/climatereport iii

6 A Human Health Perspective ON CLIMATE CHANGE Executive Su mmary limate change endangers human health, The purpose of this paper affecting all sectors of society, both domestically C and globally. The environmental consequences is to identify research needs of climate change, both those already observed and those for all aspects of the that are anticipated, such as sea-level rise, changes in precipitation resulting in f looding and drought, heat research-to-decision making waves, more intense hurricanes and storms, and degraded air quality, will affect human health both directly and pathway that will help us indirectly. Addressing the effects of climate change on human health is especially challenging because both the understand and mitigate the surrounding environment and the decisions that people make inf luence health. For example, increases in the , health effects of climate change frequency and severity of regional heat waves—likely as well as ensure that we outcomes of climate change—have the potential to harm a lot of people. Certain adverse health effects can probably choose the healthiest and be avoided if decisions made prior to the heat waves result in such things as identification of vulnerable populations most efficient approaches to such as children and the elderly and ensured access to preventive measures such as air conditioning. This is a climate change adaptation. simplified illustration; in real-life situations a host of other factors also come into play in determining vulnerability including biological susceptibility, socioeconomic status, cultural competence, and the built environment. In a world of myriad “what if” scenarios surrounding climate change, it becomes very complicated to create wise health policies for the future because of the uncertainty of predicting environmental change and human decisions. The need for sound science on which to base such policies becomes more critical than ever. www.niehs.nih.gov/climatereport iv

7 ON CLIMATE CHANGE A Human Health Perspective Recognizing the complexity of this issue, an ad hoc Interagency relationship to climate change, and identify the basic and 2 Working Group on Climate Change and Health ( applied research needs of that category, as well as crosscutting IWGCCH) ­ assembled to develop a white paper on relevant federal re issues where relevant. Most investigations of climate change and health have relied on environmental and ecological effects search and science needs, including research on mitigation and adaptation strategies. Examples of mitigation and adaptation to extrapolate potential human health impacts; the IWGCCH deliberately chose to emphasize the need for research on research needs are identified, but a comprehensive discussion human health outcomes over environmental impacts for this of these issues is not included. These research and science needs broadly include basic and applied science, technological reason: this approach highlights direct links between climate innovations and capacities, public health infrastructure, and change and federal research priorities that are often disease- or communication and education. Consideration is also given to outcome-specific, and a focus on human health outcomes enables a holistic approach to exploring climate change-related the potential structure of a federal climate change and health research agenda and the use of scientific research results for health impacts. We recognize that the health consequences identified in this document are not exhaustive, and that applications and decision making. The purpose of this paper because so many climate change effects are prospective, some is to identify research critical for understanding the impact of of the research needs enumerated may be speculative. As climate change on human health so that we can both mitigate and adapt to the environmental effects of climate change in the more information becomes available, new research needs may ­ be identified and others rejected, but it is our intent that this healthiest and most efficient ways. Although the group recog report may serve as a baseline discussion from which agencies nizes the global nature of climate change’s impacts on human health, the primary focus of this paper is on the situation in the can proceed. United States. This report is organized around 11 broad human health 3 Categories categories likely to be affected by climate change. are arranged in alphabetical order, and no prioritization—for instance as to likelihood of occurrence, severity of effects, or depth of current knowledge—is implied. Each category is broken into sections that introduce the topic, explain its ... cDc, HHs/Os, ePa, Nasa, NieHs, NiH/Fogarty, NOaa, DOs, UsDa, UsGcrP 2 asthma, allergies, and airway diseases; cancer; cardiovascular disease and stroke; alterations in normal development; 3 heat-related morbidity and mortality; mental health and stress disorders; neurological diseases and disorders; nutrition and food-borne illness; vector-borne and zoonotic disease; waterborne disease; weather-related morbidity and mortality www.niehs.nih.gov/climatereport v

8 Executive Summary A Human Health Perspective ON CLIMATE CHANGE Highlights: may affect food availability and nutrition, better monitoring for Asthma, Respiratory Allergies, and Airway Diseases— disease-causing agents, and identification and mapping of complex Respiratory allergies and diseases may become more prevalent because food webs and sentinel species that may be vulnerable to climate of increased human exposure to pollen (due to altered growing seasons), change. This research could be used to prepare the public health molds (from extreme or more frequent precipitation), air pollution and and health care sectors for new illnesses, changing surveillance aerosolized marine toxins (due to increased temperature, coastal runoff, needs, and increased incidence of disease, as well as development of and humidity) and dust (from droughts). Mitigation and adaptation may more effective outreach to affected communities. significantly reduce these risks. Research should address the relationship between climate change and the composition of air pollutant mixtures (e.g., how altered pollen counts and other effects of climate change affect Heat-Related Morbidity and Mortality— Heat-related the severity of asthma) to produce models to identify populations at risk. illness and deaths are likely to increase in response to climate Such tools support the use of science in understanding disease risks and change but aggressive public health interventions such as heat wave ­ as such, are an integral component of developing effective risk communi response plans and health alert warning systems can minimize cation and targeting the messages to vulnerable populations. morbidity and mortality. Additional science should be focused on developing and expanding these tools in different geographic regions, specifically by defining environmental risk factors, Cancer— Many potential direct effects of climate change on cancer risk, identifying vulnerable populations, and developing effective risk such as increased duration and intensity of ultraviolet (UV) radiation, communication and prevention strategies. are well understood; however the potential impact of changes in climate on exposure pathways for chemicals and toxins requires further study. Science should investigate the effects of mitigation and adaptation Two potential consequences Human Developmental Effects— measures on cancer incidence so that the best strategies can be developed of climate change would affect normal human development: and implemented; for example, research to inform understanding of malnutrition—particularly during the prenatal period and early the benefits of alternative fuels, new battery and voltaic cells, and other childhood as a result of decreased food supplies, and exposure to technologies, as well as any potential adverse risks from exposure to their toxic contaminants and biotoxins—resulting from extreme weather components and wastes. Better understanding of climate change impacts events, increased pesticide use for food production, and increases in on the capacity of ocean and coastal systems to provide cancer curative ­ harmful algal blooms in recreational areas. Research should exam agents and other health-enhancing products is also needed. ine the relationship between human development and adaptations to climate change, such as agriculture and fisheries changes that may affect food availability, increased pesticide use to control for Climate change may Cardiovascular Disease and Stroke— expanding disease vector ranges, and prevention of leaching from exacerbate existing cardiovascular disease by increasing heat stress, toxic waste sites into f loodwaters during extreme weather events, so increasing the body burden of airborne particulates, and changing the that developmental consequences can be prevented. distribution of zoonotic vectors that cause infectious diseases linked with cardiovascular disease. Science that addresses the cardiovascular effects of higher temperatures, heat waves, extreme weather, and changes in air By causing or Mental Health and Stress-Related Disorders— quality on health is needed, and this new information should be applied contributing to extreme weather events, climate change may result to development of health risk assessment models, early warning systems, in geographic displacement of populations, damage to property, health communication strategies targeting vulnerable populations, land loss of loved ones, and chronic stress, all of which can negatively use decisions, and strategies to meet air quality goals related to climate affect mental health. Research needs include identifying key change. In some areas, cardiovascular and stroke risks resulting from mental health effects and vulnerable populations, and developing climate change could be offset by reductions in air pollution due to migration monitoring networks to help ensure the availability of climate change mitigation. appropriate health care support. Climate change may be Foodborne Diseases and Nutrition— Neurological Diseases and Disorders— Climate change, as well as attempts to mitigate and adapt to it, may increase the associated with staple food shortages, malnutrition, and food contamina ­ tion (of seafood from chemical contaminants, biotoxins, and pathogenic number of neurological diseases and disorders in humans. Research in this area should focus on identifying vulnerable populations and microbes, and of crops by pesticides). Science research needs in this area include better understanding of how changes in agriculture and fisheries understanding the mechanisms and effects of human exposure to www.niehs.nih.gov/climatereport vi

9 ON CLIMATE CHANGE A Human Health Perspective Executive Summary strategies. For example, health communications research is needed neurological hazards such as biotoxins (from harmful algal blooms), to properly implement health alert warning systems for extreme heat metals (found in new battery technologies and compact f luorescent events and air pollution that especially affects people with existing lights), and pesticides (used in response to changes in agriculture), as conditions such as cardiovascular disease. Such a risk communication well as the potentially exacerbating effects of malnutrition and stress. pilot project might demonstrate communication practices that are effective in multiple areas, and contribute to a comprehensive strategy Disease risk may increase Vectorborne and Zoonotic Diseases— for addressing multiple health risks simultaneously. as a result of climate change due to related expansions in vector ranges, shortening of pathogen incubation periods, and disruption Other tools are needed and should be applied across multiple categories and relocation of large human populations. Research should enhance to close the knowledge gaps, including predictive models to improve the existing pathogen/vector control infrastructure including vector forecasting and prevention, evaluations of the vulnerability of health and host identification; integrate human with terrestrial and aquatic care and public health systems and infrastructure, and health impact animal health surveillance systems; incorporate ecological studies to assessments. Trans-disciplinary development would help to ensure provide better predictive models; and improve risk communication tools such as improved baseline monitoring that will be more widely and prevention strategies. applicable, and thus more efficient and cost effective than those currently available. In fact, many of the identified science needs will Increases in water temperature, precipita ­ Waterborne Diseases— require trans-disciplinary responses. For example, to study how heat tion frequency and severity, evaporation-transpiration rates, and waves alter ambient air pollution and the resulting combined impact of changes in coastal ecosystem health could increase the incidence of heat and pollution on human illness and death, will require expertise water contamination with harmful pathogens and chemicals, resulting in atmospheric chemistry, climate patterns, environmental health, in increased human exposure. Research should focus on understand­ epidemiology, medicine, and other science fields. Given the complexity ing where changes in water f low will occur, how water will interact of the science needs and the potential overlap of research questions with sewage in surface and underground water supplies as well as across disciplines, promoting trans-disciplinary collaboration among drinking water distribution systems, what food sources may become and within federal agencies would be a logical approach and should be a contaminated, and how to better predict and prevent human exposure high priority. to waterborne and ocean-related pathogens and biotoxins. Recently, the National Research Council issued a report addressing Increases in the Weather-Related Morbidity and Mortality— how federal research and science could be improved to provide incidence and intensity of extreme weather events such as hurricanes, support for decision and policy making on climate change and human f loods, droughts, and wildfires may adversely affect people’s health 4 health. immediately during the event or later following the event. Research Specifically, the report calls for a more complete catalogue aimed at improving the capabilities of healthcare and emergency of climate change health impacts, increasing the power of prediction services to address disaster planning and management is needed tools, enhancing integration of climate observation networks with to ensure that risks are understood and that optimal strategies are health impact surveillance tools, and improving interactions among identified, communicated, and implemented. stakeholders and decision makers. The IWGCCH approached this research needs assessment with these goals in mind. The next step In addition to the research needs identified in the individual research will be for federal agencies to discuss the findings of this white paper categories, there are crosscutting issues relevant to preventing or with stakeholders, decision makers, and the public as they work ­ avoiding many of the potential health impacts of climate change in to incorporate and prioritize appropriate research needs into their cluding identifying susceptible, vulnerable, and displaced populations; respective science agendas and collaborative research efforts. enhancing public health and health care infrastructure; developing A coordinated federal approach will bring the unique skills, capacities, capacities and skills in modeling and prediction; and improving risk and missions of the various agencies together to maximize the potential communication and public health education. Such research will lead for discovery of new information and opportunities for success in to more effective early warning systems and greater public awareness providing key information to support responsive and effective decisions of an individual’s or community's health risk from climate change, on climate change and health. ... which should translate into more successful mitigation and adaptation 4 National research council (U.s.). committee on strategic advice on the U.s. climate change science Program., et al. 2009, Washington, D.c.: National academies Press. xii, 254 p. www.niehs.nih.gov/climatereport vii

10 A Human Health Perspective ON CLIMATE CHANGE roduction Int lobal climate change has become one of the most visible environmental concerns of the st 21 G century. From pictures of polar bears clinging to melting ice f loes in Alaska to dried and cracked farmland stretching into the horizon in Africa, images of the ecological impacts of climate change have become part of our combined consciousness and inspire concern and discussion about what climate change ultimately will mean to our planet. But seldom are the effects of climate change expressed, either visually or otherwise, in terms of the real and potential costs in human lives and suffering. To date, most climate change research has focused on environmental effects and not health effects. It is clear that climate change endangers human health, but there is need to improve the science and knowledge base of how it occurs. One purpose of this document is to identify research gaps to increase the understanding of climate change and health. Expanding our understanding of the often indirect, long-term, and complex consequences of climate change for human health is a high priority and 5 challenging research task. In the developed world particu ­ larly, there is perhaps a greater perception of the ecological and environmental effects of climate change than of the human health implications. This may be due in part to the fact that images linking climate change and some already apparent wildlife and landscape effects are prevalent, and thereby, increase concern. ... 5 National research council (U.s.). committee On Health, e, and Other external costs and, et al. Board on environmental studies and Toxicology special report. 2009, Washington, D.c.: Board on environmental studies and Toxicology. www.niehs.nih.gov/climatereport 2

11 A Human Health Perspective ON CLIMATE CHANGE There is no doubt, however, that climate change is currently affect ­ long way toward informing health decision making and addressing 11 the challenges outlined in the National Research Council’s report. ing public health through myriad environmental consequences, . such as sea-level rise, changes in precipitation resulting in f looding and drought, heat waves, changes in intensity of hurricanes and Leaders including the Director, National Institute of Environmental storms, and degraded air quality, that are anticipated to continue Health Sciences (NIEHS); the Chief Scientist in the Office of the into the foreseeable future. In a tally that included just four diseases Science Advisor, U.S. Environmental Protection Agency (EPA); (cardiovascular disease, malnutrition, diarrhea, and malaria) as well the Senior Scientist for Coastal Ecology, National Oceanic and as f loods, the World Health Organization (WHO) estimated 166,000 Atmospheric Administration (NOAA); and the Director, National deaths and about 5.5 million disability-adjusted life years (DALYs, Center for Environmental Health, Centers for Disease Control and a measure of overall disease burden) were attributable to climate Prevention (CDC) initiated the development of this white paper 6 change in 2000. in February 2009. The Interagency Working Group on Climate To date, the majority of analyses on climate change Change and Health (IWGCCH) was established with representation and health have focused on diseases that predominantly affect people and participation from various federal agencies, institutes, and in the developing world, and therefore, are perceived as less relevant other organizations with an environmental health or public health to more developed countries. However, as the recent pandemic of mandate. (Participating groups are listed on the Working Group page H1N1 virus has shown us, diseases do not respect international of this document, pp. iii). The first activity of this ad hoc group was boundaries. Climate change can be a driver for disease migration, to review and distill the state of the science on the effects of climate but even so, such diseases do not represent the broadest range of change on human health from the many excellent reviews of climate possible, or even likely, human health effects of climate change, nor change already published by groups including the Intergovernmental do they ref lect the likely co-benefits of mitigation and adaptation to Panel on Climate Change, the World Health Organization, the U.S. climate change, some of which may have their greatest impact in the Global Change Research Program, the National Research Council, developed world. and others. Most of these reports take a much broader view of the is ­ sue of climate change; however, the portions that are directly relevant ­ For over 170 years, scientists have studied the complicated relation 7 to human health effects provided a critical baseline from which this ship between the weather, climate, and human health. Since the first working group could proceed to identify the research gaps and needs attempt at scientific consensus on climate change nearly four decades 8 in this area. ago, scientists have been examining whether climate is indeed changing as a result of human activity. However, the complicated This document does not attempt to be a comprehensive assessment relationships between climate change, the environment, and human of the risks associated with climate change and health or a strategic health have not represented high priorities for scientific research in plan. Rather it seeks to build on the existing knowledge of the prior the United States, and there are abundant gaps in our understand ­ 9 efforts, and extend this knowledge further by shifting the perspective ing of these links. Such gaps impair our ability to identify optimal ­ on climate change effects from a largely ecological and meteorologi strategies for mitigation and adaptation that will prevent illness and cal base to one that focuses on the human health consequences of death in current human populations while simultaneously protecting climate change, mitigation, and adaptation. Similarly, an aim of the environment and health of future generations. The purpose of this this report is to inform the federal government as it seeks to focus report is to identify the major research areas that need to be further climate change research on understanding the interactions among explored and understood, and to identify the scientific capacities that the climate, human, and environmental systems and on supporting will be needed to adequately address the problems that arise at the societal responses to climate change. In this way, it is responsive to nexus of climate, environment, and human health with the goal of the recommendations of some of these reports. The working group informing federal agencies with a human health or related research 10 has drafted this document in consultation with subject matter experts challenges. mission as they approach these daunting Research at the various agencies, seeking their review and comment throughout outcomes generated from the needs agenda outlined here would go a the process to provide a concise, credible, and broad discussion. 6 campbell-lendrum, D, et al. environmental Burden of Disease series, ed. a Pruss-Ustun, et al. 2007, Geneva: World Health Organization. 66. Dunglison, r. 1835, Philadelphia,: carey, lea & Blanchard. xi, [13]-514 p. 7 study of critical environmental Problems., et al. 1970, cambridge, mass.,: miT Press. xxii, 319 p. 8 campbell-lendrum, D, et al., The lancet, 2009. 373(9676): p. 1663-1665. 9 11 National research council (U.s.). committee on strategic advice on the U.s. climate change science Program., et al. 10 Gamble, Jl, et al. 2008, Washington, D.c.: U.s. climate change science Program. ix, 204 p. 2009, Washington, D.c.: National academies Press. xii, 254 p. www.niehs.nih.gov/climatereport 3

12 Introduction A Human Health Perspective ON CLIMATE CHANGE 12 of these diseases Figure 1 provides the conceptual framework used to develop this and disorders are not independently affected; report. In addition to the direct effects of heat on humans, the major any one disease is likely to have several drivers from the group of impacts of climate change on human health are through changes to environmental consequences that result from climate change, and the human environment such as rising oceans, changing weather conversely, any particular environmental change could affect multiple disease categories. In addition, both positive and negative synergies patterns, and decreased availability of fresh water. Mitigation of climate change refers to actions being taken to reduce greenhouse will occur among various components of the system. gas emissions and to enhance the sinks that trap or remove carbon from the atmosphere to reduce the extent of global climate change. Climate change directly affects five components of the environment: 13 Adaptation refers to actions being taken to lessen the impact on water, air, weather, oceans, and ecosystems. Changes in rainfall health and the environment due to changes that cannot be prevented and other precipitation, changing temperatures, and melting of through mitigation. Appropriate mitigation and adaptation strategies summer ice caps are already occurring and will create changes in the will positively affect both climate change and the environment, and availability and quality of water across much of the planet over the 14 thereby positively affect human health. In addition, some adaptation next 30 years. In the United States, water security, or the reliable activities will directly improve human health through changes in our availability of water for drinking, agriculture, manufacturing, and ­ public health and health care infrastructure. Gaps in our under myriad other uses, is becoming a pressing issue. This is particularly standing of how human health, climate change, the environment, true in the Western half of the country, where water shortages are and mitigation and adaptation are linked are the focus of this report. exacerbated by reduced mountain snowpack due to warming, and in the South, where severe droughts have become a more frequent occurrence in recent years. Water quality is also affected in many , and Figure 2 expands upon the conceptual framework in Figure 1 regions, particularly coastal areas, due to extreme weather events provides a global view of the complex ecological networks that can be disrupted by climate change, the human health implications of 12 For simplicity, we will use disease to include the broad spectrum of human diseases, syndromes, ailments and conditions being described here. such disruptions, and the targets of mitigation and adaptation. Many intergovernmental Panel on climate change. Working Group ii. 2007, cambridge: cambridge University Press. ix, 13 976 p, Karl, T, et al. 2009, New York: cambridge University Press. 14 intergovernmental Panel on climate change. Working Group ii. 2007, cambridge: cambridge University Press. ix, 976 p. | FIgUrE 1 Changes in greenhouse gas concentrations and other drivers change our global climate altering human health; mitigation alters climate and both mitigation and adaptation alter the human environment; the predominant impact on human health is through environmental changes as a result of climate change although there are direct impacts from both climate changes and mitigation/adaptation. Human Health Environmental Greehouse Gas Change and Other Drivers www.niehs.nih.gov/climatereport 4

13 Introduction ON CLIMATE CHANGE A Human Health Perspective human exposure to a variety of pollutants, with resulting increases in such as hurricanes and f looding. These same events, often associated asthma, cardiovascular disease, and other respiratory ailments. with sea-level rise and increased storm surges, can heavily damage human communities and alter complex coastal ecosystems with Some of the human health effects will arise from extreme weather consequences for both water and food quality and supply. events that are expected to become more common in a warmer climate. For instance, more intense hurricanes and increases in The complex atmospheric chemistry that governs air quality is f looding and wildfires may exacerbate a wide range of health effects modulated by heat, humidity, degree of ultraviolet (UV) radiation, - resulting from the release of toxic chemicals from landfills, contami and many other factors. Changes in any of these can directly reduce nation of drinking water with raw sewage as a result of damage to - air quality, particularly in urban areas, by increasing air concentra water infrastructure, increased concentrations of air pollutants that tions and human exposures to a variety of toxic air pollutants are especially harmful to susceptible populations such as children, including chemicals, fungi, and aeroallergens. In many areas of the elderly, and those with asthma or cardiovascular disease, and the country, climate change and resulting weather events such as myriad other hazards associated with these events. Extreme heat drought and wildfires will reduce general air quality and increase | Figure 2 Climate change has direct impacts on five aspects of the human environment (red lines, purple circles) that in turn impact additional environmental factors. These environmental changes then alter twelve separate aspects of human health (tan boxes). Mitigation and adaptation alter the human environment in order to address climate change and, in this way, alter human health. Finally, susceptible populations exist for all climate-targeted health points, and the health systems play an integral role in addressing the health concerns driven by climate change. Human nta l elopme Dev Effects Health & seases Di Mental ers so Di rd Stfen-Related )> C: C. 0 DJ "C - C"I "' DJ - ·- - - 0 :E ::::, ············- - .. · ············-·· ... / \ ~-------~ / ~ .! '·· ·••·· . .. ... .. ····-- ... ·· .·. · ····'\.··. . \\. . .. / ., .. ,./· ·· ······ •.. .·.·.·_··.·.· · .. ~~:~~:- .. .•... .. ·····- ~· :: ~: ~ ·· :::··.~· ·· ·· ···· ·-····' ... _ ... ~ . l ... . -. :·.·::: .. _ .. ,.-······· . ~~'.' . /./... \ ··. :;;::>'· . ~ :i . ::::~ :~: ····< ·· ···-· Sys Health t ems www.niehs.nih.gov/climatereport 5

14 A Human Health Perspective Int roduc t ion ON CLIMATE CHANGE also directly increases the risk of injury, illness, and death, as well as gas-emitting energy sources to cleaner alternatives and using carbon indirectly by contributing to illnesses such as those associated with capture and storage technologies will slow the rate at which we 15 stress. release greenhouse gases into the environment. Energy conservation mental health and and modifications in energy use will also reduce releases. Land use changes such as restricting the destruction of forests and replanting Global climate change is visibly and profoundly affecting oceans, more trees will serve to increase natural carbon storage. which in turn, affects human health. The warming of ocean waters contributes to increases in incidence and severity of toxic algal Actions to preserve other ecosystem services, such as f lood control blooms, alterations in aquatic and estuarine food webs and seafood 16 by protecting wetlands or vector control by conserving biodiversity, quality and availability, and effects on sentinel aquatic species . 20 problems. can also reduce the severity of climate change-related High concentrations of carbon dioxide in the atmosphere increase the amount that is dissolved into the ocean, leading to acidification Finally, changes in building codes, transportation infrastructure, and disruption of ecosystems. As large portions of the world’s housing density, coastal development, and other urban planning populations, including those in the United States, live in coastal strategies can reduce energy usage and thereby mitigate some areas, and many depend on marine protein for daily subsistence, the portion of climate change. Through these changes in human consequences of perturbing delicate ocean and coastal systems will activities and practices, we should be able to limit the magnitude of be far-reaching. the changes to the planet’s climate, and thus, reduce the negative impacts to human health. Though it is possible that some mitiga ­ tion strategies may exacerbate known human health stressors or Climate changes including increased heat in certain arid and introduce unanticipated potential for human harm, many strategies semi-arid parts of the United States can dramatically alter existing will provide co-benefits, simultaneously reducing the negative effects ecosystems, presenting new challenges to agricultural production of climate change while also reducing illness and death. For example, and coastal ecosystems, with consequences for food quality and reducing harmful air pollutants generally decreases global warming ­ availability. Changes in plant habitat can result in reduced availabil 17 21 but is also just more healthful to people. ity of grazing lands for livestock. Climate changes also are directly associated with many pest habitats and disease vectors, and changes in temperature can extend or reorient habitats such that organisms Recognizing that there are a broad set of issues related to both are introduced to new geographic areas or life cycles are altered, potential benefits and possible adverse effects on human health requiring increases in pesticide use or use in new areas to achieve resulting from mitigation and adaptation strategies, the IWGCCH the same yields. Global warming is also causing shifts in the ranges did not attempt to outline research needs for mitigation and adaption of disease vectors that require specific environments to thrive (for ­ in a comprehensive manner in this report, nor provide a comprehen 18 example, Lyme disease), sive overview of mitigation and adaptation approaches. These issues and increasing the threat and incidence in and their associated research needs will have to be evaluated in the humans of waterborne, vectorborne and zoonotic (those transferred context of the individual options and strategies. Instead, this report from animals to humans) diseases. focuses on some of the broader mitigation and adaptation options that are currently under development that have the potential to No current mitigation strategy or technology can prevent the provide great benefits to human health and proposes research needs change in climate that has already occurred. At present, our ability ­ that could inform decisions relating to them, and examples of mitiga to mitigate the magnitude of the climate changes that will occur tion and adaptation needs related to certain health consequences are over the next 100 years is limited by the current makeup of the included within each chapter. atmosphere, as well as what we can prevent from entering and what we are able to remove from the atmosphere in the future. The major ­ Adapting to or coping with climate change will become neces targets of climate change mitigation strategies include alternative sary in the United States and around the world. Most adaptation fuels and energy conservation, changes in land use patterns, sustain ­ strategies seek to change the human environment and decrease the able development of the built environment, and carbon capture 19 potential for illness and death by helping to prevent some of the storage. and Switching from fossil fuels and other greenhouse worst consequences of climate change. The primary environmental Noyes, PD, et al., environment international, 2009. 35(6): p. 971-986. 15 16 United states. congress. senate. committee on commerce science and Transportation. 2003, Washington: U.s. factors targeted for adaptation are water security and food security. G.P.O. ii. 8 p. ericksen, PJ, et al., environmental science and Policy, 2009. 12(4): p. 373-377. 17 estrada-Peña, a, environ Health Perspect, 2002. 110(7): p. 635-40. 18 20 corvalán, c, et al. 2005, [Geneva, switzerland]: World Health Organization. 53 p. 19 Haines, a, et al., lancet, 2006. 367(9528): p. 2101-2109. 21 smith, Kr, et al., lancet, 2009. www.niehs.nih.gov/climatereport 6

15 ON CLIMATE CHANGE A Human Health Perspective Introduction Finally, the health consequence categories, although treated as Given the likely changes that will occur in precipitation patterns, temperature, and extreme weather events, adapting the ways in individual topics, are not discrete, but rather are connected through the complicated systems within our planet and our own bodies. which we store, treat, and use water will be key to avoiding changes in water security. Similarly, food sources—whether they be crops, We have tried to draw out these connections wherever possible livestock, marine, or freshwater—will be under greater stress in and when they are of major significance. We also have identified various parts of the United States, and as a nation we need to develop a number of crosscutting issues that are critical to this discussion adaptation strategies to ensure our food security. Clean water and including susceptible, vulnerable, and displaced populations; public access to sufficient safe food are fundamental needs for human heath and health care infrastructure; capacities and skills needed; and communication and education to increase awareness of climate health, so successful adaptation methods that maintain and improve change health effects. the availability of clean water and healthy food will be critical to avoiding some of the major health impacts of climate change. There is also a need for adaptation strategies focused on community Categories of human health consequences of development and the built environment, transportation, and public 22 climate change: health infrastructure. 1. Asthma, Respiratory Allergies, and Through these environmental changes, increases—and in some rare Airway Diseases cases—decreases in adverse human health consequences are likely to occur. We have organized these health consequences into 11 broad 2. Cancer categories for discussion (listed below). In this report, we provide for each category a brief synopsis of what is known about the relation ­ Cardiovascular Disease and Stroke 3. ship between climate change; mitigation, and adaptation; effects on the risk, incidence, severity, or characteristics of the specific diseases 4. Foodborne Diseases and Nutrition or disorders; the major research needs and questions that must be addressed; and in some cases, an indication of the specific skills and Heat-Related Morbidity and Mortality 5. ­ capacities that will be needed to facilitate the research. Because fac tors including urgency, likelihood of occurrence, numbers of people Human Developmental Effects 6. affected, severity of effects, and economic issues associated with each category are broad, difficult to quantify, and largely beyond 7. Mental Health and Stress-Related Disorders the mandate of our individual agencies, we have deliberately chosen not to attempt a prioritization of the research needs, but rather seek Neurological Diseases and Disorders 8. to provide a body of knowledge to inform federal agencies, and the government as a whole, as agencies and other groups set their own Vectorborne and Zoonotic Diseases 9. priorities and agendas in this area. The scope of this analysis is largely confined to examining effects on the U.S. population, which 10. Waterborne Diseases is the primary constituency of the federal agencies, recognizing that most, if not all, of these issues are of global concern and consequence 11. Weather-Related Morbidity and Mortality as well, and in the hopes that resulting gains from this information can be applied to global collaborations in the future. Similarly, although we attempt to provide some discussion of the training, capacities, technology, and infrastructure needs that will be required to address these critical research questions, it is within the context and for the purpose of identifying and applying those resources present or anticipated within our specific federal agencies. ... 22 Haines, a, et al., ibid.2006. 367(9528): p. 2101-2109. www.niehs.nih.gov/climatereport 7

16 8

17 Crosscutting Issues for Climate Change and Health In the process of identifying and characterizing research needs on who were of low income (vulnerable) were the slowest to recover 25 disaster. the health implications of climate change for the 11 categories of from the Virtually every human disease is likely to have consequences, it became evident that multiple crosscutting issues both susceptible and vulnerable populations associated with it. One span all aspects of the research needs. In the sections below, we key aspect to mitigating the effects of climate change is a better brief ly summarize the major areas of overlap. understanding of diseases and the unique risks of various exposed or affected populations so that strategies may be developed that take such risks into account and are tailored to address them. The Susceptible, Vulnerable, and Displaced Populations. World Health Organization defines “environment” as “all modifiable In the case of diseases linked to climate change, a number of physical, chemical, and biological factors external to the human populations are particularly at risk. Children, pregnant women, and host, and all related behaviors that are critical to establishing and 23 the elderly are generally more susceptible, especially for heat- and maintaining a healthy livable environment,” . Within this definition, weather-related illness and death, vectorborne and zoonotic diseases, it is likely that the environment can affect most human diseases and 26 and waterborne and foodborne illnesses. illnesses. There are certain populations that are at increased risk Also, children and some from environmental factors that affect health, and such populations minority groups are very susceptible to asthma and allergies that present unique concerns when considering the health risks from may be exacerbated by climate change. Genetic links and markers climate change. “Susceptibility” refers to intrinsic biological factors that help to identify and define susceptible populations exist for that can increase the health risk of an individual at a given exposure many climate-related diseases. level. Examples of susceptibility factors that have been shown to increase individual health risks are certain genetic variants, life- Poverty generally makes people more vulnerable to many of the stage such as childhood, and medical history such as a prior history health effects of climate change, largely due to inadequate access of disease. “Vulnerability” refers to human populations at higher risk to health care. Poverty also increases the risk that a population due to environmental or personal factors. For example, people living displaced by extreme weather events or environmental degradation in mud brick houses in earthquake zones are much more vulnerable will not easily recover, and as a result, will suffer much higher to injury from building collapse than those living in structures built disease risks. The same is true for people who abuse drugs, those who with modern techniques and stronger materials. Populations living suffer mental illness, and others who for various reasons are socially in poverty, substance abusers, and those with mental illness are isolated For such populations, the effects of climate change such as at increased vulnerability to many of the environmental changes temperature and weather extremes, disruptions in access to public resulting from climate change. Another form of vulnerability is seen services including health care and food assistance programs, and in displaced populations, who have been shown to be at higher risk of increased stress are all magnified by their preexisting conditions or a number of diseases, including diarrheal and vectorborne diseases situations. Outdoor workers and people living in coastal and riverine resulting from exposure to poor sanitation, as well as mental health zones also are likely to experience increased vulnerability to climate- 24 illnesses due to increased acute and chronic stress. induced environmental changes resulting from f looding and extreme weather events. Populations with both susceptibility and vulnerability factors are Data to support a broad understanding of which populations referred to as “sensitive” populations. An example of a sensitive will be most susceptible and vulnerable to diseases affected by population would be certain members of the displaced population climate change are generally lacking at this time; however, data are that evacuated New Orleans following Hurricane Katrina. Studies have shown that within this population, older people (susceptible) eisenman, DP, et al., am J Public Health, 2007. 97 suppl 1: p. s109-15. 25 23 Prüss-Üstün, a, et al. 2006, Geneva, switzerland: World Health Organization. 104 p. 26 Balbus, Jm, et al., Journal of occupational and environmental medicine / american college of Occupational and 24 myers, N, Philos Trans r soc lond B Biol sci, 2002. 357(1420): p. 609-13. environmental medicine, 2009. 51(1): p. 33-37. www.niehs.nih.gov/climatereport 9 9

18 A Human Health Perspective Crosscutting Issues ON CLIMATE CHANGE available that identify vulnerable populations for some diseases hospitals in large cities, health care professionals are the primary with environmental causes or triggers that are likely to be altered source of medical treatment, prenatal and pediatric care, and by climate change. For example, reducing vehicle emissions may individual health protection and promotion for people in the United mean that populations living near freeways, who are at higher risk of States. But this infrastructure is also vulnerable to climate change cardiovascular disease, asthma, and spontaneous abortion, may see a in a number of very important ways. Disasters can severely hinder 29 27 the delivery of health care, with long-term impacts. reduction in incidence of these effects. Changes in the Expanding research on these diseases to incorporate effects of climate change will help to identify numbers of patients and the spectrum of diseases with which they vulnerable populations, and also to develop the strategies needed present could occur in some regions as the climate changes. The to adapt to climate changes and avoid excess health risks. These types of advice offered to patients with chronic conditions and the research efforts, if they are to be effective, must involve a broad infrastructure to support them may need to be adapted to protect spectrum of research scientists from epidemiologists and physicians against climate-induced changes that may make these individuals to environmental engineers and community planners. Such efforts more vulnerable. Currently there is limited research to guide these also will require a broad-based, multi-agency federal program that types of decisions. ­ builds on the strengths of each agency to develop an overall compre hensive research agenda. The public health community is in the early stages of develop ­ ing modeling skills and capacity in relation to climate change, particularly for combining climate models with ecological and other Public Health and Health Care Infrastructure. The term health outcome models for use in projecting disease dynamics under “public health” describes the science of preventing disease, prolong ­ various climate scenarios. In order to understand these dynamics, ing life, and promoting health and its application to society, com­ a sustained surveillance infrastructure that integrates human and munities, and groups. In contrast, “health care” primarily focuses ecological health (terrestrial, marine, aquatic) is critical. While the on the treatment of illness and the protection of mental and physical public health community has developed considerable expertise in well being in individuals through services provided by physicians and behavioral science and health education, this expertise has yet to be other health care professionals. Together, these two areas are tasked applied to the most trenchant issues related to climate change. with the protection of the health of the people of the United States. Sea-level rise, coastal erosion, and population displacement will Public health agencies exist across the United States in most large create challenges for public health infrastructure that has been cities, as well as at the county, state, and federal levels. Schools of constructed over a period of hundreds of years. Disruption of coastal public health and other training and research institutions add to the routes and harbors by sea-level rise will present additional challenges total public health infrastructure investment of the United States, to health care delivery and food distribution. It is doubtful that which is very large and quite complex. The public health system will transportation infrastructure will be able to adapt quickly enough to play a critical role in the prevention of human disease from climate large population shifts that may be made in response to changes in change. As such, public health agencies should be deeply involved in rainfall patterns. Displaced populations will need sewer and water researching, developing, and implementing adaptation strategies to resources in new locations. The sewer and water resources in coastal climate change. There is a critical need for research to understand locations may be threatened directly by sea-level rise. how climate change will alter our public health needs in the United 28 States, and to design optimal strategies to meet those needs. Capacities and Skills Needed. Many of the existing skills used in public health and health care are well established and applicable to The health care delivery infrastructure in the United States is even dealing with the health effects of climate change, but new skills will more diverse and complicated than the public health infrastructure also be needed. Skills used in certain types of disease surveillance (though there are multiple overlaps between the two systems). are well established. Less well established are the skills and methods From family doctors in small towns to complex university research needed to integrate current and future surveillance activities 27 clougherty, Je, et al., environ Health Perspect, 2009. 117(9): p. 1351-8, Green, rs, et al., environ Health Perspect, 2009. 117(12): p. 1939-44. 28 Bedsworth, l, environmental Health Perspectives, 2009. 117(4): p. 617-623. 29 rudowitz, r, et al., Health aff (millwood), 2006. 25(5): p. w393-406. www.niehs.nih.gov/climatereport 10

19 Crosscutting Issues A Human Health Perspective ON CLIMATE CHANGE In addition to the general public, other audiences—each with their and retrospective datasets with weather and climate information. own culture and means of acquiring information—also require Understanding of how to conceptualize and conduct epidemiological effective communication on issues of climate change. Stakeholders analysis using weather and climate as exposures is also preliminary. such as natural resource managers, policy makers, infrastructure Methods and skill in combining spatial epidemiology with ecological planners, health care providers, and others also need access to approaches are also lacking. There is a strong need for the ability to translate vulnerability mapping and health impact assessments credible and timely climate change information to inform their (HIAs) into behavioral changes and effective public health actions. decision-making. Protecting human health is an issue that crosses institutional, A greater emphasis must be placed on developing and maintaining scientific, and political boundaries. In the United States, no single interdisciplinary and inter-institutional collaborations, as well as on ensuring that established resources and expertise of all of the relevant institution at the local, regional, or federal level can fully protect disciplines, including climatology, modeling, environmental science, public health without cooperation from other institutions. In addition, no single scientific field is capable of accomplishing all risk assessment, public health, and communications and education, are applied to these pressing problems. Many additional disciplines aspects of the research needed to understand the human health including ecology, social science, economics, geography, behavioral consequences of global climate change; such an endeavor will require a broad-based, trans-disciplinary research portfolio. And psychology, and others will need to play a vital role in climate and health decision making. in our global society, the highly integrated activities of individuals around the world mean that no one country can be solely responsible for addressing the health impacts of global climate Communication and Education. Other areas where public change. Through the process of developing this white paper, it health professionals may contribute robustly to efforts to address rapidly became clear that identifying research needs; mobilizing and the impacts of climate change are in communication and education. creating the expertise, resources, tools, and technologies to address Public health educators have a strong history of promoting health them; and translating these efforts into solutions that will enable and wellness through educating individuals and communities about human adaptation to our changing environment while protecting healthy behaviors and disease prevention or management. The same public health will require collaborations on an unprecedented scale. skills are critical to helping raise awareness of the potential impacts Such collaborations should build on the strengths and capacities of of climate change, and translating the scientific research and other individual organizations in ways that maximize the efforts of the technical data into credible and accessible information for the public group toward these shared goals. to use in making informed decisions that will protect their health and the environment. Recent studies show that the majority of those living in the United States now believe that climate change is a real and serious threat that is caused by human activity. However, research is still needed to determine how to effectively educate and organize the public 30 respond. to This is complicated by recent research showing that various audiences within the American public respond to the issue 31 of climate change each in their own distinct way. Research is needed that will aid climate change communicators and educators in adapting their messages and approaches to most appropriately and effectively reach and be assimilated by each individual audience. ... 30 leiserowitz, a, et al., climate change in the american mind: americans’ climate change beliefs, attitudes, policy preferences, and actions. 2009, Yale Project on climate change, scool of Forestry and environmental sciences: New Haven, connecticut. p. 56. 31 maibach, e, et al., Global warming’s six americas 2009: an audience segmentation analysis. 2009, George mason University center for climate change communication: Washington, Dc. p. 140. www.niehs.nih.gov/climatereport 11

20 12

21 1 Allergies, Asthma, Respiratory and Airway Diseases environmental variables. As a result, changes to environment may Allergic diseases, including asthma, hay fever, rhinitis, and atopic dermatitis, impact approximately 50 million individuals within the adversely impact the severity of climate-sensitive diseases. United States and are associated with significant health care costs 32 and lost productivity. In addition to impacts on asthma and other allergic diseases, climate ­ In the early 1990s, the United States attrib change has the potential to impact airway diseases by increasing uted health care costs of $11 billion to all respiratory disease with 33 ground level ozone and possibly fine particle concentrations. an estimated loss of 3 million workdays and 10 million schooldays. Breathing ozone can trigger a variety of reactions including chest pain, Asthma is the second leading cause of chronic illness among coughing, throat irritation, and congestion; and can worsen bronchi ­ children and is rapidly rising among children less than five years of 34 tis, emphysema, and asthma. Exposure to ground-level ozone can also age; however, the prevalence of asthma is highest among adults. reduce lung function and inf lame the linings of the lungs; repeated Incidence rates of asthma and other respiratory allergic diseases 37 exposure may permanently scar lung tissue. are often difficult to obtain; however rates of prevalence and Fine particles (fewer disease exacerbation show a disproportionate trend along certain than 2.5 micrometers in diameter, or PM ) contain microscopic solids 2.5 socioeconomic lines. Hospitalization rates, emergency department or liquid droplets that are so small that they can get deep into the use, disability and death are often highest among children, African lungs where they cause serious health problems. Numerous scientific American and Hispanic populations, persons living in the inner city, studies have linked exposure to fine particle pollution to a variety of 35 and the poor. health problems including increased respiratory symptoms (irritation of the airways, coughing, difficulty breathing), decreased lung func ­ tion, aggravated asthma, development of chronic bronchitis, irregular In recent decades, the world has seen a sharp rise in prevalence as well heartbeat, nonfatal heart attacks, and premature death in people with as severity of such respiratory diseases. The incidence of respiratory 38 heart or lung disease. diseases grew markedly in the United States over the last several ­ decades but has begun to plateau in recent years. Some experts specu Impacts on Risk late that the global rise in asthma was indirectly related to climate 36 change. Climate change will affect air quality through several pathways including Many respiratory allergic diseases are seasonal with climate sensitive components; climate change may increase the incidence and production and allergenicity of aeroallergens such as pollen and mold spores and increases in regional ambient concentrations of ozone, fine exacerbation of such allergic diseases. While some risk for respiratory disease can be clearly linked to climate change, for many others the particles, and dust. Some of these pollutants can directly cause respira­ tory disease or exacerbate respiratory disease in susceptible individuals. risk attributable to climate change is unclear. Given the prevalence of these diseases and the significant disease burden imposed by asthma and respiratory allergic disease, further research into the impacts of Earlier f lower blooming resulting from temperature increases and climate change on these diseases should be a high priority. increased carbon dioxide (CO ) concentrations affects timing of dis ­ 2 tribution of aeroallergens such as pollen through plant photosynthesis 39 Management of asthma and other respiratory allergic diseases relies metabolism. and There is also a possibility that certain aeroallergens on several factors including strict control of exacerbation triggers of may become more allergenic as temperatures and CO concentrations 2 40 the diseases. Although not all asthmatic episodes are triggered by increase. Precipitation-affected aeroallergens such as mold spores environmental factors, a significant number are, including factors also are of concern, as 5% of individuals are predicted to have some 41 such as ambient air pollutants, allergens, stress, and a host of other respiratory allergic airway symptoms from molds over their lifetime. Uysal, N, et al., curr Opin Pulm med, 2003. 9(2): p. 144-50. 37 38 Kreyling, WG, et al., J aerosol med, 2006. 19(1): p. 74-83. 32 Bytomski, Jr, et al., curr sports med rep, 2003. 2(6): p. 320-4. stitt, m, Plant cell and environment, 1991. 14(8): p. 741-762. 39 33 smith, DH, et al., am J respir crit care med, 1997. 156(3 Pt 1): p. 787-93, Weiss, KB, et al., N engl J med, 1992. cassassa, G, et al. 2007, cambridge: cambridge University Press, rogers, ca, et al., environmental Health 40 326(13): p. 862-6. Perspectives, 2006. 114(6): p. 865-869, shea, Km, et al., Journal of allergy and clinical immunology, 2008. 122(3): 34 Benson, V, et al., Vital Health stat 10, 1998(190): p. 1-428. 443-453, Vose, rs, et al., Nature, 2004. 427(6971): p. 213-214, Wan, sQ, et al., american Journal of Botany, 2002. p. mannino, Dm, et al., mmWr cDc surveill summ, 1998. 47(1): p. 1-27a 35 89(11): p. 1843-1846, Ziska, lH, et al., Global change Biology, 2005. 11(10): p. 1798-1807. D’amato, G, et al., clinical and experimental allergy, 2008. 38(8): p. 1264-1274. 36 41 Hardin, BD, et al., J Occup environ med, 2003. 45(5): p. 470-8. www.niehs.nih.gov/climatereport 13

22 A Human Health Perspective Asthma, Respiratory Allergies, and Airway Diseases ON CLIMATE CHANGE 49 In the presence of certain air emissions, the rate of ozone formation adults over 65 years of age. Increased incidence of wildfires in some increases with higher temperatures and increased sunlight, and can areas can also contribute to PM concentrations. In certain areas airborne dust serves as a carrier of specific diseases, such as coccidioidomycosis, also be affected by changes in storm tracks, humidity, and stability of 42 the boundary layer (lowest part of the or “valley fever,” in the desert Southwest, the incidence of which has atmosphere). Humidity and 50 increased in recent years. temperature also partly determine the formation of PM Prolonged drought will lead to more dust and . Research 2.5 particulate pollution while increased rainfall will cleanse the air but may studies associate fine particles with negative cardiovascular outcomes such as heart attacks, formation of deep vein blood clots, and increased create more mold and microbial pollution. In addition, drought, declining 43 water quality, and increased temperatures contribute to the growth of mortality from several other causes. These adverse health impacts 44 harmful algal blooms that produce toxins that can be aerosolized and intensify as temperatures rise. Studies also link elevated exposure 51 exacerbate asthma and respiratory diseases. to ground-level ozone, PM , coarse thoracic PM, and aeroallergens to 2.5 decreased lung function, aggravation of asthma, rhinitis, exacerbations of chronic obstructive pulmonary disease, hospitalizations for respira ­ Despite strong evidence of associations between a wide range of tory and cardiovascular diseases, and premature mortality. environmental variables impacted by climate and respiratory disease, the direct impacts of climate change on asthma, respiratory allergies, and airway diseases need further study to evaluate the fraction of Air pollution overcomes the mucosal barrier in lungs by inducing airway 45 respiratory disease risk that can be attributed to climate change and inf lammation, which results in allergen-induced respiratory responses. potentially mitigated or avoided. In addition, air pollutants such as PM ­ and ozone may alter the al 2.5 lergenicity of aeroallergens like pollen, thereby promoting further airway 46 Mitigation and Adaptation sensitization. The triggers for such adverse respiratory responses vary and include climatic factors (meteorological events, rainfall patterns, Mitigation and adaptation strategies have the potential to both and temperature anomalies), high levels of vehicle emissions, land-use positively and negativel affect human health. Reduction of vehicle patterns, variables in the built environment, geography, and distance miles traveled will reduce ozone precursors, thereby reducing the 47 from roadways. ozone associated with myriad respiratory health effects. Alternative Physiology also plays a significant role, as individuals transportation options such as walking and bicycling will reduce toxic with existing respiratory conditions are most vulnerable to disease 48 emissions while providing positive benefits for health such as increasing exacerbations triggered by the environment. The populations most cardiovascular fitness and contributing to weight loss (although such vulnerable to the increased disease risks include children, pregnant activities also have the potential to increase exposure to harmful women, persons of low socioeconomic status, persons situated near high outdoor air pollutants, particularly in urban areas, simply by virtue of ­ traffic zones within urban centers, and those with preexisting respira 52 increased time spent outdoors) tory and cardiovascular diseases. . Mitigation of short-lived contaminant species that are both air pollutants and greenhouse gases is gaining 53 Other airborne exposures are also likely to worsen with climate vari ­ momentum. For example, controlling ozone or black carbon could ability and change. Changes in the hydrologic cycle with increasingly bring short-term climate benefits and alleviate a fraction of the current variable precipitation and more frequent drought may also lead to a global health burden from these pollutants. Urban tree cover has been shown 54 increase of airborne dust, which, when coupled with anticipated stagnant to reduce ambient concentrations of ozone, PM, and other pollutants. air masses and increasingly strong inversion layers, will trap ozone and Significant co-benefits of urban vegetation include shade, which reduces other airborne pollutants near the ground causing exacerbations of the heat-island effect and decreases energy required to cool buildings, 55 respiratory disease. Coarse thoracic PM (between 2.5 and 10 micrometers emissions. and a concomitant reduction in greenhouse gas in diameter) is associated with increased risk of emergency department visits and hospitalizations for cardiovascular outcomes, especially among 42 Houghton, JT, et al. 2001, cambridge ; New York: cambridge University Press. x, 881 p. 49 Ballester, F, et al., Gac sanit, 2006. 20 suppl 1: p. 160-74, le Tertre, a, et al., J epidemiol community Health, 2002. 43 Bytomski, Jr, et al., curr sports med rep, 2003. 2(6): p. 320-4, Vose, rs, et al., Nature, 2004. 427(6971): p. 213-214, 56(10): p. 773-9, Zanobetti, a, et al., environ Health Perspect, 2003. 111(9): p. 1188-93. Baccarelli, a, et al., archives of internal medicine, 2008. 168(9): p. 920-927, confalonieri, U, et al. in climate 50 Komatsu, K, et al., Journal of the american medical association, 2003. 289(12): p. 1500-1502, Vugla, DJ, et al., change 2007: impacts, adaptation and Vulnerability. contribution of Working Group ii to the Fourth assessment Journal of the american medical association, 2009. 301(17): p. 1760-1762. report of the intergovernmental Panel on climate change, m Parry, et al., editors. 2007, cambridge University Press: cambridge. p. 391-431, O’Neill, s, et al., Occupational and environmental medicine, 2007. 64(6): p. 373-379, Peters, abraham, Wm, et al., environmental Health Perspectives, 2005. 113(5): p. 632-637, Fleming, le, et al., chest, 2007. 51 a, et al., circulation, 2001. 103(23): p. 2810-2815, samoli, e, et al., environmental Health Perspectives, 2008. 116(11): 131(1): p. 187-194. p. 1480 -1486. 52 Woodcock, J, et al., lancet, 2009. 374(9705): p. 1930-43. 44 Qian, Zm, et al., environmental Health Perspectives, 2008. 116(9): p. 1172-1178. 53 smith, Kr, et al., ibid. D’amato, G, et al., clinical and experimental allergy, 2008. 38(8): p. 1264-1274. 45 54 Bowker, G, et al., atmospheric environment, 2007. 41: p. 8128-8139, Nowak, D, et al., Urban Forestry and Urban 46 D’amato, G, et al., respiratory medicine, 2001. 95(7): p. 606-611. Greening, 2006. 4: p. 115-123. shea, Km, et al., Journal of allergy and clinical immunology, 2008. 122(3): p. 443-453. 47 55 Bolund, P, et al., ecological economics, 1999. 29: p. 293-301, mcPherson, e, et al., Urban ecosystems, 1997. 1: p. 49 - 61. D’amato, G, et al., clinical and experimental allergy, 2008. 38(8): p. 1264-1274. 48 www.niehs.nih.gov/climatereport 14

23 Asthma, Respiratory Allergies, and Airway Diseases A Human Health Perspective ON CLIMATE CHANGE Adaptive measures such as increased use of air conditioning may al ­ studying the health effects of airborne and indoor dust on asthma • leviate some of the health effects associated with exposure to chronic exacerbation, including changes in dust composition resulting from or acute heat, but also can potentially result in higher greenhouse climate change gas emissions and further declines in air quality, depending on the understanding the acute and long-term impacts of wildfires on • method of power generation. Health-based research to inform the use asthma and other respiratory diseases of novel fuel mixtures and electric vehicles will be important. Some examining chemicals used in energy efficient technologies to ensure • impacts have been well characterized through life-cycle analyses, that they do not contribute to lung sensitization, asthma, or other while others, particularly those related to novel fuels and energy respiratory diseases sources, have yet to be assessed. Careful analyses of mitigation and adaptation co-benefits and tradeoffs are necessary so that appropriate examining the relative risks for respiratory disease based on • strategies are adopted. chemicals with lower global warming potential than existing greenhouse gases Research Needs developing early warning systems for state and local governments • Climate change will likely amplify existing environmental stimulation and public and environmental health officials to anticipate and of asthma, respiratory allergies, and airway disease, resulting in more mitigate climate-related health impacts severe and frequent disease exacerbations and an increase in the overall burden of these conditions. Thus, continued research on climate improving methods of identifying risks and communicating with • change’s effect on alterations in the composition of aeroallergens vulnerable populations to reduce climate change impacts on all and air pollutant mixtures and their consequent effects on health is respiratory diseases essential. Research needs include: ­ developing decision support tools including health impact assess • developing and validating real-time remote sensing and other • in ments (HIAs) of the burden of respiratory diseases attributable to situ monitoring techniques to evaluate air quality, aeroallergens, climate change for help in identifying and selecting climate change aerosolized pathogens, dust burdens, and other climate-sensitive and air quality mitigation and adaptation policies that will promote exposures directly linked to asthma and airway diseases health benefits understanding and modeling the impact of climate change on air • Research needs also call for improvements in various capacities and quality, aeroallergens, and aerosolized marine toxins, and the result ­ skills. Air pollution modeling is well established and the health impacts ing effects on asthma and airway diseases including in vulnerable of several species of particles and aeroallergens are reasonably well populations understood. However, the complex introduction of aeroallergens under a changing climate will require the expansion of scientific expertise applying modeling originally developed to assess health effects of air • to include botany and ecology in addition to meteorology and the built pollution and other ecological niche modeling to climate-sensitive environment. Research will require the use of geographic information diseases systems (GIS) and remote sensing expertise in new ways, as well as the establishing climate-sensitive exposure metrics, with appropriate • application of novel vulnerability mapping techniques, early warning temporal and spatial dimensions, that are most strongly associated systems, and other public health tools. Spatial epidemiological methods with asthma, allergy, and airway diseases will bring new power to ecological studies of air quality and public health. Identification and collection of integrated and appropriately identifying and mapping populations and communities at increased • scaled social, ecological, and epidemiological data are needed for risk of climate-related respiratory disease, which will also help to effective monitoring and modeling. For health communications, novel identify populations at risk for other climate-related health impacts strategies are required to identify vulnerable populations and develop as many environmentally mediated diseases share common risk communication strategies that will effectively reduce risk. factors using epidemiological investigations to study the relationship • between climate variables; altered production, distribution, and reactivity of pollen and marine toxins; changes in air pollutants; and the prevalence, severity, and onset of asthma exacerbations www.niehs.nih.gov/climatereport 15

24 16

25 2 Cancer C ancer refers to a group of diseases in which abnormal cells divide development include pathogens, environmental contaminants, age, and genetics. Given the challenges of understanding the causes of without control and are able to invade other tissues. There are more cancer, the links between climate change and cancer are a mixture of than 100 different types of cancer, and they are generally referred to by the organ or type of cell in which they arise (e.g. breast, prostate, fact and supposition, and research is needed to fill in the gaps in what colon). Cancer is the second leading cause of death in the United we know. States after heart disease, killing more than half a million people 56 Impacts on Risks every year. Lung cancers, with about 220,000 new cases per year 57 and about 160,000 deaths, One possible direct impact of climate change on cancer may be account for about 30% of overall deaths 58 through increases in exposure to toxic chemicals that are known States. from cancer in the United The main cause of lung cancer is 59 or suspected to cause cancer following heavy rainfall and by smoking, especially cigarettes, but air pollution, including indoor 61 60 increased volatilization of chemicals under conditions of increased air pollution and fine particulates, also contributes to the burden temperature. In the case of heavy rainfall or f looding, there may of lung cancers. be an increase in leaching of toxic chemicals and heavy metals from storage sites and increased contamination of water with There are potential impacts on cancer both directly from climate runoff containing persistent chemicals that are already in the change and indirectly from climate change mitigation strategies. environment. Marine animals, including mammals, also may suffer Climate change will result in higher ambient temperatures that may direct effects of cancer linked to sustained or chronic exposure to increase the transfer of volatile and semi-volatile compounds from chemical contaminants in the marine environment, and thereby water and wastewater into the atmosphere, and alter the distribution 64 serve as indicators of similar risks to humans. of contaminants to places more distant from the sources, changing Climate impact 62 subsequent human exposures. studies on such model cancer populations may provide added Climate change is also expected to dimensions to our understanding of the human impacts. increase heavy precipitation and f looding events, which may increase the chance of toxic contamination leaks from storage facilities or runoff into water from land containing toxic pollutants. Very little is Another direct effect of climate change, depletion of stratospheric known about how such transfers will affect people’s exposure to these ozone, will result in increased ultraviolet (UV) radiation exposure. chemicals—some of which are known carcinogens—and its ultimate UV radiation exposure increases the risk of skin cancers and cata ­ 65 63 impact on incidence of cancer. racts. The incidence of typically nonlethal basal cell and squamous ­ More research is needed to deter cell skin cancers is directly correlated to the amount of exposure to mine the likelihood of this type of contamination, the geographical areas and populations most likely to be impacted, and the health UV radiation. This effect is compounded by several other variables including temperature and exposure to other compounds that can outcomes that could result. 66 amplify the carcinogenic potential of UV radiation. Rising tempera ­ Although the exact mechanisms of cancer in humans and animals tures (such as occur at night versus day and in summer versus winter) are not completely understood for all cancers, factors in cancer are associated with increases in UV exposure. If increases in average or peak temperatures occur as a result of climate change, an increase 67 56 National cancer institute. What is cancer?, 2009 [cited 2009 July 21]; available from: http://www.cancer.gov/ occur. in the incidence of non-melanoma skin cancers may Previous cancertopics/what-is-cancer. National cancer institute. lung cancer, 2009 57 [cited 2009 July 26]; available from: http://www.cancer.gov/ studies have shown that increased UV radiation exposure combined cancertopics/types/lung. 58 centers for Disease control and Prevention. leading causes of death, 2006, 2009 [cited 2009 July 22]; available with certain polycyclic aromatic hydrocarbons (PAHs) can enhance from: http://www.cdc.gov/nchs/FasTaTs/lcod.htm. 59 Beelen, r, et al., epidemiology, 2008. 19(5): p. 702-10. 60 ibid. mcaloose, D, et al., Nat rev cancer, 2009. 9(7): p. 517-26. 64 61 Krewski, D, et al., res rep Health eff inst, 2009(140): p. 5-114; discussion 115-36, Pope, ca, 3rd, et al., Jama, 2002. 287(9): p. 1132-41. 65 Tucker, ma, Hematol Oncol clin North am, 2009. 23(3): p. 383-95, vii. macdonald, rW, et al., Human and ecological risk assessment, 2003. 9(3): p. 643-660. 62 66 Burke, Ke, et al., Toxicol ind Health, 2009. 25(4-5): p. 219-24. Bates, B, et al., climate change and water. 2008, intergovernmental Panel on climate change: Geneva. p. 210. 63 67 van der leun, Jc, et al., Photochem Photobiol sci, 2008. 7(6): p. 730-3. www.niehs.nih.gov/climatereport 17

26 A Human Health Perspective Cancer ON CLIMATE CHANGE 68 However, For example, nanotechnology may be promising for mitigating the phototoxicity of these compounds and damage DNA. it is also possible that increased exposure to UV radiation could climate change through its use in efficient hydrogen powered vehicles, enhanced and cheaper solar power technology, and the development elevate levels of circulating Vitamin D, which has been associated 69 with a decreased risk for certain cancers such as colorectal of a new generation of batteries and supercapacitors, yet little is known cancer. about potential links to cancer and other health outcomes. Increased UV radiation also could impact the human immune system and alter the body’s ability to remove the earliest mutant cells that New technologies have been proposed to decrease our dependence on begin the cancer process, although it is unclear whether these changes 70 greenhouse gas-intensive power generation and fuel use. However, would be beneficial or detrimental. many of these have potential impacts on cancer that should be more Mitigation and Adaptation ­ fully investigated prior to being implemented. The widespread adop tion of biofuels may have unintended consequences including possible In addition to direct impacts of climate change on cancer, the impact increases or decreases in cancer due to a change in the level of existing of mitigation strategies on cancer should also be considered. For 73 pollutants or the creation and emissions of new air pollutants. instance, co-benefits of decreased greenhouse gas emissions and decreased cancer incidence may be attainable with energy efficient Also, barring changes in agricultural practices, there is potential for power generation and reduced emissions through lower vehicle miles increased pesticide use for the growth of certain biofuels such as corn traveled. These benefits could be realized through decreases in toxic ethanol. Exposure to some legacy pesticides has been implicated for 74 outputs of fossil fuel-based power generation and transportation, cancer in both adults and children, leading to current efforts by the including sulfur oxide and particulate matter (PM), which have been EPA to avoid this problem in new products. 71 implicated in lung cancer. Research is needed to understand if there are cancer implications from the use of electric vehicles, including the production and Decreases in greenhouse gas emissions are generally associated with disposal of portable electric storage systems. Manufacturing of decreases in cancers that occur due exposure to such pollutants. batteries for electric cars and photovoltaic (solar) power systems may Increased energy efficiency will lead to reductions in emissions of sulfur have consequences including increased exposure to metals. The most dioxide, nitrous oxides, and PM, which should lead to reductions in rates 72 common type of battery currently in use is the nickel-metal-hydride of premature death including from certain cancers. In most cases, (NiMH) battery, with other types of batteries (lithium ion, lithium these emission reductions will also result in subsequent reductions ion polymer, valve regulated lead acid, and nickel-cadmium) also in ambient concentrations of ozone and secondary PM , which have 2.5 under development for vehicle use. Increased use of NiMH batteries been implicated in a variety of health effects including lung cancer. will necessarily require significant increases in nickel production and Reductions in other hazardous air pollutants, such as heavy metals from the impacts associated with nickel mining and refining. High-level power generation and industrial processes that are known or suspected nickel exposure is associated with increased cancer risk, respiratory to cause cancer or other serious health effects, may also occur. disease, and birth defects; the same is true with certain other metals, especially cadmium and lead. Several technologies currently being pursued to decrease greenhouse gas emissions may also help to reduce cancer incidence. For example, Increased production of solar cells also can lead to increased environ ­ reducing greenhouse gas emissions from the transportation sector may 75 mental risks. be accomplished by reducing vehicle miles traveled through a variety For example, cadmium-tellurium (CdTe) compounds of approaches such as high-density development, preservation of green in photovoltaic systems and the potential for increased cadmium space, and widespread use of mass transit. However, the impacts of emissions from mining, refining, and the manufacture, utilization, some mitigation technologies on cancer have not been fully explored. and disposal of photovoltaic modules. Cadmium and cadmium compounds like CdTe are classified as known human carcinogens 68 Dong, s, et al., chem res Toxicol, 2000. 13(7): p. 585-93, Toyooka, T, et al., environ mol mutagen, 2006. 47(1): p. 3 8 - 47. 73 Hill, J, et al., Proceedings of the National academy of sciences of the United states of america, 2009. 106(6): p. Garland, cF, et al., ann epidemiol, 2009. 19(7): p. 468-83. 69 2077-2082. sleijffers, a, et al., J immunotoxicol, 2004. 1(1): p. 3-14. 70 74 Flower, KB, et al., environ Health Perspect, 2004. 112(5): p. 631-5, Kang, D, et al., environ res, 2008. 107(2): p. 71 Pope, ca, 3rd, et al., Jama, 2002. 287(9): p. 1132-41. 271-6, mahajan, r, et al., environ Health Perspect, 2006. 114(12): p. 1838-42. Woodcock, J, et al., lancet, 2009. 374(9705): p. 1930-43, Haines, a, et al., lancet, 2009, Wilkinson, P, et al., lancet, 72 75 Fthenakis, V in Practical handbook of photovoltaics : fundamentals and applications, T markvart, et al., editors. 2003, 2009. 374(9705): p. 1917-29. elsevier advanced Technology: New York, Fthenakis, Vm, et al., environ sci Technol, 2008. 42(6): p. 2168-74. www.niehs.nih.gov/climatereport 18

27 Cancer A Human Health Perspective ON CLIMATE CHANGE their potential to increase or decrease cancer risks. Research needs by the National Toxicology Program and the International Agency include: for Research on Cancer and as probable human carcinogens by the 76 E PA . Acute exposure to CdTe can result in respiratory irritation utilizing animal cancer surveillance and investigations as sentinel • and toxicity. Some of the other hazardous materials present in biomedical models to better understand the environmental factors, ­ solar manufacturing include arsenic compounds, carbon tetra mechanisms, and pathways of mammalian cancer risk chloride, hydrogen f luoride, hydrogen sulfide, lead, and selenium 77 developing and sustaining facilities and expertise to rapidly • compounds, many of which have been linked with multiple health assess and monitor the threat of previously unrecognized toxins, effects, including cancer. carcinogens, and other bioactive molecules produced in response to stress on marine environments Production of hydrogen fuel cells will require significant increases in the total amount of platinum consumed worldwide, with a similar understanding the impact of increased heavy precipitation and • increase in mining and the environmental impacts associated with f looding events on the risk of toxic contamination of the environ ­ mining, processing, and transport. If hydrogen is used in a significant ment from storage facilities or runoff from land containing toxic way as a transportation fuel, consideration must be given to the impacts chemicals, including the geographical areas, ecosystems, and of emissions from leaks during production, fueling, and operation. populations most likely to be impacted and the health outcomes Increased hydrogen leaks could result in stratospheric ozone depletion that could result 78 by up to 20%, which could lead to increased incidence of skin cancer. ­ understanding how climate changes such as changes in tempera • ture and precipitation affect exposure to toxic chemicals including For mitigation of climate change, nuclear power has been suggested volatile and semi-volatile compounds and known or suspected as a possible alternative to coal-based power generation. Although human carcinogens the risks associated with direct exposure to radiation from nuclear power generation have been below accepted danger levels throughout elucidating the effects of ambient temperature on UV radiation- • the industry’s history, the human health consequences over the full induced skin cancers, including the amplification of non- nuclear energy life cycle (production through waste disposal) may be melanoma skin cancers 79 of greater concern. evaluating the potential cancer risks through the entire life cycle • of biofuel production, including risks from novel air pollutants and Heatlth Impact Assessments (HIAs) are a useful emerging strategy changes in agricultural practices that may increase exposures to for evaluating the health effects of novel policies and technologies pesticides, herbicides, and other environmental contaminants at various scales, and have already been applied to several potential 80 climate change mitigation strategies. ­ Given the widespread uncer understanding cancer risks from the life cycle emissions of • tainty regarding the potential health impacts, including cancer, of carcinogens and untested compounds associated with alternative certain mitigation strategies, HIAs can be a valuable tool for evaluating energy and transportation technologies, particularly electricity possible health effects, especially when used in combination with other storage systems and photovoltaic systems approaches to life-cycle assessment. clarifying the life cycle cancer risks of nuclear energy radiation, • including through occupational and environmental exposures Research Needs Many of the cancer risks resulting from the direct effects of climate developing mechanisms to conserve and explore marine and • change have been fairly well studied. The largest research gaps are in terrestrial biodiversity in environments likely to yield cancer cures the materials and methods used for mitigation and adaptation, and and treatments ... characterizing and quantifying changes in cancer rates from • 76 rep carcinog, 2005(11): p. 1-a32. 77 Fthenakis, V in Practical handbook of photovoltaics : fundamentals and applications, T markvart, et al., editors. 2003, implementation of specific greenhouse gas mitigation strategies, elsevier advanced Technology: New York. Tromp, TK, et al., science, 2003. 300(5626): p. 1740-2. 78 especially for existing fossil fuel-based energy production and use 79 massachusetts institute of Technology. 2003, [Boston ma]: miT. x, 170 p. Patz, J, et al., Health impact assessment of global climate change: expanding on comparative risk assessment 80 approaches for policy making, in annual review of Public Health. 2008. p. 27-39. www.niehs.nih.gov/climatereport 19

28 20

29 3 Cardiovascular Disease and Stroke Impacts on Risk Cardiovascular disease refers to a class of diseases that pertain to the heart or blood vessels. Cardiovascular disease is the leading cause of Cardiovascular mortality associated with heat has been declining death in the United States, with 631,636 deaths in 2006, the last year over time, presumably the result of increased air conditioning use; 86 for which statistics are available. Stroke is the third leading cause, constant. mortality associated with extreme cold has remained 81 87, 88 with 131,119 deaths in 2006. Cardiovascular hospital admissions increase with heat. Approximately 80 million Americans 89 Dysrhythmias are primarily associated with extreme cold, have some form of cardiovascular disease including hypertension, 82 coronary artery disease, heart attack, or stroke. though associations with dysrhythmias and heat illness have been Other cardiovascular 90 reported. diseases such as cardiac dysrhythmias (abnormal electrical activity Stroke incidence increases with increasing tempera­ 91 in the heart), deep venous thrombosis (blood clots), and pulmonary ture, as well. For all direct associations between temperature and embolism (blood clots in the lung) increase the numbers further. The cardiovascular disease and stroke, elderly and isolated individuals American Heart Association and the National Heart, Lung, and Blood are at greatest risk. Institute together estimate that cardiovascular disease will be respon ­ sible for $475.3 billion in direct and indirect health care expenditures Indirect impacts of weather, weather variability, and climate changes 83 in 2009. on cardiovascular disease are many and varied. Associations between Altogether, this diverse set of conditions is a major driver of air quality, especially ozone and particulate burdens, and cardiovas ­ health care expenditures and disability. cular disease appear to be modified by weather and climate. Ozone, whose formation increases with temperature, increases cardiac There is evidence of climate sensitivity for several cardiovascular 92 effort and impairs pulmonary gas exchange. diseases, with both extreme cold and extreme heat directly affecting Ozone concentrations the incidence of hospital admissions for chest pain, acute coronary modify the association between temperature and cardiovascular 93 syndrome, stroke, and variations in cardiac dysrhythmias, though mortality, and are also associated with acute myocardial infarc ­ 94 the reported magnitude of the exposure-outcome associations tion (as discussed in the chapter on Asthma, Respiratory Allergies, 84 is variable. and Airway Diseases). Particulate matter is associated with a variety Weather conditions such as extreme heat serve as of pathophysiological changes including systemic inf lammation, stressors in individuals with pre-existing cardiovascular disease, 85 deranged coagulation and thrombosis, blood vessel dysfunction and and can directly precipitate exacerbations. There is also evidence atherosclerotic disease, compromised heart function, deep venous that heat amplifies the adverse impacts of ozone and particulates on 96 95 thromboses, cardiovascular disease. These pollutants are likely to be affected by Increased burden of PM and pulmonary embolism. 2.5 climate change mitigation activities, and thus, likely reduce rates of is associated with increased hospital admissions and mortality from 97 98 cardiovascular morbidity and mortality. While the fraction of disease cardiovascular disease, as well as ischemic heart disease. risk attributable to weather and associated environmental exposures is not known, given the prevalence of cardiovascular disease and the Other climate-related exposures are indirectly associated with preventable nature of the exposures, further research into associations incidence of cardiovascular disease and disease exacerbations. between weather, climate variability, long-term climate change, and Barnett, aG, epidemiology, 2007. 18(3): p. 369-72. 86 cardiovascular disease is an immediate need. 87 ebi, Kl, et al., int J Biometeorol, 2004. 49(1): p. 48-58, morabito, m, et al., international Journal of cardiology, 2005. 105(3): p. 288-293. schwartz, J, et al., epidemiology, 2004. 15(6): p. 755-761. 88 Kysely, J, et al., Bmc Public Health, 2009 Jan 15;9:19.. 89 centers for Disease control and Prevention. leading causes of death, 2006, 2009 [cited 2009 July 22]; available 81 al-Harthi, ss, et al., int J cardiol, 1992. 37(2): p. 151-4. 90 from: http://www.cdc.gov/nchs/FasTaTs/lcod.htm. 91 ebi, Kl, et al., int J Biometeorol, 2004. 49(1): p. 48-58. american Heart association. cardiovascular disease statistics, 2006, 2009 [cited 2009 July 22]; available from: 82 92 Gong, H, et al., american Journal of respiratory and critical care medicine, 1998. 158(2): p. 538-546. http://www.americanheart.org/presenter.jhtml?identifier=4478 . ren, c, et al., Occupational and environmental medicine, 2008. 65(4): p. 255-260. 93 american Heart association. cardiovascular disease cost, 2009, 2009 [cited 2009 July 22]; available from: http:// 83 . www.americanheart.org/presenter.jhtml?identifier=4475 94 ruidavets, JB, et al., circulation, 2005. 111(5): p. 563-569. Bassil, Kl, et al., environmental research, 2009. 109(5): p. 600-606, Kilbourne, em, am J Prev med, 1999. 16(4): 84 Baccarelli, a, et al., archives of internal medicine, 2008. 168(9): p. 920-927. 95 p. 359-60, mcGeehin, ma, et al., environ Health Perspect, 2001. 109 suppl 2: p. 185-9, Piver, WT, et al., environ 96 Brook, rD, clinical science, 2008. 115(6): p. 175-187. Health Perspect, 1999. 107(11): p. 911-6, Ye, F, et al., environ Health Perspect, 2001. 109(4): p. 355-9. 97 Jerrett, m, et al., New england Journal of medicine, 2009. 360(11): p. 1085-1095. Fouillet, a, et al., international archives of Occupational and environmental Health, 2006. 80(1): p. 16-24, 85 98 Pope, ca, et al., Journal of the air & Waste management association, 2006. 56(6): p. 709-742. Wainwright, s, et al., american Journal of epidemiology, 1994. 139(11): p. s49-s49. www.niehs.nih.gov/climatereport 21

30 A Human Health Perspective ON CLIMATE CHANGE Cardiovascular Disease and Stroke Extreme weather events affect cardiovascular health through several Mitigation and Adaptation pathways. Directly, the stress of the event and anxiety over event The likely impacts of climate change mitigation activities on risk of 99 recurrence are associated with myocardial infarction, cardiovascular disease and stroke depend primarily on emissions- sudden car ­ 100 101 associated energy production activities, particularly in the transpor ­ and development of stress-related cardiomyopathy. diac death, tation sector. Some mitigation activities related to energy production, Indirectly, displacement related to disasters is frequently associated 102 such as the increased use of wind, wave, solar, and nuclear sources of with interruptions of medical care for chronic medical conditions, power generation, are likely to reduce cardiovascular disease risks by putting populations with chronic cardiovascular conditions at risk reducing particulate and other air pollution emissions. for disease exacerbations. Mitigation activities such as increasing the density of urban develop ­ Climate is also implicated in another indirect risk for cardiovascular ment, enhancing public transportation options, and encouraging disease: the incidence of certain vectorborne and zoonotic diseases alternatives to single occupancy vehicle use are likely to benefit (VBZD) with cardiovascular manifestations. One estimate holds that cardiovascular fitness, reducing the overall burden of cardiovascular approximately 10% of strokes in the developing world are related to 103 108 disease. exposure to certain VBZD, many of which are climate sensitive. In More research is needed, including economic analyses, to determine the most beneficial strategies to pursue. As with repara particular, Chagas disease is an important cause of stroke worldwide ­ tory health risks, risks of cardiovascular disease and stroke may be (although not in the United States); 20 million people globally have reduced in urban populations through filtration of ambient pollut ­ chronic Chagas, which is an independent risk factor for stroke 109 104 ants by tree cover. in Latin America Co-benefits of tree cover include heat-island and a leading cause of heart failure in South 105 alleviation, reduced energy use to cool buildings, and consequent America. There is some evidence of climate sensitivity for Chagas 110 106 reductions in greenhouse gas emissions. disease, though the topic is little studied. In the United States, Lyme disease is a prevalent vectorborne disease that has cardiovas ­ 107 cular manifestations, though the incidence of such manifestations Fuel mixtures each have different particulate and other criteria is much lower than that associated with Chagas disease. ­ pollutant profiles, and variously reduce net greenhouse gas emis 111 sions. Fuel mixtures associated with high emissions of particulates or other pollutants such as nitrous oxides and carbon monoxide will There is little published literature on the projected direct and indi ­ 112 have adverse impacts on cardiovascular health, rect impacts of climate change on cardiovascular disease incidence. as these pollutants Many of the studies coupling down-scaled climate projections with are associated with incidence of cardiovascular hospital admissions 113 health outcomes have examined a particular exposure, such as heat among those with existing heart disease. Preliminary analysis of 114 or ozone, and projected mortality based on known associations, but certain biodiesel blends is promising but more research is needed do not make specific projections as to the incidence of cardiovascular to fully characterize likely health impacts of large-scale mitigation 115 morbidity and mortality. Insofar as climate change will bring activities related to transport fuels. Some biodiesel blends appear 116 increased ambient temperatures, increasingly variable weather, and to produce emissions with few negative health consequences. increased extreme events, we can infer that climate change will likely While an association between PM exposure and increased risk of have an overall adverse impact on the incidence of cardiovascular cardiovascular disease has been demonstrated, it is unclear which disease. Similarly, the impact of climate change on the incidence chemical constituents mediate this effect. More research is needed of cardiovascular complications from extreme weather events and to better identify these pollutants, which in turn will help to predict 117 certain VBZD is also likely to increase. However, the magnitude the potential benefits of alternative combustible fuels. Due to of these effects and the degree to which they can be lessened with Frumkin, H, et al., american Journal of Public Health, 2008. 98(3): p. 435-445. 108 adaptation efforts is unclear and warrants much further study. 109 Bowker, G, et al., atmospheric environment, 2007. 41: p. 8128-8139, Nowak, D, et al., Urban Forestry and Urban Greening, 2006. 4: p. 115-123. 110 Bolund, P, et al., ecological economics, 1999. 29: p. 293-301, mcPherson, e, et al., Urban ecosystems, 1997. 1: p. 99 suzuki, s, et al., american Heart Journal, 1997. 134(5): p. 974-977. 49 - 61. 100 leor, J, et al., New england Journal of medicine, 1996. 334(7): p. 413-419. 111 Hill, J, et al., Proc Natl acad sci U s a, 2006. 103(30): p. 11206-10. Watanabe, H, et al., Journal of the american medical association, 2005. 294(3): p. 305-307. 101 112 Hill, J, et al., Proceedings of the National academy of sciences of the United states of america, 2009. 106(6): p. Krousel-Wood, ma, et al., american Journal of the medical sciences, 2008. 336(2): p. 99-104. 102 2077-2082. 103 carod-artal, FJ, revista De Neurologia, 2007. 44(12): p. 755-763. 113 mann, JK, et al., environmental Health Perspectives, 2002. 110(12): p. 1247-1252. 104 ibid. 114 mccormick, rl, inhalation Toxicology, 2007. 19(12): p. 1033-1039. Bocchi, ea, et al., Heart, 2009. 95(3): p. 181-189. 105 115 swanson, KJ, et al., environmental Health Perspectives, 2007. 115(4): p. 496-499. carcavallo, rU, memorias Do instituto Oswaldo cruz, 1999. 94: p. 367-369. 106 116 mccormick, rl, inhalation Toxicology, 2007. 19(12): p. 1033-1039. cox, J, et al., american Heart Journal, 1991. 122(5): p. 1449-1455. 107 117 Brook, rD, et al., circulation, 2004. 109(21): p. 2655-71. www.niehs.nih.gov/climatereport 22

31 A Human Health Perspective ON CLIMATE CHANGE Cardiovascular Disease and Stroke the unique electrophysiological properties associated with the very developing a national standard for heat-related mortality to • high heart rates of the rodents most commonly used in researching facilitate epidemiologic study of mortality from heat and other 119 dysrhythmia, these biomedical models do not always closely replicate co-morbid conditions human conditions. In contrast, the rates and underlying physiology • targeting research on early warning systems and health com ­ of fish hearts are closer to humans and, as such, fish models should munications aimed at groups particularly at risk for adverse be explored as tools for understanding and screening the effects of cardiovascular outcomes related to climate change 118 various transport fuels. identifying and quantifying the co-benefits to cardiovascular • health of reducing our reliance on fossil fuel-based energy and Projecting the health impacts of adaptation activities, particularly the changing emission scenarios increased use of air conditioning to protect vulnerable populations from extreme heat, requires assumptions regarding how these activi ­ characterizing both the potential health risks and benefits of novel • ties will be powered. For instance, if significant additional electricity fuels and other energy production activities being considered for demand is met through increased fossil fuel combustion, then there is large-scale adoption as part of a national mitigation strategy likely to be increased exposure to particulates and ozone as a result. However, these exposures may be partially offset by the protective Several cardiovascular disease research priorities dovetail with effect of air conditioning. Most other adaptation activities are likely to other areas. In particular, research into health impacts of increased have little direct impact on cardiovascular disease incidence. temperature, extreme weather, and changes in air quality associated with climate change will inform research into cardiovascular health Research Needs impacts. Similarly, research into early warning systems and inte ­ grated assessment models is transferable to other health outcomes As noted, there are significant gaps in our understanding of climate associated with climate change, and research into the health impacts change impacts on cardiovascular disease, particularly for morbidity, of potential mitigation and adaptation activities can be applied to and there is virtually no research projecting future cardiovascular other health outcomes sensitive to particulate and other emissions. health impacts of climate change. Research needs include: increasing research on the incidence of cardiac dysrhythmias and • associations with temperature and other environmental exposures enhancing research on the complex synergistic effect of • temperature, weather variability, long-term climate change, and environmental exposures such as criteria air pollutants on the incidence of various cardiovascular disease outcomes intensifying investigation of the likely cardiovascular complica ­ • tions of VBZD prevalent in the United States and globally characterizing the multiple individual constituents of air pollution • to better anticipate the health effects from switching the mix of pollutants in air through the use of alternative fuels studying strategies for incorporating cardiovascular disease • outcomes in HIAs and integrated assessment climate models, including further characterization of exposure-outcome associa ­ tions for cardiovascular morbidity in different geographic regions 119 Wainwright, s, et al., american Journal of epidemiology, 1994. 139(11): p. s49-s49. 118 milan, DJ, et al., ibid.2009. 120(7): p. 553-9. www.niehs.nih.gov/climatereport 23

32 24

33 4 Foodborne Diseases and Nutrition N utrition is the sum of the processes by which humans and other living rESEArCH HIgHLIgHT organisms take in food and use it for growth and nourishment. Along Climate change may impact rates of with clean air, water, and shelter, nutritious food is a basic necessity foodborne illness through increased of life. Failure to obtain sufficient calories and an adequate mixture of temperatures, which are associated macronutrients (calories, fat, proteins, carbohydrates), micronutrients with increased incidence of foodborne (vitamins, minerals) and other bioactive components of food can result gastroenteritis. Several species of in illness and death. According to the United Nations Development , naturally occurring marine Vibrio ­ Program, some 3.7 billion people worldwide are currently malnour bacteria, are sensitive to changes ished. While malnutrition and hunger are predominantly problems Vibrio in ocean temperature. in the developing world, the United States and other developed infects oysters and is paraheamolyticus countries still have significant populations affected by insufficient 120 the leading cause of Vibrio-associated food resources and undernutrition. Extreme weather events and 1 gastroenteritis in the United States. changes in temperature and precipitation patterns can directly damage An outbreak in 2004 in Alaska has been linked to higher than normal or destroy crops and other food supplies, as well as interrupt transport 2 and distribution of food. This may happen seasonally, but is anticipated Other studies show a predictive relationship ocean temperatures. to become a more chronic problem under changing climate conditions. and V. vulnificus V. cholera . Climate- between sea surface temperature and Indirectly, there is potential for harm from undernutrition or even driven changes in ocean temperature and coastal water quality are famine resulting from damage to agricultural crops and related trade, expected to increase the geographic range of these bacteria, and could economic, and social instability; diversion of staple crops for use in be used to predict outbreaks. Increased temperatures also affect rates of biofuels (corn for ethanol or other biofuels); changes in agricultural other foodborne illnesses including campylobacteriosis and salmonellosis. practices including those intended to mitigate or adapt to climate A recent article examined the relationship between temperature and change; impaired ability to grow crops due to changing environmental the weekly rates of several foodborne illnesses in England and Wales, conditions and water availability; and reduced availability and including food poisoning, campylobacteriosis, and salmonellosis nutritional quality of protein from fisheries, aquaculture, and other infections, and demonstrated this relationship. Research shows a marine-based foods. significant correlation of these illnesses with ambient temperature at the 3 Depending time of illness and with the previous week’s temperature. In addition to being a source of essential nutrients, food can be a on the type of foodborne illness, for every degree centigrade rise in source of exposure for foodborne illness. Such illness results from ingesting food that is spoiled or contaminated with microbes, chemical temperature, results showed 2.5–6% relative increase in the risk of residues such as pesticides, biotoxins, or other toxic substances. It is foodborne illness. In the United States, good statistics on foodborne estimated that there are 38 million cases of foodborne illness in the diseases are lacking, although estimates range from 6 million to 81 million United States each year, resulting in over 180,000 hospitalizations and illnesses and up to 9,000 deaths each year. Though current surveillance 121 2,700 deaths. Seafood contaminated with metals, biotoxins, toxi ­ of foodborne illness in the United States is patchy and the burden of cants, or pathogens; crops burdened with chemical pesticide residues severe disease is not well known, further research may make it possible to or microbes; extreme shortages of staple foods; and malnutrition are translate these numbers into health impacts. among the possible effects of climate change on the production, quality, 122 and availability of food. The potential effects of climate change on foodborne illness, nutrition, and security are for the most part indirect Nord, m, et al., Hosehold food security in the United states, 2008, er service, editor. November, 2009, Us Department 120 1 Us Food and Drug administration, Quantitative risk assessment on the public health impact of pathogenic Vibrio of agriculture: Washington, Dc. parahaemolyticus in raw oysters. 2005. mead, Ps, et al., emerg infect Dis, 1999. 5(5): p. 607-25. 121 2 mclaughlin, JB, et al., N engl J med, 2005. 353(14): p. 1463-70. intergovernmental Panel on climate change. Working Group ii. 2007, cambridge: cambridge University Press. ix, 976 p. 122 3 lake, ir, et al., epidemiol infect, 2009. 137, p. 1538–1547. 25 www.niehs.nih.gov/climatereport

34 Foodborne Disease and Nutrition A Human Health Perspective ON CLIMATE CHANGE season, hydrology, and precipitation patterns, will alter contaminant and, in the United States at least, may be moderate and unlikely 130 except in the event of disruption of government regulatory programs. and pathogen pathways. Contaminants include a wide range of However, on a global scale they are huge in terms of numbers of chemicals and metals such as PCBs, PAHs, mercury, and cadmium; people likely to be affected and consequent human suffering. The pharmaceuticals such as synthetic hormones, statins, and antibiot ­ Intergovernmental Panel on Climate Change projected with high ics; widely used industrial chemicals such as fire retardants, stain confidence an increase in malnutrition and consequent disorders, repellants, and non-stick coatings; and pesticides and herbicides for including those related to child growth and development, as a result agricultural use and vector control for public health protection. The 123 of climate change. health effects of human exposure to these environmental agents Some of these effects are already being felt in via complex land and ocean food webs are not well documented or the wake of extreme weather events such as droughts, f looding, and understood, but evidence from animal studies is showing that such hurricanes, and as such present a fairly immediate concern. The compounds accumulate in foods at concentrations that may affect World Health Organization estimated that in 2000, there were over fetal development, immune function, and other biological processes. 77,000 deaths from malnutrition and 47,000 deaths from diarrhea 124 These agents often occur together and may act synergistically, (many from foodborne exposures) due to climate change. producing potentially greater harm than a single agent. Impacts on Risks Recent findings demonstrate that pathogens that can pose disease The U.S. Climate Change Science Program (CCSP) reported a likely risks to humans occur widely in marine organisms and may be increase in the spread of several foodborne pathogens due to climate 131 affected by climate change. change, depending on the pathogens’ survival, persistence, habitat In one specific example, the CCSP 125 range, and transmission in a changing environment. noted the strong association between sea surface temperature and Drought has bacteria species that occur naturally in proliferation of many Vibrio been shown to encourage crop pests such as aphids, locusts, and the environment (including those that cause cholera), and suggested that Aspergillus f lavus whitef lies, as well as the spread of the mold that rising temperatures would likely lead to increased occurrence ­ produces af latoxin, a substance that may contribute to the develop Vibrio of illness associated with bacteria in the United States, ment of liver cancer in people who eat contaminated corn and nuts. V. vulnificus and especially seafood-borne disease associated with Agronomists are also concerned that climate change-based increases 132 . parahaemolyticus V. in a variety of blasts, rusts, blights, and rots will further devastate Rising temperatures and impacts on other already stressed crops, and thereby exacerbate malnutrition, poverty, environmental parameters such as ocean acidification may also lead and the need for human migration. The spread of agricultural pests to more virulent strains of existing pathogens and changes in their 133 and weeds may lead to the need for greater use of some toxic chemi ­ distribution, or the emergence of new pathogens. Increased risks 126 cal herbicides, fungicides, and insecticides, from animal-borne disease pathogens could be especially acute in resulting in potential 127 human populations that are highly dependant on marine-based diets immediate hazards to farm workers and their families, as well as 128 for subsistence and who live where environmental effects resulting longer-term hazards to consumers, particularly children. from climate change are pronounced (for example in certain native 134 populations in Alaska). Increased acidity of water associated The safety of agricultural crops and fisheries also may be threatened with climate change may alter environmental conditions leading to through contamination with metals, chemicals, and other toxicants greater proliferation of microbes of a public health concern. This is a that may be released into the environment as a result of extreme ­ significant concern in molluscan shellfish, because ocean acidifica weather events, particularly f looding, drought, and wildfires, due to 129 tion may affect formation of their carbonate shells and immune climate change. Global changes in ocean currents and water mass responses, making them more vulnerable to microbial infection. distribution, along with changes in Arctic ice cover, length of melt The combined impact of potential contaminant-induced immune ibid. 123 suppression and expanding ranges of disease-causing pathogens and 124 campbell-lendrum, D, et al. environmental Burden of Disease series, ed. a Pruss-Ustun, et al. 2007, Geneva: World Health Organization. 66. biotoxins on food supply could be significant. Gamble, Jl, et al. 2008, Washington, D.c.: U.s. climate change science Program. ix, 204 p. 125 126 Gregory, PJ, et al., J exp Bot, 2009. 60(10): p. 2827-38. 130 ibid. lynch, sm, et al., environ res, 2009. 109(7): p. 860-8, Park, sK, et al., int J Occup environ Health, 2009. 15(3): p. 127 131 moore, sK, et al., environmental Health: a Global access science source, 2008. 7(sUPPl. 2). 274-81, rusiecki, Ja, et al., environ Health Perspect, 2009. 117(4): p. 581-6. ebi, K, et al. in analyses of the effects of global change on human health and welfare and human systems. 132 128 eskenazi, B, et al., Basic clin Pharmacol Toxicol, 2008. 102(2): p. 228-36, rosas, lG, et al., curr Opin Pediatr, 2008. a report by the U.s. climate change science Program and the subcommittee on Global change research, J 20(2): p. 191-7. Gamble, et al., editors. 2008, UsePa: Washington, D. c. 129 ebi, K, et al. in analyses of the effects of global change on human health and welfare and human systems. smolinski, ms, et al. 2003, Washington, D.c.: National academies Press. xxviii, 367 p. 133 a report by the U.s. climate change science Program and the subcommittee on Global change research, J Gamble, et al., editors. 2008, UsePa: Washington, D. c. 134 sokurenko, eV, et al., Nat rev microbiol, 2006. 4(7): p. 548-55. www.niehs.nih.gov/climatereport 26

35 Foodborne Disease and Nutrition ON CLIMATE CHANGE A Human Health Perspective Mitigation and Adaptation understanding and predicting potential ecosystem changes from • In the long term, mitigation and adaptation decisions affecting food climate change that may establish new foodborne pathogens, and nutrition including, for example, the diversion of staple crops for chemical contaminants, or biotoxins, as well as new pathways for biofuel feedstock, the increased need for agricultural chemicals due human exposure to climate-related increases in pests and changes in pest habitats, and assessing the impacts of climate change on outbreak incidence, • planning needs for the maintenance of food supply infrastructure and geographic range, and growth cycles of insect pests and pathogens transport in the wake of extreme weather events are important factors that can infect food crops and seafood, and cause human disease to be considered in a strategic research plan for climate change and understanding the effects of changes in food safety due to climate • health. The benefits of biofuels, genetically modified organisms, new change-related alterations in the accumulation and toxicity of pesticides, and alternative energy on nutrition and foodborne illness foodborne contaminants, biotoxins, and pathogens must also be considered. All of these technologies have great potential to help humans mitigate and adapt to climate change, and each should understanding of changes in nutritional status associated with • be carefully evaluated to ensure that the best are implemented. climate change that may increase individual susceptibility to the adverse health impacts of other environmental exposures such as Health implications, both positive and negative, of changes in animal chemicals and heavy metals agriculture and aquaculture as a result of climate change mitigation improving surveillance of disease-causing agents (chemical • and adaptation need to be identified and quantified. For example, contaminants, pathogens, toxins) in food animals, agricultural climate change events such as drought and f looding can result in crops, and seafood, as well as monitoring of exposed human changes in animal feed quality and the use of marginal lands for populations in order to improve estimates of disease related to ­ animal grazing affects water and habitat quality. Better understand contamination of the food supply ing is needed of effects of the use of new or increased herbicides and pesticides in response to changes in growing conditions caused by identifying and characterizing aspects of food production and • climate change, as well as potential health effects for both humans distribution systems that will reduce risk of contamination and and animals of ingestion of crops that have been genetically modified disease and ensure sustainability under climate change scenarios to withstand stress conditions caused by climate change. The health understanding the effect of ocean acidification from climate • implications of biomass-based energy and biofuels, including interac ­ change-related increases in air pollution on seafood quality and tions between climate mitigation strategies affecting agricultural availability and energy policies and availability of food, must be a priority area of research. developing and implementing models linking climate change and • other environmental data (such as land use, land cover, hydrology) Research Needs to crops and seafood to improve prediction and risk assessment New efforts are needed to combine current and anticipated advances developing and implementing early warning systems to manage • in detection and warning systems for food, nutrition, and foodborne agriculture and fisheries risks related to climate change, including health threats with epidemiologic studies on the occurrence and improved communications with domestic and international food severity of poor nutrition and foodborne disease in humans. This is security agencies especially needed for high-risk populations such as women, infants, and children, and people in resource-constrained settings. Research needs include: projecting impacts of climate change including increases in CO , • 2 temperature, drought, f loods, and other extreme weather events, and changes in growing seasons on food production, availability, contamination, and nutritional value www.niehs.nih.gov/climatereport 27

36 28

37 5 Heat-Related Morbidity and Mortality general, risk of respiratory death due to heat stress is greater than A s a result of anthropogenic climate change, global mean tempera ­ that of cardiovascular effects. Sensitivity to cerebrovascular disease- tures are rising, and are expected to continue to increase regardless 135 145 of progress in reducing greenhouse emissions. related death has been reported in Europe. More commonly, Global average temperatures are projected to increase between 1.8 and 4.0°C by sensitivity to cardiovascular disease-related mortality associated 136 with heat has been seen in the whole population, as well as among end of this century. Climate change is expected to raise overall the elderly. Elevated hyperthermia death risk also has been seen temperature distribution and contribute to an increase in the 146 137 among the elderly in the United States. frequency of extreme heat events, or heat waves. Temp e r at u r e , However, heat-related risks are not regionally or locally uniform; demographic shifts in particularly temperature extremes, is associated with a wide range the United States will produce concentrations of larger populations of health impacts. with higher mean age, and thereby, heightened vulnerability to 147 excessive heat. The health outcomes of prolonged heat exposure include heat 138 exhaustion, heat cramps, heat stroke, and death. Extreme heat Impacts on Risk events cause more deaths annually in the United States than all other 139 extreme weather events combined. In the United States, an average Both increased average temperatures and increasingly frequent and 140 of 688 persons succumb to heat-related death per year. severe extreme heat events produce increased risks of heat-related Prolonged illness and death that can be significant: the European heat wave of exposure to heat may also result in additional illness and death by 148 2003 caused more than 35,000 excess deaths. exacerbating preexisting chronic conditions such as various ­ Human susceptibil 141 respiratory, cerebral, and cardiovascular diseases, ity to heat-related illness depends on several different factors, from as well as physiologic adaptation to the local environment to socioeconomic increasing risk for patients taking psychotropic drug treatment for 142 status, and the impact of these changing exposures will depend on mental disorders, due to the body’s impaired ability to regulate the vulnerability of exposed populations. As noted above, host factors ­ temperature. Figures for these illnesses and deaths may be dramati such as age and the burden of other serious illnesses such as heart cally underestimated as disparities in health care make morbidity disease and diabetes that might exacerbate heat-related problems are measurements difficult and heat is rarely identified as an official important. In the United States, the number of individuals 65 years cause of death. Some public health response organizations are in the of age and older (who are more susceptible to heat effects) is expected process of developing heat early warning systems for anticipated heat 149 to increase from 12.4% in 2000 to 20% in 2060. wave events and extended warm periods. Socioeconomic factors also determine vulnerability; economically disadvantaged and 150 socially isolated people face higher burdens of death from heat. Varying age groups have been shown to be sensitive to all-cause mortality under excessive heat stress, including adults over 65, 143 children, and infants under 1 year of age. Cities and climate are co-evolving in a manner that will certainly For type-specific amplify both the health effects of heat and the vulnerability of urban mortality, sensitivity to death from respiratory disease has been 144 populations to heat-related deaths by magnifying the increased demonstrated in the general population and in the elderly. In temperatures caused by climate change as compared to adjacent 135 Houghton, JT, et al. 2001, cambridge ; New York: cambridge University Press. x, 881 p. 151,152 136 intergovernmental Panel on climate change. Working Group ii. 2007, cambridge: cambridge University Press. ix, rural and suburban locales. The urban built environment can 976 p. 137 meehl, Ga, et al., science, 2004. 305(5686): p. 994-7. 138 ellis, FP, Trans r soc Trop med Hyg, 1976. 70(5-6): p. 402-11.; Kilbourne, em, et al., Jama, 1982. 247(24): p. 3332-6. Gosling, sN, et al., climatic change, 2009. 92(3-4): p. 299-341. 145 139 luber, G, et al., am J Prev med, 2008. 35(5): p. 429-35. curriero, Fc, et al., am J epidemiol, 2002. 155(1): p. 80-7. 146 merchandani, H, et al., Journal of the american medical association, 1993. 270(7): p. 810-810. 140 luber, G, et al., am J Prev med, 2008. 35(5): p. 429-35. 147 Kovats, rs, et al., Heat stress and public health: a critical review, in annual review of Public Health. 2008. p. 41-55. 141 Vandentorren, s, et al., am J Public Health, 2004. 94(9): p. 1518-20. 148 Davido, a, et al., emerg med J, 2006. 23(7): p. 515-8. 142 Wilmoth, Jm, et al., research on aging, 2006. 28(3): p. 269-288. 149 Bytomski, Jr, et al., curr sports med rep, 2003. 2(6): p. 320-4, Piver, WT, et al., environ Health Perspect, 1999. 143 Gosling, sN, et al., climatic change, 2009. 92(3-4): p. 299-341. 150 107(11): p. 911-6, Ye, F, et al., environ Health Perspect, 2001. 109(4): p. 355-9, curriero, Fc, et al., am J epidemiol, 151 Brazel, aJ, et al. in encyclopedia of world climatology, Je Oliver, editor. 2005, springer: Dordrecht, The Netherlands. 2002. 155(1): p. 80-7, Davis, re, et al., environmental Health Perspectives, 2003. 111(14): p. 1712-1718, Gosling, sN, et al., climatic change, 2009. 92(3-4): p. 299-341. XX, 854 p. 152 Patz, Ja, et al., Nature, 2005. 438(7066): p. 310-7. Kovats, rs, et al., Heat stress and public health: a critical review, in annual review of Public Health. 2008. p. 41-55. 144 www.niehs.nih.gov/climatereport 29

38 A Human Health Perspective ON CLIMATE CHANGE Heat-Related Morbidity and Mortality both exacerbate and alleviate the effects of heat. For example, high trends, there will be a small increase in the overall U.S. heat- 159 related death rate by the end of the 21st century. concentrations of buildings in urban areas cause what is known as A standardized the urban heat island effect: generating as well as absorbing and definition and methodology for identifying heat-related health releasing heat, resulting in urban centers that are several degrees outcomes is needed for surveillance and to evaluate temperature- warmer than surrounding areas. Expanding parks and green spaces related illness and death. and increasing the density of trees in and around cities can help to 153 Mitigation and Adaptation reduce this effect. It is estimated that 60% of the global population will live in cities by 2030, greatly increasing the total human popula ­ While climate change is likely to increase the burden of heat-related 154 tion exposed to extreme heat. illness and death in the United States, many of these outcomes are preventable. With aggressive public health actions and widespread physiologic and behavioral adaptations such as robust heat early Researchers comparing annual heat-related deaths for the city of warning systems and other health communications, increased air ­ Los Angeles in the 1990s to those projected for the mid- and late st conditioning use, decreased time spent outdoors, and increased 21 century have concluded that heat-related deaths will increase, 155 wearing of sun-shielding clothing it will be possible to reduce overall perhaps up to seven-fold. Another study assessing 21 U.S. cities rates of illness and death, though some of these measures may result estimates that for most of the cities, summer deaths will increase 160 in negative health consequences as well. dramatically and winter deaths will decrease slightly, even with acclimatization. This shift to higher summer heat-related deaths 156 will likely outweigh the extra winter deaths averted. Climate Adaptation occurs through a range of physiological, behavioral, and change is projected to increase the average number of summer ­ technological mechanisms, and the slight reduction in heat-related time heat-related deaths, with the greatest increases occurring deaths in the United States, despite warming trends, is likely a in mid-latitude major cities where summer climate variability is result of adaptation. In a report on acclimatization in elderly people greatest. Noting that the number of current heat-related deaths over time, researchers showed both a declining risk of heat-related in U.S. cities is considerable in spite of mortality displacement cardiovascular deaths until no excess risk remained and a steady 161 (reduced mortality in the months following a heat event due to risk of cold-related deaths. This effect was observed in other increased early deaths of critically ill people who would have populations as well: over four 10-year time periods in the 20th century in London, progressive reductions in temperature-related deaths (both died in the near-term regardless) and the increased use of air 162 cold and hot) were reported, despite an aging population. conditioning, a substantial rise in weather-related deaths is the Cities 157 most likely direct health outcome of climate change. with cooler climates tend to experience more heat-related deaths than those with warmer climates because populations can acclimatize to some extent to heat and because populations in warmer climates are It is difficult to make valid projections of heat-related illness and more likely to have access to air conditioning. Heat-related death rates death under varying climate change scenarios. A review of past declined significantly over four decades (the period of 1964–1998) in changes in heat-related deaths found few significant relationships 163 19 of 28 U.S. metropolitan areas for any decade or demographic group, and suggested that improved although the trend seems to have 164 medical care, air conditioning use, and other adaptation efforts leveled off since the 1990s. were the causes of reduced death, stating that despite increasing stressful weather events, heat–related deaths are preventable, as Although air conditioning may explain the reduced heat-related evidenced by the decline of all-cause mortality during heat events death risk, it also may be due to improved standards of living, 158 over the past 35 years. better access to medical care, biophysical coping mechanisms, Overall, research suggests that under a and infrastructural adaptations. Depending on methods of power climate change scenario using current anthropogenic emissions generation and the air conditioning technology used, however, Bolund, P, et al., ecological economics, 1999. 29: p. 293-301, mcPherson, e, et al., Urban ecosystems, 1997. 1: p. 49-61. 153 159 Deschenes, O, et al., climate change, mortality, and adaptation: evidence from annual Fluctuations in Weather in the Us, United Nations Department of economic and social affairs Population Division World Urbanization Prospects: 154 in center for the study of energy markets Paper. 2007, center for the study of energy markets: santa Barbara, ca. p. 61. The 2005 revision, PD United Nations Department of economic and social affairs, editor. 2006, United Nations mcGeehin, ma, et al., environ Health Perspect, 2001. 109 suppl 2: p. 185-9. 160 Department of economic and social affairs, Population Division: Geneva. 155 Hayhoe, K, et al., Proc Natl acad sci U s a, 2004. 101(34): p. 12422-7. 161 Barnett, aG, epidemiology, 2007. 18(3): p. 369-72. mcmichael, aJ, et al., lancet, 2006. 367(9513): p. 859-869. carson, c, et al., am J epidemiol, 2006. 164(1): p. 77-84. 162 156 157 Kalkstein, ls, et al., environ Health Perspect, 1997. 105(1): p. 84-93. 163 Davis, re, et al., environmental Health Perspectives, 2003. 111(14): p. 1712-1718. 158 Davis, re, et al., climate research, 2002. 22(2): p. 175-184. 164 sheridan, sc, et al., Natural Hazards, 2009. 50(1): p. 145-160. www.niehs.nih.gov/climatereport 30

39 ON CLIMATE CHANGE A Human Health Perspective Heat-Related Morbidity and Mortality • characterizing the likelihood and nature of multi-system failures, increased use of air conditioning may result in higher greenhouse 165 such as power grid failure, that could lead to significant morbidity gas emissions. In addition, to the extent that power grids become and mortality during a heat wave overburdened during excessive heat events, resulting blackouts and brownouts could leave populations at increased risk of deaths. enhancing the ability of current climate models to capture the • observed frequency and intensity of heat waves across various From a public health perspective, proactive heat wave response plans timescales to support weather-climate predictions and use of heat may prove to be a more sustainable adaptation strategy. Following early warning systems in decision making a 2003 heat wave in Western Europe, France established a National evaluating heat response plans, focusing on environmental • Heat Plan incorporating several preventive measures aimed at risk factors, identification of high-risk populations, effective reducing the risks related to high temperatures including a heat early communications strategies, and rigorous methods for evaluating warning system. During a lasting and severe heat wave in 2006, the effectiveness on the local level excess death rate in France was much lower than expected given the high numbers of deaths three years earlier; research suggests that the 166 decrease may have resulted from implementation of this plan. Research Needs Research needs to improve understanding of heat-related illness and death, as well as impacts of heat mitigation and adaptation, include: developing and implementing a standard definition of heat-related • health outcomes, as well as standard methodologies for surveil­ lance of outcomes and evaluation of adaptations understanding risk factors for illness and death associated with • both acute exposure to extreme heat events and long-term, chronic exposure to increased average temperatures, including how such exposure may alter human physiology (for example, by impacting the body’s ability to metabolize and excrete harmful environmental toxicants) identifying which temperature-related metrics are most strongly • related to increased hospitalization and mortality during heat waves quantifying the combined effects of exposure to heat waves and • ambient air pollution on excessive illness and death conducting comparative analyses of heat-related death risks for • application to national scale analyses determining attributes of communities, including regional and • seasonal differences, that are more resilient or vulnerable to adverse health impacts from heat waves assessing the health benefits of the use of environmental design • principles to reduce the high thermal mass of urban areas ... Yoshida, Y, carbon Balance manag, 2006. 1: p. 12. 165 Fouillet, a, et al., int J epidemiol, 2008. 37(2): p. 309-17. 166 www.niehs.nih.gov/climatereport 31

40 32

41 6 Human Development al Effects M ost humans develop in a predictable fashion, growing from a rESEArCH HIgHLIgHT fertilized egg to fetus, newborn, toddler, child, adolescent, and Many of the chemicals that we use to control adult in a way that is fairly well understood. The environment pests and improve crop yields can impact can be a potent modifier of normal development and behavior. human development. Climate change will Environmental effects on development include subtle changes 167 alter rainfall and temperature in various parts such as small reductions in IQ from exposure to lead, changes of the planet. In some cases, climate change in onset of puberty from exposure to endocrine disrupting 168 will lead to changes in agricultural practices chemicals, birth defects such as cleft palate due to dioxin-like 169 compounds, and fetal loss through exposure-related spontane­ for crop yields that might increase pesticide 170 ous abortion. According to the Centers for Disease Control use and thereby increase human exposures. and Prevention, about 3% of all children born in the United Changes in the range of mosquitoes and States have a birth defect, some of which can be attributed to other pests that can carry disease also may environmental causes. Birth defects are a leading cause of death lead to an increase in the use of legacy pesticides (e.g. DDT). Malaria in children, accounting for almost 20% of all infant deaths. Babies is rare in the United States, although the number of cases (imported or born with birth defects also have a greater chance of illness and 171 1 long-term disability than children without birth defects. Some indigenous) have been increasing over the last decade in some locations. of these birth defects have been steadily increasing over the The insecticide DDT is highly efficient for the control of mosquitoes that last 20 years, for example the rates of congenital heart defects are capable of transmitting malaria to humans. Although withdrawn 172 have doubled, suggesting a possible environmental linkage, from use in the United States, DDT is still used as a desperate expedient although other explanations such as better reporting may also to control mosquitoes in malaria-endemic areas around the world. DDT explain the rise. and its principal metabolite, DDE, are persistent in the environment and in humans. Research has shown that women whose mothers had Recent research into early functional programming has opened a new perspective on the developmental and early life origins of have shortened in utero high DDT levels in their blood when they were 173 human disease. Vulnerable periods during human development menstrual cycles and a reduced chance of getting pregnant. A landmark include preconception (gametogenesis), preimplantation, the fetal study showed that for every 10 milligrams per liter of DDT in mother’s period, and early childhood. Environmental exposures during 2 serum, the probability of pregnancy for the daughter dropped by 32%. these periods can lead to functional deficits and developmental 3 Other pesticides also have been linked to similar decreases in fertility. changes through several mechanisms including genetic mutations ­ Later studies on similar exposures showed equivocal results on time-to and epigenetic change. Some chemicals damage DNA directly, causing mutations in gametes or the developing fetus that can pregnancy, but suggested effects on fetal loss, child growth, and male 4 lead to later disease or conditions that increase disease risks such reproductive development. 174 as obesity. For example, toxins such as domoic acid, a biotoxin WHO. Global malaria Programme. 2008, Geneva: World Health Organization. xx, 190 p. 1 released from harmful algal blooms and taken up by seafood and 2 cohn, Ba, et al., lancet, 2003. 361(9376): p. 2205-6. 3 roeleveld, N, et al., curr Opin Obstet Gynecol, 2008. 20(3): p. 229-33. 4 longnecker, mP, et al., am J epidemiol, 2002. 155(4): p. 313-22, law, Dc, et al., am J epidemiol, 2005. 162(6): stein, J, et al., J Dev Behav Pediatr, 2002. 23(1 suppl): p. s13-22. 167 523-32, longnecker, mP, et al., environ res, 2005. 97(2): p. 127-33, ribas-Fitó, N, et al., int J epidemiol, 2006. p. rogan, WJ, et al., int J Hyg environ Health, 2007. 210(5): p. 659-67. 168 35(4): p. 853-8. Pradat, P, et al., Birth Defects res a clin mol Teratol, 2003. 67(12): p. 968-70. 169 170 Bukowski, Ja, regul Toxicol Pharmacol, 2001. 33(2): p. 147-56. cDc. Birth Defects, 2009 171 [cited 2009 July 22]; available from: http://www.cdc.gov/ncbddd/bd/. 172 correa-Villaseñor a, et al., Birth Defects res a clin mol Teratol, 2003. 67(9): p. 617-24. aagaard-Tillery, Km, et al., Journal of molecular endocrinology, 2008. 41(2): p. 91-102. 173 174 Wadhwa, PD, et al., semin reprod med, 2009. 27(5): p. 358-68. www.niehs.nih.gov/climatereport 33

42 A Human Health Perspective ON CLIMATE CHANGE Human Development 182 Similarly, an increase marine mammals, can bioaccumulate in amniotic f luid and alter fetal concern for human developmental effects. 175 in the use of herbicides and pesticides for agricultural purposes, as development. Chemicals can also cause epigenetic changes that well as alterations in environmental degradation of such chemicals alter the way DNA is interpreted, leading to inheritable functional due to changes in climate, could result in increased exposures that changes without changing DNA itself. These epigenetic changes could 176 would exceed safety guidelines and increase the risk of developmen ­ have consequences for many diseases and developmental changes. 183 tal changes. For example, maternal undernutrition may act on the developing fetus to program the risks for adverse health outcomes such as cardiovascular disease, obesity, and metabolic syndrome in adult Other environmental exposures to pregnant women and to children exposure in utero life. In this way, changes in maternal nutrition and that areassociated with climate change also present hazards to to certain chemicals or biotoxins due to climate change may impact normal human development. For example, certain commercial the health of future generations through epigenetic changes before chemicals present in storage sites or hazardous waste sites can conception and during pregnancy. Developmental changes can result alter human development. Flooding from extreme weather events in a lifetime of suffering and have significant societal costs in terms of and sea-level rise are likely to result in the release of some of these 177 resources, medical care, and lost productivity. chemicals and heavy metals, most likely affecting drinking and recreational waters. Some of these, including mercury and lead, have Impacts on Risk known negative developmental effects. People at different stages of life can respond very differently to And while more research is required, there is good reason for environmental changes. Some changes to the environment resulting concern based on our current body of knowledge of certain toxic from climate change could alter normal human development both metals and persistent organic compounds. Of the metals likely to in the womb and later in life. Foodborne illness and food insecurity, become more prevalent in human environments due to climate both likely outcomes of climate change [see chapter on Nutrition and change, inorganic arsenic is of great concern because it is a potent Foodborne Diseases], may lead to malnutrition. While adult humans human carcinogen, it alters the immune system, and it is a general exposed to mild famine usually recover quite well when food again poison that is lethal at certain doses. More than 100 million people becomes plentiful, nutritional reductions to a fetus in the womb 178 worldwide are exposed to arsenic through groundwater contamina ­ appear to have lasting effects throughout life. Malnutrition and tion and industrial emissions. Both inorganic and methylated undernutrition in pregnant women are a global cause of low birth forms of arsenic have been shown to impede fetal development and weight and other poor birth outcomes that are associated with later 184 increase spontaneous abortions. developmental deficits. Malnutrition is predominantly a problem in Persistent organic compounds, the developing world, but in the United States, one in six children even those no longer in use in many locales such as DDT and PCBs, 179 still live in poverty, could increase in some human environments and decrease in others and other developed countries also have as a result of f looding and extreme weather events due to climate ­ substantial populations with insufficient food resources and under 185 180 change nutrition that could be made worse by climate change. Climate Many of the Superfund toxic waste sites in the United change effects on food availability and nutritional content could have ­ States contain PCBs and dioxins that have been linked to cogni 181 a marked, multigenerational effect on human development. tive deficits in children that continue throughout their lives. It is expected that every person on the planet carries some body burden ­ of PCBs, but people living near contaminated sites have greater expo Changes in patterns and concentrations of contaminants entering 186 sures and an increased risk of disease. the marine environment due to climate change will impact seafood Dioxins, PCBs, asbestos, species, many of which provide a major source of protein to global benzene, f lame retardants, certain pesticides, and other chemicals populations. Such contaminants, particularly metals such as are known to be immunotoxicants. Changes to the immune system mercury and lead that accumulate in fish and seafood, are a special during development can remain throughout life, possibly resulting in a reduced capacity to fight serious infection and an increased risk of several other diseases including cancer. maucher, Jm, et al., environmental Health Perspectives, 2007. 115(12): p. 1743-1746. 175 mathers, Jc, Nutrigenomics - Opportunities in asia, 2007. 60: p. 42-48. 176 cDc. Birth Defects, 2009 177 [cited 2009 July 22]; available from: http://www.cdc.gov/ncbddd/bd/. 182 Booth, s, et al., environ Health Perspect, 2005. 113(5): p. 521-6. mathers, Jc, Nutrigenomics - Opportunities in asia, 2007. 60: p. 42-48. 178 macdonald, rW, et al., Human and ecological risk assessment, 2003. 9(3): p. 643-660. 183 Nord, m, et al., Hosehold food security in the United states, 2008, er service, editor. November, 2009, Us 179 Tofail, F, et al., environmental Health Perspectives, 2009. 117(2): p. 288-293. 184 Department of agriculture: Washington, Dc. macdonald, rW, et al., Human and ecological risk assessment, 2003. 9(3): p. 643-660, macdonald, rW, et al., sci Nord, m, et al., Hosehold food security in the United states, 2008, er service, editor. November, 2009, Us 180 185 Total environ, 2005. 342(1-3): p. 5-86. Department of agriculture: Washington, Dc. Noyes, PD, et al., environment international, 2009. 35(6): p. 971-986. 181 186 Franzblau, a, et al., chemosphere, 2009. 74(3): p. 395-403. www.niehs.nih.gov/climatereport 34

43 ON CLIMATE CHANGE Human Development A Human Health Perspective Research Needs Climate change may alter the abundance and distribution of harmful algal blooms and their associated biotoxin accumulation in fish and Research is needed to evaluate climate-related impacts at different 187 seafood. life stages including direct and epigenetic effects (through exposures Currently there are over 100 known biotoxins associated to mothers and fathers) that may be hazardous to human develop ­ with harmful algal blooms, and the biological effects of most are ment. Such research could improve understanding of the long-term currently unknown; however, some have been shown to cross the 188 effects on human development and provide guidance on how placenta and affect the developing fetus. It is partly for this reason mitigation and adaptation can reduce this health burden. Research though that fish species provide excellent biomedical models for needs include: developmental toxicity research, particularly the study of congenital heart defects. Such defects are notoriously difficult to study in understanding the effects of climate change-induced stress on • standard rodent models due to the early dependency of mammalian human reproduction and development, including chronic and ­ embryos on circulatory function to provide oxygen. Because fish em acute heat stress, and traumatic stress as a result of extreme bryos are not dependent on early circulation for oxygen, fish models weather events have made highly significant contributions to cardiac developmental 189 understanding how malnutrition may alter human development, • studies in the past decade. how climate change may exacerbate such alterations, and how to Mitigation and Adaptation ­ develop effective strategies to minimize these impacts in vulner able populations In regions where water availability is a growing concern, there will be an increasing need to reuse water or seek alternate sources of water understanding the impacts of changes in weather patterns and • that may be of lower quality. This may result in new treatment options ecosystems on the incidence, exposure, and distribution of chemi ­ that may require the use of additional or more toxic chemicals. cal contaminants and biotoxins known to cause developmental disorders Changes in energy source policies also could increase exposures expanding the use of marine species as biomedical models and • to numerous airborne metal particulates, many of which, such as 190 sentinels for understanding effects of contaminants and biotoxins lead, have known adverse developmental impacts. Given the large on human reproduction and development number of chemicals that are currently in commerce, the unknown degree to which climate change will alter human exposure to these understanding the implications of mitigation strategies, including • compounds, and the lack of data on the developmental toxicity of ­ changes in energy policies and new technologies, on the produc ­ most of these compounds, this is an area strongly in need of ad tion, use, and storage of heavy metals and chemicals that are ditional research. known to cause developmental disorders understanding how weather events affect access to health care and • Access to prenatal health care and to early intervention services is the implications of this for normal human development critical in preventing and mitigating birth defects and impacts on human development. Following extreme weather events, such health care and services potentially may be disrupted for extended periods of time, increasing the risk of adverse long-term consequences for mothers, children, and society. ························································································· 187 Niemi, G, et al., environmental Health Perspectives, 2004. 112(9): p. 979-986. 188 ibid. 189 chico, TJ, et al., Trends cardiovasc med, 2008. 18(4): p. 150-5. 190 Gohlke, Jm, et al., environmental Health Perspectives, 2008. 116(6): p. a236-a237. www.niehs.nih.gov/climatereport 35

44 36

45 7 Mental Health and Stress-Related Disorders M ental health disorders comprise a broad class of illnesses from social, economic, and environmental disruption. Individuals already vulnerable to mental health disease and stress-related mild disorders, such as social phobias and fear of speaking in public, disorders are likely to be at increased risk of exacerbated effects to severe diseases including depression and suicidal ideation. Many following extreme weather or other climate change events. mental health disorders can also lead to other chronic diseases and even death. Stress-related disorders derive from abnormal Prolonged heat and cold events can create chronic stress situations responses to acute or prolonged anxiety, and include diseases such as that may initiate or exacerbate health problems in populations al ­ obsessive-compulsive disorder and post-traumatic stress disorder. It ready suffering from mental disease and stress-related disorders. is estimated that 26.2% of Americans over the age of 18 suffer from In addition, psychotropic drugs interfere with the body’s ability to a diagnosable mental health disorder in a given year; 9.5% suffer regulate temperature; individuals being treated with these drugs 191 could be at increased risk of heat-related illness during extreme from mood disorders, and 6% suffer from serious mental illness. 197 heat events. However, mental health is an area of public health that is often a low research priority and one whose impacts on human and societal well being are typically underestimated, both within the United States and The severity of mental health impacts following an extreme climate globally. It also is an area of public health in which disparities exist event will depend on the degree to which there is sufficient coping 198 among socioeconomic groups in both access to and quality of care and support capacity, both during and following the event. 192 and treatment. During the recovery period following an extreme event, mental ­ health problems and stress-related disorders can arise from geo graphic displacement, damage or loss of property, death or injury Psychological impacts of climate change, ranging from mild stress 199 of loved ones, and the stress involved with recovery efforts. responses to chronic stress or other mental health disorders, are The generally indirect and have only recently been considered among most common mental health conditions associated with extreme 193 the collection of health impacts of climate change. ­ events range from acute traumatic stress to more chronic stress-re Mental health lated conditions such as post-traumatic stress disorder, complicated concerns are among some of the most potentially devastating grief, depression, anxiety disorders, somatic complaints, poor con­ effects in terms of human suffering, and among the most difficult centration, sleep difficulties, sexual dysfunction, social avoidance, to quantify and address. A variety of psychological impacts can be 200 irritability, and drug or alcohol abuse. associated with extreme weather and other climate related events. The chronic stress-related There has been significant research conducted depicting ways in conditions and disorders resulting from severe weather or other which extreme weather events can lead to mental health disorders climate change-related events may lead to additional negative health associated with loss, social disruption, and displacement, as well effects. Studies have shown a negative relationship between stress as cumulative effects from repeated exposure to natural disas ­ and blood glucose levels, including inf luence on glycemic control 201 194 ters. among patients with type 2 diabetes. The effects of climate change impact the social, economic, Evidence has also shown and environmental determinants of mental health, with the most that human response to repeated episodes of acute psychological stress or to chronic psychological stress may result in cardiovascu severe consequences being felt by communities who were already ­ 195 202 lar disease. disadvantaged prior to the event. Extreme weather events Although a direct cause and effect relationship has not yet been proven, some research has indicated a link between such as hurricanes, wildfires, and f looding, can create increased 196 anxiety and emotional stress about the future, various psychological factors and an increased risk of developing as well as create added stress to vulnerable communities already experiencing martin-latry, K, et al., eur Psychiatry, 2007. 22(6): p. 335-8. 197 198 Tapsell, sm, et al., Philos Transact a math Phys eng sci, 2002. 360(1796): p. 1511-25. 191 Kessler, rc, et al., arch Gen Psychiatry, 2005. 62(6): p. 617-27. 199 ebi, K, et al. in analyses of the effects of global change on human health and welfare and human systems. a report ibid. 192 by the U.s. climate change science Program and the subcommittee on Global change research, J Gamble, et al., editors. 2008, UsePa: Washington, D. c. 193 Fritze, JG, et al., int J ment Health syst, 2008. 2(1): p. 13. silove, D, et al., J Postgrad med, 2006. 52(2): p. 121-5, Weisler, rH, et al., Jama, 2006. 296(5): p. 585-8. 200 194 ibid. 195 ibid. 201 surwit, rs, et al., Diabetes care, 2002. 25(1): p. 30-4. ibid. 196 202 Black, PH, et al., J Psychosom res, 2002. 52(1): p. 1-23. www.niehs.nih.gov/climatereport 37

46 A Human Health Perspective ON CLIMATE CHANGE Mental Health and Stress-Related Disorders some forms of cancer, as well as the progression of cancer in those events such as hurricanes, wildfires, f looding, and tornadoes is likely 203 209 to continue, and perhaps worsen. already presenting with the disease. Climate change has the potential to create sustained natural and It is also highly likely that the long-term effects of climate change will humanitarian disasters beyond the scale of those we are experiencing displace significant numbers of people, many of whom are already today, which may exceed the capacity of our public health systems vulnerable members of society. Extreme weather events, sea-level 204 to cope with societal demands. rise, destruction of local economies, resource scarcity, and associated In the United States, this was conf lict due to climate change are predicted to displace millions of demonstrated in 2005 by the devastating impact of Hurricane Katrina. 210 people worldwide over the coming century. Globally, climate change will continue to act as a threat to natural The most commonly resources and ecosystem services that are already stressed, which may cited figure of projected population displacement from climate change 211 force the migration of large communities and create conditions leading is 200 million people worldwide by 2050. ­ Those with lower socio 205 to hostile political environments, conf lict, and war. economic standing are more likely to choose to relocate permanently The resources following a devastating event, often due to limited resources to rebuild required to meet the psychological needs of those affected by extreme 212 property and restore livelihood. weather events, environmental conf licts, or other effects of climate In addition, people will continue 206 change may be limited immediately following such an event, to experience place-based distress caused by the effects of climate or as change due to involuntary migration or the loss of connection to one’s people migrate in search of more stable natural environments. 213 home environment, a phenomenon called “Solastalgia.” Research on mental health service delivery following disaster events has only recently become a higher profile topic of scientific interest. The mental health impacts of environmentally displaced popula­ 214 Though some mental health diseases and stress-related disorders tions in conf lict stricken areas have been well documented; have been incorporated into the collection of health impacts of however, additional research is needed to better understand extreme weather and temperature events, numerous research gaps mental health impacts on such people as they relate to climate remain. More work is necessary to understand the effects of climate change and climate change-related migration. While there wil change and extreme weather events on mental health status, to likely be some displacement of populations in the United States determine how to mitigate these effects, and to overcome the barriers caused by the effects of climate change, this issue is anticipated to utilization and delivery of mental health services following extreme to have far greater consequences on a global scale. The results of weather events. climate science research on sea-level rise, extreme events such as f looding and droughts, the impacts of climate change on natural Impacts on Risks resources, and other impacts caused by climate variability and change must be connected to social science research. This link to The number of people killed by climatic, hydrological, and me ­ social sciences, including behavioral science research, will help to teorological disasters in 2008 was the highest of the last decade, 207 build an understanding of when, how, and where population shifts with 147,722 deaths reported worldwide. In the United States, may occur, thereby increasing the likelihood that necessary mental Hurricanes Katrina and Rita, which hit the Gulf Coast in 2005, health services and support can be made available where and when were two of the most damaging hurricanes recorded in U.S. history, they are needed most. impacting more than 90,000 square miles and directly affecting more than 1.5 million people, including forcing 800,000 citizens to 208 be relocated from their homes. Scientific evidence supports that global warming will be accompanied by changes in the intensity, duration, and geographical extent of weather and climate extreme events; therefore, the threat to human health and well being from 209 ccsP, Weather and climate extremes in a changing climate. regions of Focus: North america, Hawaii, caribbean, and U.s. Pacific islands. a report by the U.s. climate change science Program and the subcommittee on Global antoni, mH, et al., Nat rev cancer, 2006. 6(3): p. 240-8. 203 change research., T Karl, et al., editors. 2008, Department of commerce, NOaa’s National climatic Data center: Washington, Dc, Usa. p. 164. 204 The cNa corporation, 2007: p. 68. 210 Fritze, JG, et al., int J ment Health syst, 2008. 2(1): p. 13. Kessler, rc, et al., arch Gen Psychiatry, 2005. 62(6): p. 617-27. 205 211 myers, N, Philos Trans r soc lond B Biol sci, 2002. 357(1420): p. 609-13. 206 Tapsell, sm, et al., Philos Transact a math Phys eng sci, 2002. 360(1796): p. 1511-25. Hunter, lm, Population and environment, 2005. 26(4): p. 273-302. 212 international Federation of red cross and red crescent societies, World Disaster report 2009, in World Disaster 207 report, l Knight, editor. 2009, international Federation of red cross and red crescent societies: Geneva. p. 210. 213 albrecht, G, et al., australasian Psychiatry, 2007. 15: p. s95-s98. crowley, c, J am acad Nurse Pract, 2009. 21(6): p. 322-31, mills, e, et al., med confl surviv, 2008. 24(1): p. 5-15, 208 Department of Homeland security. The First Year after Hurricane Katrina: What the Federal Government Did., 2009 214 [cited 2009 July 22]; available from: www.dhs.gov/xfoia/archives/gc_1157649340100.shtm. Naeem, F, et al., J ayub med coll abbottabad, 2005. 17(2): p. 23-5, Hollifield, m, et al., Jama, 2002. 288(5): p. 611-21. www.niehs.nih.gov/climatereport 38

47 ON CLIMATE CHANGE A Human Health Perspective Mental Health and Stress-Related Disorders Mitigation and Adaptation • improving methods of identifying vulnerable mental health ­ There is a need to fully understand what gaps currently exist in men populations, and understanding the implications for these popula ­ tal health infrastructure, resources, and services; how these gaps may tions at the local and regional level be exacerbated due to climate change; and the resulting impacts on identifying the most beneficial means of encouraging utilization • mental health status, both in the United States and worldwide. This of mental health services and delivering such services following information can then be incorporated into mitigation and adaptation extreme weather or other climate change events strategies. The information can also be used to ensure adequate developing mental health promotion and communication • resources are allocated to enable services to prepare for and deal with programs related to proposed climate change mitigation and the impending challenges associated with climate change including adaptation strategies both extreme and chronic weather events and sea-level rise. In addition, much work needs to be done to help individuals better self- identify their mental health needs and to increase their awareness of the existence of mental health services in their communities. Work also needs to be done to eradicate the stigma associated with the need for mental health care so that individuals will seek out mental health services following extreme weather or other climate-related events. While some climate change adaptation measures may prevent the need for displacement and migration of communities, socioeconomi­ cally disadvantaged communities both within the United States and globally may not be able to effectively implement such adaptation measures. The effect may be social instability of the surrounding community, which will create additional stress and exacerbate the threat to overall mental health and well being. Research Needs Immediate research needs on the mental health implications of 215 climate change include: understanding of how psychological stress acts synergistically • with other forms of environmental exposures to cause adverse mental health effects understanding the critical social and economic determinants for • mental health and overall community well-being that might be altered by climate change identifying and incorporating key mental health outcomes • in health impact assessments, both for U.S. populations and worldwide, under a range of climate change scenarios developing and implementing monitoring networks to help track • the migration of environmentally displaced populations to assist with the provision of mental health care and services ... 215 Fritze, JG, et al., int J ment Health syst, 2008. 2(1): p. 13. www.niehs.nih.gov/climatereport 39

48 40

49 8 Neurological Diseases and Disorders T he United States has seen an increasing trend in the prevalence rESEArCH HIgHLIgHT 216 of neurological diseases and deficits. Onset of diseases such as Harmful algal blooms (HABs) are Alzheimer Disease (AD) and Parkinson Disease (PD) is occurring increasing worldwide and global at earlier ages across the population. Environmental factors are climate change is thought to play a suspected of playing a large role in both the onset and severity of significant role. Many HAB-related these conditions, although there is a gap in our understanding of this 217 biotoxins cause significant neurotoxic role, especially in relation to genetics, aging, and other factors. effects in both animals and humans While some of these changes in neurological health likely are due to the aging of a large portion of the population, learning disabilities including permanent neurological that affect children also are on the rise, and there are indicators Pseudo­ impairment. The algae that environmental factors may be involved including changes in spp. produce domoic acid, nitzschia climate that may exacerbate factors affecting the rates and severity a potent neurotoxin that causes 218,219 of neurological conditions. Neurological conditions generally amnesiac shellfish poisoning in people. Blooms of this algae have been carry high costs in terms of quality of life for both the sufferer and increasing off the California coast resulting in significant illness and the caregiver and increased healthcare stresses on the economy and the workforce. The combination of these factors could affect a death in marine animals. A decade of monitoring of health of California sizable portion of the U.S. population, and have significant impacts sea lions, a sentinel species for human health effects, indicates changes on productivity. in the neurologic symptomatology and epidemiology of domoic acid toxicosis. Three separate clinical syndromes are now present in ­ Factors affected by climate with particular implications for neurologi 220 exposed animals: acute domoic acid toxicosis with seizure, permanent cal functioning include malnutrition; exposure to hazardous 221 hippocampal atrophy, and death; a second novel neurological syndrome chemicals, biotoxins, and metals in air, food, and water; and 222 characterized by epilepsy associated with the chronic consequences of changes in pest management. Understanding the role of climate in the incidence and progression of neurological conditions and how to sub-lethal exposure to domoic acid; and a third syndrome associated prevent them is a critical need for public health and health care in the exposures resulting in premature parturition, neonatal in utero with 223 United States. Studies such as the National Children’s Study are an death, and significant neurotoxicity in the developing fetus resulting in excellent opportunity to improve our understanding in this area. seizure activity as the animal grows, as well as long-lasting impacts on 1 These observations indicate significant potential memory and learning. Impacts on Risk implications for human health effects, although their exact nature is not Numerous recent reports have described observed and anticipated detrimental effects of climate change on ocean health, resulting known and needs further study. in increased risks to neurological health from ingestion of or 216 steenland, K, et al., alzheimer Dis assoc Disord, 2009. 23(2): p. 165-70. Goldstein, T, et al., Proceedings of the royal society B-Biological sciences, 2008. 275(1632): p. 267-276. 1 ramsdell, Js and Ts Zabka, marine drugs, 2008. 6(2): p. 262-90. 217 Bronstein, J, et al., environmental Health Perspectives, 2009. 117(1): p. 117-121, Hendrie, Hc, et al., canadian Journal of Psychiatry-revue canadienne De Psychiatrie, 2004. 49(2): p. 92-99, mayeux, r, annals of Neurology, 2004. 55(2): p. 156 -158. 218 Bronstein, J, et al., environmental Health Perspectives, 2009. 117(1): p. 117-121, mayeux, r, annals of Neurology, 2004. 55(2): p. 156-158, Jones, l, et al., lancet, 2009. 374(9690): p. 654-61. 219 altevogt, Bm, et al., Pediatrics, 2008. 121(6): p. 1225-1229. 220 Kar, Br, et al., Behav Brain Funct, 2008. 4: p. 31. 221 Kozma, c, am J med Genet a, 2005. 132(4): p. 441-4, Papanikolaou, Nc, et al., med sci monit, 2005. 11(10): p. ra329-36. Handal, aJ, et al., epidemiology, 2007. 18(3): p. 312-20. 222 223 landrigan, PJ, et al., Pediatrics, 2006. 118(5): p. 2173-86. www.niehs.nih.gov/climatereport 41

50 A Human Health Perspective ON CLIMATE CHANGE Neurological Diseases and Disorders 224 Emerging research suggests that exposure to a number of agents exposure to neurotoxins in seafood and fresh and marine waters. whose environmental presence may increase with climate change Neurotoxins produced by harmful algal blooms and other marine microorganisms can cause serious illness and death in humans. may have effects on neurological development and functioning. For example, exposure to pesticides and herbicides during specific Under the correct conditions, harmful algal blooms produce potent neurotoxins that are often taken up and bioaccumulated in filter- developmental windows, in combination with other exposures later feeding molluscan shellfish including oysters, clams, and mussels, as in life, could increase the risk of PD and other neurological diseas ­ 235 225 es. well as by certain marine and freshwater fish. The most frequent Exposure to heavy metals is known to exacerbate neurological 236 human exposures are via consumption of seafood containing algal deficits and learning disabilities in children, and is suspected 237 toxins, although some toxins may be present in freshwater sources of being associated with both onset and exacerbation of AD and of drinking water, and others may be aerosolized by surf breaking PD. Evidence suggests that early-life occurrence of inf lammation on beaches and then transported by winds to where they can cause in the brain, as a consequence of either brain injury or exposure to 226 238 respiratory distress in susceptible individuals who breathe them. infectious agents, also may play a role in the pathogenesis of PD. Because cooking or other means of food preparation do not kill In addition to conditions such as PD and AD, post-traumatic stress seafood biotoxins, it is essential to identify contaminated seafood disorder (PTSD) is likely to have profound effects on the neurological before it reaches consumers. Health effects including amnesia, functioning of populations exposed to the stress of extreme weather events, and the resulting dislocation and deprivation that may result ­ diarrhea, numbness, liver damage, skin and eye irritation, respira 239 tory paralysis, and PD- and AD-like symptoms may be severe, from climate change. 227 chronic, and even lead to death. It has recently been reported Mitigation and Adaptation that even a single low-level exposure to algal toxins can result in 228 physiological changes indicative of neurodegeneration. Mitigation to climate change may reduce our reliance on fossil fuels. Work done This reduction in fossil fuel use will reduce the release of a number on biotoxin-related neurologic disease in marine mammals indicates of neurotoxicants including arsenic, mercury, and other metals into that domoic acid exposure can cause acute neurologic symptoms 240 the environment. by crossing the placenta and accumulating in the amniotic f luid Simple actions that reduce the amount of energy where it can impact neural development in the fetus, alter postnatal needed, such as expanded use of compact f luorescent light bulbs, 229,230,231 development, and lead to chronic illnesses such as epilepsy. will reduce the amount of toxic metals emitted into the air by coal- fired power plants. However, additional mercury releases into the Climate change may alter the geographic range in which harmful environment might occur due to breakage of these f luorescent bulbs algal bloom toxins appear, the frequency of toxin production, and or improper disposal, resulting in human exposures and potential the actual delivery of toxins (both increasing and decreasing in 232 241 neurological effects. some cases) due to extreme weather. Harmful algal blooms are In more complicated mitigation strategies increasing in frequency, intensity, and duration globally, partially as such as the expansion of the use of electric vehicles, heavy metals 233 a result of climate change, although this link is poorly understood. used in the batteries for such vehicles may present manufacturing and disposal challenges that will be of particular significance to the Nonetheless, it is clear that changes in precipitation and ocean 242 risk of neurological deficits. temperatures, coupled with increased nutrient loading, may lead to earlier seasonal occurrence, as well as longer lasting and possibly 234 more toxic harmful algal blooms. Adaptation efforts such as the increased use of pesticides to improve crop yield in areas with reduced farming capabilities may result in runoff of potentially neurotoxic pesticides into reservoirs and 224 National research council (U.s.). committee on ecological impacts of climate change. 2008, Washington, D.c.: National academies Press. xii, 57 p, sandifer, P, et al., interagency oceans and human health research coasts used to capture water for human use, thereby increasing implementation plan: a prescription for the future. 2007, interagency Working Group on Harmful algal Blooms, Hypoxia and Human Health of the Joint subcommittee on Ocean science and Technology: Washington, Dc, Usa. 225 Wang, DZ, marine Drugs, 2008. 6(2): p. 349-71. 226 Kirkpatrick, B, et al., sci Total environ, 2008. 402(1): p. 1-8. costello, s, et al., am J epidemiol, 2009. 169(8): p. 919-26. 235 227 Wang, DZ, marine Drugs, 2008. 6(2): p. 349-71. 236 Kozma, c, am J med Genet a, 2005. 132(4): p. 441-4. 228 lefebvre, Ka, et al., Toxicol sci, 2009. 107(1): p. 65-77. 237 Kotermanski, se, et al., J Neurosci, 2009. 29(9): p. 2774-9, lovell, ma, J alzheimers Dis, 2009. 16(3): p. 471-83, ramsdell, Js, et al., marine Drugs, 2008. 6(2): p. 262-90. 229 mendes, cT, et al., eur arch Psychiatry clin Neurosci, 2009. 259(1): p. 16-22, Quinn, JF, et al., expert rev Neurother, Brodie, ec, et al., marine mammal science, 2006. 22(3): p. 700-707. 230 2009. 9(5): p. 631-7. maucher, Jm, et al., environmental Health Perspectives, 2007. 115(12): p. 1743-1746. 231 238 miller, DB, et al., metabolism, 2008. 57 suppl 2: p. s44-9. moore, sK, et al., environmental Health: a Global access science source, 2008. 7(sUPPl. 2), sandifer, P, et 232 Naeem, F, et al., J ayub med coll abbottabad, 2005. 17(2): p. 23-5. 239 al., interagency oceans and human health research implementation plan: a prescription for the future. 2007, 240 Gustin, ms, et al., J air Waste manag assoc, 2004. 54(3): p. 320-30, Narukawa, T, et al., J environ monit, 2005. interagency Working Group on Harmful algal Blooms, Hypoxia and Human Health of the Joint subcommittee on Ocean science and Technology: Washington, Dc, Usa. 7(12): p. 1342-8, ito, s, et al., sci Total environ, 2006. 368(1): p. 397-402. 241 Noyes, PD, et al., environment international, 2009. 35(6): p. 971-986. moore, sK, et al., environmental Health: a Global access science source, 2008. 7(sUPPl. 2). 233 242 Bronstein, J, et al., environmental Health Perspectives, 2009. 117(1): p. 117-121. Paerl, HW, et al., science, 2008. 320(5872): p. 57-8. 234 www.niehs.nih.gov/climatereport 42

51 ON CLIMATE CHANGE A Human Health Perspective Neurological Diseases and Disorders 243 • improving our understanding of the impact of increased heavy Alternately, recent research has shown multiple human exposures. precipitation, ice melts, and f looding events on the risk of toxic benefits on mental and neurological functioning as a result of contamination of the environment from storage-related issues or increased exposure to natural and green space settings, particularly 244 runoff, focusing on the likelihood of the event, the geographical in urban areas. Adaptation strategies that encourage and allow areas and populations likely to be impacted, and the health walkable cities and exercise, increases in green space and urban outcomes that could result forestry, and improved green building methods that reduce the potential for exposure to chemicals such as arsenic and lead that examining the neurological health benefits and costs of new • leach from building materials could all contribute to reductions in climate change mitigation technologies, including research on neurological deficits. Numerous other mitigation and adaptation the toxicity of new metals and metal compounds, including strategies may have both positive and negative health effects, most nanotechnologies, being used to improve battery performance for of which are poorly recognized or understood. Thus, any proposed electric vehicles mitigation and adaptation strategies will need to be carefully evaluated for both benefits and potential neurological effects. Research Needs More research is needed regarding the link between environmental exposures, the onset and severity of neurological diseases and disorders, and the relationship to climate change. Research needs include: identifying the factors that initiate harmful algal blooms and • bacterial proliferations, focusing on the effects of temperature changes, shifts in rainfall patterns, and other climate-associated factors on their distribution, occurrence, and severity improving understanding of the mechanisms and pathways of • acute and chronic exposures to harmful algal biotoxins and their impacts on fetal, postnatal, and adult development utilizing marine animal models to better understand the • mechanisms and outcomes of exposure to harmful algal biotoxins individually and in conjunction with chemical exposures developing and validating strategies to inhibit the formation and • severity of harmful algal blooms expanding research on the toxicity of chemicals known or • suspected to cause neurological disorders, particularly pesticides, and on understanding how climate change may affect human exposure to such chemicals ... 243 Noyes, PD, et al., environment international, 2009. 35(6): p. 971-986. 244 Frumkin, H, et al. 2004, Washington, Dc: island Press. xxi, 338 p. www.niehs.nih.gov/climatereport 43

52 44

53 9 Vectorborne and Zoonotic Disease s V ectorborne and zoonotic diseases (VBZD) are infectious dis ­ rESEArCH HIgHLIgHT eases whose transmission cycles involve animal hosts or vectors. Climate is one of several factors that Vectorborne diseases are those in which organisms, typically influence the distribution of vectorborne blood-feeding arthropods (insects, ticks, or mites) carry the pathogen and zoonotic diseases (VBZD) such as from one host to another, generally with amplification (increased Lyme disease, Hantavirus, West Nile virulence) in the vector (for example, malaria). Zoonoses are diseases virus, and malaria. There is substantial that can be transmitted from animals to humans by either contact concern that climate change will make with animals or by vectors that can carry zoonotic pathogens from animals to humans (for example, avian f lu). Both domestic animals certain environments more suitable and wildlife, including marine mammals, fish, sea turtles, and for some VBZD, worsening their seabirds may play roles in VBZD transmission by serving as zoonotic already significant global burden and reservoirs for human pathogens or as means of interspecies transmis ­ potentially reintroducing some diseases into geographic areas where they sion of pathogens. The epidemiology of VBZD in the United States has had been previously eradicated. Recent public health experience with changed significantly over the past century, and many diseases that 245 the outbreak and establishment of West Nile virus in the United States previously caused significant illness and death, including malaria, 8 24 247 246 are now rarely and murine typhus, yellow fever, dengue, reveals the complexity of such epidemics, and the lack of preparedness seen in this country. This dramatic change is a result of intentional required by public health officials to contain a national VBZD threat. programs to control vectors, vaccinate against disease, and detect and Though unlikely, West Nile virus might have been contained when it treat cases, with additional benefits from improvements in sanitation, emerged in New York City in 1999; however, delays of only a few weeks in development, and environmental modification. Examples of vector - recognizing the outbreak in birds and identifying the virus, combined with borne diseases currently prevalent in the United States include Lyme 249 the absence of a robust mosquito abatement capability, allowed West Nile disease and ehrlichiosis, bacterial diseases that are transmitted virus to spread quickly to surrounding areas. Relying on expertise from primarily by ticks. Other important zoonoses in the United States, 251 250 some of which are also vectorborne, include rabies, Q fever, the mosquito abatement community, aerial spraying was applied fairly anthrax, pathogenic E. coli, tularemia, hantavirus pulmonary rapidly to combat mosquitoes in infected areas, but these efforts were 252 syndrome, and plague. Although VBZD currently are not a leading not adequate to decrease populations of mosquitoes in time. From New cause of morbidity or mortality in the United States, there is cause for York, the virus traveled across the entire United States, and by 2003, it had some urgency on this issue. Our population is directly susceptible to thoroughly established itself in the avian population. To date, individual the VBZD that circulate in warmer climates, and vulnerable as a result mosquito abatement districts have been able to significantly protect their of global trade and travel. Our ability to respond to such threats on both a national and international level is currently limited. populations due to increased national funding combined with decades of experience in their local areas. However, underserved regions did not get Many vectorborne diseases that have been virtually eliminated from significant protection despite efforts to identify them. the industrialized world are still prevalent in developing countries. Resurgence of vectorborne disease as a result of climate change is also a Globally, VBZD cause significant morbidity and mortality. For 245 Faust, e in malariology; a comprehensive survey of all aspects of this group of diseases from a global standpoint, mF major concern. Despite energetic interventions, the availability of drugs Boyd, editor. 1949, saunders: Philadelphia,. p. 2 v. (xxi, 1643 p.). 246 adler, P, et al., american entomologist, 2003. 49: p. 216-228. Petri, Wa, Jr., am J Trop med Hyg, 2004. 71(1): p. 2-16. 247 248 White, Pc, Jr., mil med, 1965. 130: p. 386-8. 249 Bacon, rm, et al., mmWr surveill summ, 2008. 57(10): p. 1-9. 250 Blanton, JD, et al., J am Vet med assoc, 2008. 233(6): p. 884-97. 251 mcQuiston, JH, et al., am J Trop med Hyg, 2006. 75(1): p. 36-40. 252 Douglass, rJ, et al., Vector Borne Zoonotic Dis, 2005. 5(2): p. 189-92. www.niehs.nih.gov/climatereport 45

54 A Human Health Perspective Vectorborne and Zoonotic Disease ON CLIMATE CHANGE Impacts on Risks example, in 2006 there were 247 million cases of malaria and 253 881,000 malaria-related deaths worldwide. The World Health VBZD ecology is complex, and weather and climate are among Organization estimates that malaria is responsible for 2.9% of several factors that inf luence transmission cycles and human disease 254 260 incidence. the world’s total disability-adjusted life years (DALYs). Impacts in certain ecosystems are better understood; In the however, for others such as marine ecosystems, their role in VBZD long term, climate change’s potential to cause social upheaval and 261 has not been well characterized. population displacement may provide opportunities for resurgence Changes in temperature and of certain VBZD in the United States, which has already seen ­ precipitation patterns affect VBZD directly through pathogen 255 some redistribution of vector species. host-vector interactions, and indirectly through ecosystem changes Disruption of economies, (humidity, soil moisture, water temperature, salinity, acidity) and transportation routes, agriculture, and environmental services could species composition. Social and cultural behaviors also affect disease result in large-scale population movements within and between transmission. Many VBZD exhibit some degree of climate sensitiv ­ countries, as well as a general decrease in what are now considered 256 ity, and ecological shifts associated with climate variability and minimum standards of living. A severe degradation of rural and long-term climate change are expected to impact the distribution ­ urban climate and sanitation conditions could bring malaria, epi 262 and incidence of many of these diseases. demic typhus, plague, and yellow fever to their former prominence. For instance, the range of Lyme disease is expected to expand northward as the range of 263 the deer tick that transmits it expands. Valid projections on likely impacts of climate change on VBZD In another example, the are lacking, and a scientific consensus has yet to emerge. Even frequency of hantavirus pulmonary syndrome outbreaks, caused by though we now have the technical knowledge to treat or vaccinate human exposure to the virus in deer mice urine or feces, may change against many VBZD, in the absence of these technologies, some with increasingly variable rainfall in the desert Southwest, which experts believe that population-level mortality from certain disease affects the populations of deer mice and other rodents through 257 264 outbreaks could reach as high as 20–50%. changes in production of the pine nuts on which they feed. Ultimately, projections must be specific to location, altitude, ecosystem, and host or vector. Health impacts from changing distributions of VBZD are likely to Similarly, certain VBZD may decrease in particular regions as unfold over the next several decades, and prevention and control habitats become less suitable for host or vector populations and for activities must be developed and honed prior to significant vector sustained disease transmission. Coastal and marine ecosystems will range expansion in order to be most effective. be particularly impacted by increasing temperatures, changes in ­ precipitation patterns, sea-level rise, altered salinity, ocean acidi fication, and more frequent and intense extreme weather events. ­ Emerging zoonotic disease outbreaks are increasing, with the major These changes will directly and indirectly affect ocean and coastal ity of recent major human infectious disease outbreaks worldwide, ecosystems by inf luencing community structure, biodiversity, and as well as significant emerging diseases such as SARS, Nipah 258 the growth, survival, persistence, distribution, transmission, and virus, and HIV/AIDS, originating in animals. A recent report 265 severity of disease-causing organisms, vectors, and reservoirs. noted that the United States remains the world’s largest importer of wildlife, both legal and illegal; these animals represent a potential Also of concern for both terrestrial and aquatic/marine ecosystems 259 source of zoonotic pathogen introduction into U.S. communities. is the loss of biodiversity (which underlies ecosystem services) that further exacerbates the impacts of climate change on vectors Interactions of wildlife with domestic animals and with people will or animal reservoir populations. Such alterations in ecosystem likely increase in the United States due to changes to ecosystems and functions may alter the emergence of VBZD in populations within disease transmission resulting from both climate change and from the United States. With the loss of predators, insect vectors may adaptation and response strategies. increase, making necessary either chemical or mechanical controls. 253 WHO. Global malaria Programme. 2008, Geneva: World Health Organization. xx, 190 p. WHO. 2002, Geneva: World Health Organization. xx, 190 p. Boxall, aBa, et al., environmental Health Perspectives, 2009. 117(4): p. 508-514. 260 254 255 constantin de magny, G, et al., Trans am clin climatol assoc, 2009. 120: p. 119-28. 261 carroll, JF, Proc. of the entomological society of Washington, 2007. 109(1): p. 253-256. 262 costello, a, et al., The lancet, 2009. 373(9676): p. 1693-1733. 256 Gage, Kl, et al., am J Prev med, 2008. 35(5): p. 436-50. estrada-Peña , a, environ Health Perspect, 2002. 110(7): p. 635-40. 263 Orenstein, Wa, et al., Health aff (millwood), 2005. 24(3): p. 599-610. 257 institute of medicine (U.s.). committee on achieving sustainable Global capacity for surveillance and response to 258 264 Douglass, rJ, et al., Vector Borne Zoonotic Dis, 2005. 5(2): p. 189-92, costello, a, et al., The lancet, 2009. emerging Diseases of Zoonotic Origin., et al. 2009, Washington, Dc: National academies Press. xxv, 312 p. 373(9676): p. 1693-1733, ebi, Kl, et al., environmental Health Perspectives, 2006. 114(9): p. 1318-1324. 259 Pavlin, Bi, et al., emerg infect Dis, 2009. 15(11): p. 1721-6. 265 Niemi, G, et al., environmental Health Perspectives, 2004. 112(9): p. 979-986. www.niehs.nih.gov/climatereport 46

55 Vectorborne and Zoonotic Disease ON CLIMATE CHANGE A Human Health Perspective continued rESEArCH HIgHLIgHT for treatment, and vector control strategies supported by strong scientific Projecting VBZD incidence is difficult given the complexity of VBZD transmission cycles, the variability of regional and local impacts understanding, malaria continues to be a severe problem in Africa and a of climate change, and the limited information currently available persistent one in Asia and Latin America. Malaria could present a threatened regarding the ecology of many VBZD. For instance, while malaria 1 Korea provides return to its former importance in more temperate climates. transmission increases with temperature and humidity, the decrease a recent case study with respect to the more chronic, less fatal species of the in disease incidence seen with prolonged drought may negate these 2 Plasmodium vivax . Malaria became a severe problem on the Korean parasite, effects. Human rural and urban development efforts, such as the peninsula during and following the Korean War in 1950–1953. A combination creation of clean water sources for animal husbandry or swamp clearance to increase availability of land for human settlement, also of case detection, treatment, and vector control reduced the number of 3 have significant impacts on transmission dynamics that can offset The cases and finally eliminated the parasite from South Korea by 1988. climate impacts. disease reemerged in 1993 and quickly became a problem in the military population by 1996, with cases of temperate-adapted parasites exported to The incidence of VBZD in the United States will likely increase 4 Subsequent studies of the vector mosquitoes revealed the United States. under anticipated climate change scenarios, for several reasons. The Anopheles that a complex of multiple species, including a powerful vector, distribution of vectors currently restricted to warmer climates will that is prevalent in China, is responsible for the reemergence. anthropophagus expand into the United States. For example, the habitats of two potent mosquito vectors of malaria, Anopheles albimanus Anopheles and This reemergence may have been exacerbated by increases in severe rainfall 5 pseudopunctipennis , currently range as far north as northern events and temperature, but this has not yet been definitively established. Mexico, and would presumably expand northwards across the 266 The story is different in sub-Saharan Africa, where malaria is responsible for U.S.–Mexico border. The extrinsic incubation period of pathogens 6 in invertebrate vectors is highly dependent on ambient temperature. Researchers have a large proportion of the infant and childhood mortality. Since the lifespan of vector species is relatively constant, changes in examined whether the wider distribution of malaria in highland regions is ­ the incubation period due to precipitation and temperature signifi associated with climate change, and have performed quantitative predictions 267 cantly alter the likelihood of transmission. Also, large disruption of the effects of various climate change scenarios on distribution of the and subsequent movement of human populations create conditions 7 Climate change induced increases in temperature may have several disease. for wider distribution of pathogens and greater exposure to vector 268 effects: increase the altitude at which malaria transmission is possible, intensify species. And, climate change is already affecting the biodiversity transmission at lower altitudes, and generally make greater demands on the of marine and terrestrial ecosystems, which in turn will alter the dynamics of predator–prey relationships, as well as vector and efficacy of vector control efforts. reservoir pathogen populations. This may alter the types and quality of subsistence animal foods, and present dependent communities 269 1 Faust, e in malariology; a comprehensive survey of all aspects of this group of diseases from a global standpoint, mF with new pathogen risks. The time scale of this threat will be Boyd, editor. 1949, saunders: Philadelphia,. p. 2 v. (xxi, 1643 p.). ree, Hi, Korean J Parasitol, 2000. 38(3): p. 119-38. 2 continuous unless mitigating measures are taken. Economic and 3 Paik, YH, et al., Jpn J exp med, 1988. 58(2): p. 55-66. 4 Feighner, BH, et al., emerg infect Dis, 1998. 4(2): p. 295-7. regulatory restrictions continue to slow the development and use of 5 Foley, DH, et al., J med entomol, 2009. 46(3): p. 680-92. 6 WHO. Global malaria Programme. 2008, Geneva: World Health Organization. xx, 190 p. new modes of action against vectors. ebi, Kl, et al., climatic change, 2005. 73(3): p. 375-393, Thomson, mc, et al., Trends in Parasitology, 2001. 17(9): p. 7 438-445, Zhou, G, et al., Trends Parasitol, 2005. 21(2): p. 54-6. rogers, DJ, et al., science, 2000. 289(5485): p. 1763-6. 266 strickman, D, et al., american Journal of Tropical medicine and Hygiene, 2003. 68(2): p. 209-217. 267 268 scoville, a in rickettsial diseases of man; a symposium, Fr moulton, editor. 1948, american association for the advancement of science.: Washington, D.c.,. p. 247 p. Niemi, G, et al., environmental Health Perspectives, 2004. 112(9): p. 979-986, Jentsch, a, et al., comptes rendus 269 Geoscience, 2008. 340(9-10): p. 621-628. www.niehs.nih.gov/climatereport 47

56 A Human Health Perspective ON CLIMATE CHANGE Vectorborne and Zoonotic Disease Mitigation and Adaptation Research Needs Given the potential for significant increases in the burden of VBZD Climate change mitigation includes activities to reduce greenhouse gas emissions such as decreased reliance on fossil fuels for energy as a result of climate change, public health preparation is required, generation and transport and changes in land use such as reducing and research needs include: deforestation and conversion of forested land to cropland. Strategies understanding of VBZD transmission cycles and the impact of • focused on alternative energy sources with lower greenhouse gas ecological management and disruption on VBZD transmission, ­ emission profiles, such as nuclear power, may inf luence local ecolo including the impact of new and intensified selective pressures 270, 271 gies by increasing water demands, temperature, and currents. due to climate change This, in turn, might alter the life cycles of certain disease vectors and developing methods to detect, quantify, characterize, and • ­ animals that are part of VBZD transmission cycles. Increased reli monitor potential VBZD transmission associated with changes in ance on hydroelectric power, which typically requires construction of terrestrial, ocean, coastal, and Great Lakes environments dams, also may change local VBZD ecologies and alter transmission cycles. Mitigation activities focused on land use changes, particularly developing and validating models of VBZD ecology that link • preservation of forests and wetlands, are likely to impact VBZD established datasets of VBZD disease transmission, identify 270 ecology and transmission cycles as well. For example, changes to relevant climate-related patterns, and integrate downscaled wetlands may affect mosquito burden in certain areas by altering climate projections of likely impacts breeding area size and potentially altering the incidence of malaria, 271 understanding of secondary effects of climate change such as • dengue, or other mosquito-borne diseases. Because the margins of increased malnutrition, conf lict, and population displacement on disturbed ecosystems can be associated with outbreaks of zoonotic 272 VBZD, and evaluation of the effectiveness of prevention strategies infections such as Ebola and Marburg viruses, ­ ecosystem preser vation may also reduce the incidence of these VBZD. The net impact, enhancing research on the effectiveness of novel personal disease • either beneficial or detrimental, of these mitigations strategies on prevention methods including vaccines, repellents, bed nets, 274 human health is difficult to determine, and more research is needed chemoproprophylaxis, and others to elucidate these effects. developing new pesticides aimed at controlling disease vectors • that combine the qualities of specificity (affecting only the target Climate change adaptation strategies include activities that provide ­ arthropods), adjustable persistence through formulation (chemi early warning and reduce exposure to environmental hazards cally labile but persistent for useful periods), environmental associated with climate change, and limit susceptibility in exposed safety (no bioaccumulation or effect on non-target organisms), populations. Some adaptation activities may impact VBZD or alter low susceptibility to resistance (through either inherent the potential for human exposure. For example, encouraging air physiology or effective resistance management techniques), and conditioning use as an adaptation strategy against extreme heat may application to creative control strategies provide a co-benefit of reduced exposure to VBZD. The use of central air conditioning has been shown to be a protective factor against enhancing existing public health surveillance infrastructure to • dengue infection in studies comparing dengue incidence on opposite include longitudinal surveillance focused on the periphery of 273 sides of the U.S.-Mexico border. Negative impacts of adaptation endemic areas to detect range expansion and on ports of entry are also possible. For example, capture and storage of water runoff to (airports, seaports) where vectors may penetrate after long- adapt to increasingly sporadic rainfall might provide more suitable distance travel breeding habitat for mosquitoes, thereby increasing incidence of enhancing existing animal health surveillance (both domestic • West Nile virus and other VBZD. animals and wildlife) and early detection of emerging diseases of animal origin with particular emphasis on increased human to attwood, sW, Journal of molluscan studies, 1995. 61: p. 29-42, Kay, BH, et al., Journal of the american mosquito 270 control association, 1996. 12(3): p. 421-428, maszle, Dr, et al., science of the Total environment, 1998. 216(3): p. wildlife contact 193-203. 271 Vasconcelos, cH, et al., igarss 2003: ieee international Geoscience and remote sensing symposium, Vols i - Vii, Proceedings, 2003: p. 4567-4569, 4610, Yohannes, m, et al., Tropical medicine & international Health, 2005. 10 (12): p. 1274 -1285. 272 leGuenno, B, arch Virol suppl, 1997. 13: p. 191-199. 273 Brunkard, Jm, et al., emerging infectious Diseases, 2007. 13(10): p. 1477-1483, reiter, P, et al., emerging infectious Diseases, 2003. 9(1): p. 86-89. 274 strickman, D, et al. 2009, Oxford ; New York: Oxford University Press. xviii, 323 p., [8] p. of plates. www.niehs.nih.gov/climatereport 48

57 Vectorborne and Zoonotic Disease A Human Health Perspective ON CLIMATE CHANGE developing early warning systems that integrate public and animal • health surveillance, risk assessments, and mitigation and adapta­ tion strategies related to VBZD transmission enhancing research on risk communication and prevention • strategies related to VBZD outbreak response including evaluation of their effectiveness The research needs identified for VBZD include crosscutting issues and opportunities for leveraging co-benefits. Enhanced surveil­ lance capacity is transferable to other health categories. Deeper understanding of the ecology of VBZD will enable understanding of other ecosystems, and improve our ability to preserve ecosystem services and limit ecosystem mismanagement. Developing mathematical models of VBZD ecology and linking these models with downscaled climate projections will generate novel modeling methodologies, as well as new methods in spatial epidemiology and mapping, and enhance existing public health workforce capacity. Research into risk communication and prevention strategies for VBZD can be applied to other health risks, both climate-related and otherwise. Novel strategies for application of vector control will benefit public health and infrastructure development in general. Because vector abatement efforts require organization that reaches multiple levels (household, farm), such efforts will form an interactive customer base for the application of environmental tools such as spatial analysis and monitoring to other environmental services such as building code enforcement, water standards, and sanitation, as well as provide additional resources for gathering operational data on the status of populations. www.niehs.nih.gov/climatereport 49

58 50

59 10 Waterborne Diseases Waterborne diseases are caused by a wide variety of pathogenic rESEArCH HIgHLIgHT microorganisms, biotoxins, and toxic contaminants found in the There is a clear association between water we drink, clean with, play in, and are exposed to through increases in precipitation and other less direct pathways such as cooling systems. Waterborne outbreaks of waterborne disease, microorganisms include protozoa that cause cryptosporidiosis, both domestically and globally. parasites that cause schistosomiasis, bacteria that cause cholera Climate change is expected to produce and legionellosis, viruses that cause viral gastroenteritis, amoebas more frequent and severe extreme that cause amoebic meningoencephalitis, and algae that cause 275 precipitation events worldwide. neurotoxicity. In the United States, the majority of waterborne In the United States from 1948 to disease is gastrointestinal, though waterborne pathogens affect 1994, heavy rainfall correlated with most human organ systems and the epidemiology is dynamic. A more than half of the outbreaks of recent shift has been seen in waterborne disease outbreaks from 1 Some of the largest outbreaks of waterborne waterborne diseases. gastrointestinal toward respiratory infections such as that caused , which lives in cooling ponds and is transmitted by Legionella disease in North America, particularly in the Great Lakes, have resulted 276 through air conditioning systems. In addition to diarrheal after extreme rainfall events. For example, in May 2000, heavy rainfall in disease, waterborne pathogens are implicated in other illnesses Walkerton, Ontario resulted in approximately 2,300 illnesses and seven with immunologic, neurologic, hematologic, metabolic, pulmonary, E. coli deaths after the town’s drinking water became contaminated with 277 2 ocular, renal and nutritional complications. The World Health There are 734 combined sewage and Campylobacter jejuni. O157:H7 and Organization estimates that 4.8% of the global burden of disease wastewater systems in and around the Great Lakes, with an estimated (as measured in disability-adjusted life years, or DALYs) and 3.7% 3 Using a discharge of 850 billion gallons of untreated overflow water. of all mortality attributable to the environment is due to diarrheal suite of seven climate change models to project extreme precipitation 278 disease. Most of these diseases produce more serious symptoms 279 events in the Great Lakes region, scientists have been able to estimate and greater risk of death in children and pregnant women. 4 the potential impact of climate change on waterborne disease rates. Their models predict more than 2.5 inches of rain in a single day will For most waterborne pathogens in the United States, surveillance cause a combined sewer overflow into Lake Michigan, resulting in is spotty, diagnoses are not uniform, and our understanding of 50–100% more waterborne disease outbreaks in the region per year. the impact of normal weather and climate variation on disease incidence, as well as illness and death burdens, is not firmly Considering that the Great Lakes serves as the primary water source for established. Impacts of any intensifying of climate events at local, over 40 million people and is surrounded by a number of large cities, regional, national, and global levels are a growing concern. Experts both past events and these projections indicate a serious threat to public estimate that there is a high incidence of mild symptoms from health in this region due to climate change alterations in the frequency of waterborne pathogens and a relatively small, but not negligible extreme precipitation. 280 mortality burden. curriero, Fc, et al., am J Public Health, 2001. 91(8): p. 1194-9. 1 Batterman, s, et al., environ Health Perspect, 2009. 117(7): p. 1023-32. 275 Hrudey, se, et al., Water science and Technology, 2003. 47(3): p. 7-14. 2 276 Yoder, J, et al., mmWr surveill summ, 2008. 57(9): p. 39-62. 3 Us environmental Protection agency, report to congress: impacts and control of csOs and ssOs. Office of meinhardt, Pl, J Water Health, 2006. 4 suppl 1: p. 27-34. 277 Wastewater management. 2004, Us environmental Protection agency,: Washington, Dc. 278 mathers, c, et al. 2008, Geneva, switzerland: World Health Organization. vii, 146 p. 4 Patz, Ja, et al., am J Prev med, 2008. 35(5): p. 451-8. ibid. 279 craun, GF, et al., J Water Health, 2006. 4 suppl 2: p. 101-19. 280 www.niehs.nih.gov/climatereport 51

60 A Human Health Perspective Waterborne Diseases ON CLIMATE CHANGE Globally, the impact of waterborne diarrheal disease is high and closing beaches to the public, and these areas need immediate additional research. expected to climb with climate change. Improving domestic surveillance is a high priority, as this would enhance epidemiologic characterization of the drivers of epidemic disease. In particular, ­ The effects of climate changes on the distribution and bioaccumu weather and climate-related drivers are not well understood. lation of chemical contaminants in marine food webs are poorly Waterborne disease outbreaks are highly correlated with extreme understood and may be significant for vulnerable populations of 281 precipitation events, humans and animals. The U.S. Climate Change Science Program but this correlation is based on limited (CCSP) reported a likely increase in the spread of waterborne research and needs further investigation and confirmation. pathogens depending on the pathogens’ survival, persistence, Prevention and treatment strategies for waterborne disease are 286 habitat range, and transmission in a changing environment. well established throughout the developed world; climate change is not likely to greatly impact the efficacy of these strategies in the In one specific example, the CCSP noted the strong association United States. However, climate change is very likely to increase Vibrio between sea surface temperature and proliferation of many global diarrheal disease incidence, and changes in the hydrologic species and suggested that rising temperatures would likely lead cycle including increases in the frequency and intensity of extreme to increased occurrence of enteric disease associated with Vibrio weather events and droughts may greatly complicate already bacteri a ( V. cholerae, V. vulnificus, and V. parahaemolyticus) in inadequate prevention efforts. Enhanced understanding and the United States, including the potential for the occurrence of reinvigorated global prevention efforts are very important. cholera and wound infections. Further, recent findings demon ­ strate that pathogens that can pose disease risks to humans occur Ocean-related diseases are those associated with direct contact widely in marine vertebrates and regularly contaminate shellfish 287 with marine waters (aerosolized in some cases) or sediments and aquacultured finfish. (including beach sands), ingestion of contaminated seafood, or 282 Impacts on Risk exposure to zoonotics. Pathogenic microorganisms (bacteria, viruses, protozoa, and fungi) that may occur naturally in ocean, Climate directly impacts the incidence of waterborne disease coastal, and Great Lakes waters, or as a result of sewage pollution through effects on water temperature and precipitation frequency 283 and runoff, are the primary etiologic agents. and intensity. These effects are pathogen and pollutant specific, Human exposure to ­ and risks for human disease are markedly affected by local condi these agents may result in a variety of infectious diseases including tions, including regional water and sewage treatment capacities serious wound and skin infections, diarrhea, respiratory effects, 284 and practices. Domestic water treatment plants may be susceptible and others. Research has concluded that the antibiotic resistant to climate change leading to human health risks. For example, methicillin resistant ) is persistent Staphylococcus aureus (MRSA droughts may cause problems with increased concentrations of in both fresh and seawater and could become waterborne if 285 eff luent pathogens and overwhelm water treatment plants; aging released into these waters in sufficient quantities. While this has 288 water treatment plants are particularly at risk. yet to emerge as a significant public health concern, the potential Urbanization for recreational exposure is significant, as people make nearly one of coastal regions may lead to additional nutrient, chemical, and 289 billion trips to the beach annually in the United States alone. In pathogen loading in runoff. contrast to diarrheal disease, there are few effective preventive strategies for marine-based environmental exposures beyond ebi, K, et al. in analyses of the effects of global change on human health and welfare and human systems. a 286 report by the U.s. climate change science Program and the subcommittee on Global change research, J Gamble, et al., editors. 2008, UsePa: Washington, D. c. moore, sK, et al., environmental Health: a Global access science source, 2008. 7(sUPPl. 2). 287 curriero, Fc, et al., am J Public Health, 2001. 91(8): p. 1194-9. 281 Kistermann, T, et al., applied and environmental microbiology, 2002. 68(5): p. 2188-2197, Patz, Ja, et al., am 288 J Prev med, 2008. 35(5): p. 451-8, senhorst, HaJ, et al., Water science and Technology, 2005. 51(5): p. 53-59, 282 Heaney, cD, et al., am J epidemiol, 2009. 170(2): p. 164-72. Wilby, r, et al., Weather, 2005. 60(7): p. 206-211. mos, l, et al., environ Toxicol chem, 2006. 25(12): p. 3110-7. 283 289 Dwight, rH, et al., american Journal of Public Health, 2004. 94(4): p. 565-567, Dwight, rH, et al., Water stewart, Jr, et al., environ Health, 2008. 7 suppl 2: p. s3. 284 environment research, 2002. 74(1): p. 82-90, semenza, Jc, et al., lancet infectious Diseases, 2009. 9(6): p. 365­ 285 Tolba, O, et al., int J Hyg environ Health, 2008. 211(3-4): p. 398-402. 375. www.niehs.nih.gov/climatereport 52

61 ON CLIMATE CHANGE Waterborne Diseases A Human Health Perspective 294 Other climate-related likely be exacerbated by climate change. Our understanding of weather and climate impacts on specific ­ environmental changes may impact marine food webs as well, such pathogens is incomplete. Climate also indirectly impacts water borne disease through changes in ocean and coastal ecosystems as pesticide runoff, leaching of arsenic, f luoride, and nitrates from fertilizers, and lead contamination of drinking and recreational including changes in pH, nutrient and contaminant runoff, salinity, and water security. These indirect impacts are likely to result in waters through excess rainfall and f looding. degradation of fresh water available for drinking, washing food, Mitigation and Adaptation cooking, and irrigation, particularly in developing and emerging economies where much of the population still uses untreated Alternative energy production, carbon sequestration, and water reuse surface water from rivers, streams, and other open sources for these and recycling are some of the mitigation and adaptation options that needs. Even in countries that treat water, climate-induced changes could have the greatest implications for human health. As with all in the frequency and intensity of extreme weather events could lead technologies, the costs and benefits of each will need to be carefully to damage or f looding of water and sewage treatment facilities, considered and the most beneficial implemented. increasing the risk of waterborne diseases. Severe outbreaks of cholera, in particular, have been directly associated with f looding in The potential impacts of different mitigation strategies for 290 Africa and India. waterborne illness depend on the strategy. For instance, increased A rise in sea level, combined with increasingly hydroelectric power generation will have significant impacts on ­ severe weather events, is likely to make f looding events common local ecologies where dams are built, often resulting in increased place worldwide. A 40 cm rise in sea level is expected to increase or decreased incidence of waterborne disease, as was the case with the average annual numbers of people affected by coastal storm schistosomiasis (increase) and haematobium infection (decrease) surges from less than 50 million at present to nearly 250 million by 295 291 after construction of the Aswan Dam in Egypt. 2080. Other modes of ­ electric power generation, including nuclear, consume large quanti ties of water and have great potential environmental impacts ranging ­ Several secondary impacts are also a concern. Ecosystem degrada from increased water scarcity to discharge of warmed eff luent into tion from climate change will likely result in pressure on agricul ­ local surface water bodies. Shifting to wind and solar power, however, tural productivity, crop failure, malnutrition, starvation, increasing will reduce demand on surface waters and, therefore, limit impacts population displacement, and resource conf lict, all of which are on local water ecosystems and potentially reduce risks of waterborne predisposing factors for increased human susceptibility and diseases. The impacts on waterborne pathogen ecology of other increased risk of waterborne disease transmission due to surface ­ geoengineering mitigation strategies, such as carbon sequestra water contamination with human waste and increased contact with 292,293 tion, have the potential to be substantial but are currently largely such waters through washing and consumption. 296 unknown. Thorough health impact and environmental impact assessments are necessary prior to implementation and widespread Climate change may also affect the distribution and concentrations adoption of any novel mitigation technology. of ch emical contaminants in coastal and ocean waters, for example through release of chemical contaminants previously bound up in polar ice sheets or sediments, through changes in volume and There is also significant potential for adaptation activities to impact composition of runoff from coastal and watershed development, the ecology of waterborne infectious disease. Certain adaptation or through changes in coastal and ocean goods and services. Both strategies are likely to have a beneficial impact on water quality; for naturally occurring and pollution-related ocean health threats will instance, protecting wetlands to reduce damage from severe storms. 294 sandifer, P, et al., interagency oceans and human health research implementation plan: a prescription for the future. sidley, P, BmJ, 2008. 336(7642): p. 471, sur, D, et al., indian J med res, 2000. 112: p. 178-82. 290 2007, interagency Working Group on Harmful algal Blooms, Hypoxia and Human Health of the Joint subcommittee on Ocean science and Technology: Washington, Dc, Usa. 291 Ford, Te, et al., emerging infectious Diseases, 2009. 15(9): p. 1341-1346. shultz, a, et al., american Journal of Tropical medicine and Hygiene, 2009. 80(4): p. 640-645. 292 295 abdel-Wahab, mF, et al., lancet, 1979. 2(8136): p. 242-4. 293 Diaz, JH, am J Disaster med, 2007. 2(1): p. 33-42. 296 White, cm, et al., energy & Fuels, 2005. 19(3): p. 659-724. www.niehs.nih.gov/climatereport 53

62 Waterborne Diseases ON CLIMATE CHANGE A Human Health Perspective Research Needs Under drought conditions, water reuse or the use of water sources 297 that may be of lower quality is likely to increase. The extent to which the United States is vulnerable to increased risk of Local water waterborne diseases and ocean-related illness due to climate change recycling and so-called grey-water reuse, as well as urban design 299 has not been adequately addressed. strategies to increase green space and reduce runoff, may result Research needs include: in slower rates of water table depletion and reduce the impact understanding the likelihood and potential magnitude of • of extreme precipitation events in urban areas where runoff is waterborne disease outbreaks due to climate change including concentrated. increases in the frequency and intensity of precipitation, temperature changes, extreme weather events, and storm surges Other adaptation efforts may have both positive and negative researching the vulnerability of water systems to sewer overf low • effects. For instance, if the response to increasingly frequent and or f looding caused by extreme weather events, especially in severe heat waves is widespread adoption of air conditioning, the water systems where there is already considerable water reuse; associated increase in electricity demand will require additional and examining the impacts of other water reuse and recycling power, which in turn could impact water availability and regional strategies water ecology. In parts of the developing world, changing weather patterns and decreased food availability could lead to increased understanding how toxins, pathogens, and chemicals in • desertification, or at the least the need for more above-ground land-based runoff and water overf low interact synergistically irrigation. If such projects are implemented in areas where parasitic and with marine species, especially those important for human diseases such as schistosomiasis are prevalent without close consumption, and the potential health risks of changing water attention to potential ecosystem impacts, there may be changes in quality regional parasite transport and associated increases or decreases in developing means of identifying sentinel species for waterborne • human exposure. disease and understanding of how they may provide early warning of human health threats Climate-induced changes to coastal ecosystems are poorly understood, especially with regard to ecosystem goods and services ­ developing or improving vaccines, antibiotics and other preven • related to human health and well being, and ocean and coastal tive strategies to prevent and reduce the health consequences of 298 disease threats. Interactions among climate change factors such waterborne disease on a global basis as rising temperature, extreme weather events, inundation, ocean improving understanding of harmful algal blooms including • acidification, and changes in precipitation and runoff with coastal their initiation, development, and termination, as well as the development, aquacultural practices, and other water use issues exact nature of the toxins associated with them need to be studied. Frumkin, H, et al., american Journal of Public Health, 2008. 98(3): p. 435-445, ebi, K, et al. in analyses of the 299 effects of global change on human health and welfare and human systems. a report by the U.s. climate change science Program and the subcommittee on Global change research, J Gamble, et al., editors. 2008, UsePa: 297 corwin, Dl, et al., J environ Qual, 2008. 37(5 suppl): p. s1-7. Washington, D. c, sandifer, P, et al., interagency oceans and human health research implementation plan: a 298 United states. congress. senate. committee on commerce science and Transportation. 2003, Washington: U.s. prescription for the future. 2007, interagency Working Group on Harmful algal Blooms, Hypoxia and Human Health of the Joint subcommittee on Ocean science and Technology: Washington, Dc, Usa. ii. 8 p. G.P.O. www.niehs.nih.gov/climatereport 54

63 A Human Health Perspective Waterborne Diseases ON CLIMATE CHANGE conducting epidemiologic studies on the occurrence and severity • of ocean-related diseases among humans, especially high risk populations, in relation to climate change evaluating and monitoring exposures and health risks of chemical • contaminants likely to be increasingly released and mobilized due to climate change improving methods to detect, quantify, and forecast ocean- • related health threats including improved surveillance and monitoring of disease-causing agents in coastal waters; in marine organisms (especially seafood), aerosols, and sediments; and in exposed human populations assessing the capacity of the nation’s public health infrastructure to • detect and respond to increased waterborne disease incidence, and developing training and evaluation tools to address identified gaps www.niehs.nih.gov/climatereport 55

64 56 \

65 11 Weather-Related Morbidity and Mortality increased preparedness levels could lower costs and minimize The United States experiences a variety of extreme weather events ranging from hurricanes and f loods to blizzards and drought. Many morbidity and mortality from future events. of these events cause severe infrastructure damage and lead to Impacts on Risk significant morbidity and mortality. From 1940 to 2005, hurricanes caused approximately 4,300 deaths and f looding caused 7,000 A changing climate coupled with changing demographics is ex ­ 300 deaths, primarily from injuries and drowning. pected to magnify the already significant adverse effects of extreme Climate change is weather on public health. For example, the intensity and frequency expected to increase the frequency and intensity of some extreme of precipitation events in the United States have increased over weather events, including f loods, droughts, and heat waves, though 301 307 the past 100 years in many locations. how these events will manifest on a regional level is uncertain. In the Midwest and The health impacts of these extreme weather events can be severe, Northeastern United States, heavy rainfall events (defined as those in excess of 1 inch of rainfall) have increased by as much as 100%, and include both direct impacts such as death and mental health effects, and indirect impacts such as population displacement and and recent f looding events, such as the June 2008 f looding in the ­ waterborne disease outbreaks such as the 1993 Milwaukee cryp Midwest, have caused billions of dollars of damage and significant 308 loss of life. tosporidium outbreak caused by f looding that sickened an estimated In line with this observed trend, there is a projected 302,303 400,000 people. increase in intensity of precipitation events in some areas of the country, particularly in the Northeast, which has experienced a 67% increase in the amount of heavy precipitation events in the past 50 The populations most at risk from such extreme events also are 309,310 years. growing, particularly as a result of increased coastal development, Precipitation extremes also are expected to increase as recent f looding events and hurricanes have shown. Sea-level rise more than the mean. Regional variability appears to be increasing associated with climate change will amplify the threat from storm so that even though extreme precipitation events will become 304 surge associated with extreme weather events in coastal areas. more common, some areas will concurrently experience drought, 311 especially in the northeast and southwest. Other areas, such as the Southwest, are at risk for decreased agricultural productivity due to increased drought and possible compromise of potable water supplies due to f looding from heavy The intensity of extreme precipitation events is projected to increase 312 305 precipitation events. with future warming. This could limit the ability to capture and Given the increased incidence of extreme store water in reservoirs, leading to f lash f looding events. Climate weather events and the increasing number of people at risk, research in this area is an immediate and significant need. Preparation has variability resulting from naturally occurring climate phenomena a significant impact on outcomes of extreme weather events. Poor such as El Niño, La Niña, and global monsoons, are associated 313 preparedness and response to Hurricane Katrina led to increased with extreme weather events around the globe. El Niño and La morbidity and mortality, as well as economic costs associated with Niña conditions lead to changes in the patterns of tropical rainfall 306 recovery, which were estimated to be in excess of $150 billion. 307 Karl, T, et al. 2009, New York: cambridge University Press, Kunkel, Ke, Natural Hazards, 2003. 29(2): p. 291-305. By increasing research funding related to extreme weather events, 308 Black, H, environmental Health Perspectives, 2008. 116(9): p. a390-+, Kunkel, Ke, et al., Journal of climate, 1999. 12(8): p. 2515-2527. 309 Kunkel, Ke, Natural Hazards, 2003. 29(2): p. 291-305, Balling, rc, et al., Natural Hazards, 2003. 29(2): p. 103-112, Groisman, PY, et al., climatic change, 1999. 42(1): p. 243-283. 300 ashley, sT, et al., Journal of applied meteorology and climatology, 2008. 47(3): p. 805-818, National Weather 310 meehl, Gaas, T. F. and collins, W. D. and Friedlingstein, a. T. and Gaye, a. T. and Gregory, J. m. and Kitoh, a. and service, summary of Natural Hazard statistics for 2007 in the United states. 2007: Washington. Knutti, r. and murphy, J. m. and Noda, a. and raper, s. c. B. and Watterson, i. G. and Weaver, a. J. and Zhao, in climate change 2007 : the physical science basis : contribution of Working Group i to the Fourth assessment Z. Greenough, G, et al., environmental Health Perspectives, 2001. 109: p. 191-198, Trenberth, Ke, et al., Bulletin of 301 report of the intergovernmental Panel on climate change, s solomon, et al., editors. 2007, cambridge University the american meteorological society, 2003. 84(9): p. 1205-+. Press: cambridge ; New York. p. 747-845. 302 mac Kenzie, Wr, et al., N engl J med, 1994. 331(3): p. 161-7. christensen, JH, et al. ibid, Hayhoe, K, et al., climate Dynamics, 2007. 28(4): p. 381-407, milly, PcD, et al., Nature, 311 303 Greenough, G, et al., environmental Health Perspectives, 2001. 109: p. 191-198, mills, Dm, Journal of 2005. 438(7066): p. 347-350. Occupational and environmental medicine, 2009. 51(1): p. 26-32, Verger, P, et al., Journal of exposure analysis and meehl, Gaas, T. F. and collins, W. D. and Friedlingstein, a. T. and Gaye, a. T. and Gregory, J. m. and Kitoh, a. and 312 environmental epidemiology, 2003. 13(6): p. 436-442. Knutti, r. and murphy, J. m. and Noda, a. and raper, s. c. B. and Watterson, i. G. and Weaver, a. J. and Zhao, Karl, T, et al., Weather and climate extremes in a changing climate regions of focus: North america, Hawaii, 304 in climate change 2007 : the physical science basis : contribution of Working Group i to the Fourth assessment Z. caribbean, and U.s. Pacific islands, in synthesis and assessment product 3.3. 2008, U.s. climate change science report of the intergovernmental Panel on climate change, s solomon, et al., editors. 2007, cambridge University Program: Washington, Dc. p. x, 162 p. Press: cambridge ; New York. p. 747-845. 305 ibid. 313 Karl, T, et al., Weather and climate extremes in a changing climate regions of focus: North america, Hawaii, Burton, m, et al., Hurricane Katrina: Preliminary estimates of commercial and public sector damages. 2005, center 306 caribbean, and U.s. Pacific islands, in synthesis and assessment product 3.3. 2008, U.s. climate change science for Business and economic research, marshall University: Huntington, WV. Program: Washington, Dc. p. x, 162 p. www.niehs.nih.gov/climatereport 57

66 A Human Health Perspective Weather-Related Morbidity and Mortality ON CLIMATE CHANGE 318 In addition, f looding and in the weather patterns in mid-latitudes, including changes in infrastructure and more costly hurricanes. and coastal changes could lead to ecosystem changes such as loss of the frequency and intensity of weather extremes. El Niño is also wetlands that could indirectly impact human health. Hurricane track projected to increase in both frequency and intensity as the climate forecasting and modeling methods have improved, and mortality warms, though there is uncertainty about the relative frequency of rates for major storms have declined over time, but the combination El Niño and La Niña in the future. Increased precipitation associated of increased coastal population density, increased intensity of tropical with stronger El Niño events would affect the Western United States, particularly California, the Pacific Northwest, and the Gulf Coast storms, and sea-level rise will result in significantly increased risk 314 319 going forward. more than other regions of the country. Some models show that what were 20-year f loods in 1860 in the United Heavy precipitation events will be highly variable in magnitude, du ­ Kingdom are now 5-year f loods; even greater impacts are expected in ration, and geographic location. Increased variability in weather and 320 tropical regions. climate extremes is difficult to predict, and will impact the ability of In the United States, large f loods are more frequent 321 th human systems to manage for and adapt to heavy precipitation and now than at the beginning of the 20 c ent u r y. Monsoon-related f lood ­ f looding events. An observed divergence of precipitation patterns ing results in damaged infrastructure, increased disease, and loss of life. has lead to increased variability in the amount of precipitation per During El Niño, areas includig Indonesia, southern Africa, northeastern event, resulting in both extreme amounts of precipitation, as well as Australia, and northeastern Brazil usually experience extensive periods 315 322 abnormally small precipitation events. of dry weather and warmer-than-average temperatures. These These effects have already been observed globally. A study in Germany found that winter conditions have historically resulted in a variety of adverse effects, such ­ as mudslides, forest fires and resulting increased air pollution, mass storms from 1901 to 2000 showed an increasing trend of precipita 323 th migrations, and famines. tion events both exceeding the 95 percentile and falling below the th 5 percentile; while from 1956 to 2004 the Dongxiang River in China Mitigation and Adaptation became increasingly likely to be at either extreme f lood f low or 316 abnormally low-f low. Climate change mitigation includes activities that reduce greenhouse gas emissions. Important sources include land use changes, transport, ­ energy production, and buildings. Some proposed mitigation strate The current evidence is insufficient to determine if the frequency gies to reduce the occurrence of extreme weather events could impact of tropical cyclones in the Atlantic Basin will change. The observed human health. A reduction in personal automobile usage is one way to frequency of tropical cyclones in the Atlantic Basin has increased ­ lower carbon emissions. However, a greater reliance on pubic trans since the mid-1990s, though the numbers are not unprecedented and portation could either improve or reduce the ability to quickly evacuate must be reconciled with active multi-decadal periods of the past, 317 a city prior to a severe weather event, depending on how it is managed. such as the 1950s and 1960s. Increases in sea surface temperature Mitigation activities related to land use may have other health impacts; and decreases in wind shear may lead to more intense Atlantic anthropogenic reforestation, when combined with shifting weather hurricanes, though some models also show a decrease in the number patterns, could provide habitats for zoonotic and vectorborne diseases of intense hurricanes in the Atlantic Basin. while reducing land available for agricultural uses. It is difficult to adequately evaluate the likely health impacts of various mitigation The spatial distribution of hurricanes also is likely to change, with strategies, though Health Impact Assessments are proving a very storm surges becoming more damaging in areas unaccustomed to fac ­ useful public health tool for this purpose. ing large hurricanes. The combination of sea-level rise with increasing storm intensity could lead to significant destruction of coastal meehl, Gaas, T. F. and collins, W. D. and Friedlingstein, a. T. and Gaye, a. T. and Gregory, J. m. and Kitoh, a. and 318 Knutti, r. and murphy, J. m. and Noda, a. and raper, s. c. B. and Watterson, i. G. and Weaver, a. J. and Zhao, ibid, easterling, Dr, et al., science, 2000. 289(5487): p. 2068-2074. 314 in climate change 2007 : the physical science basis : contribution of Working Group i to the Fourth assessment Z. report of the intergovernmental Panel on climate change, s solomon, et al., editors. 2007, cambridge University 315 Jentsch, a, et al., comptes rendus Geoscience, 2008. 340(9-10): p. 621-628, christensen, JH, et al. in climate Press: cambridge ; New York. p. 747-845. change 2007 : the physical science basis : contribution of Working Group i to the Fourth assessment report of the intergovernmental Panel on climate change, s solomon, et al., editors. 2007, cambridge University Press: 319 rappaport, eN, et al., Weather and Forecasting, 2009. 24(2): p. 395-419. cambridge ; New York. p. 747-845. 320 allen, mr, et al., Nature, 2002. 419(6903): p. 224-+. 316 Tromel, s, et al., Theoretical and applied climatology, 2007. 87(1-4): p. 29-39, Wang, W, et al., Hydrology and earth 321 Trenberth, Ke, et al., Bulletin of the american meteorological society, 2003. 84(9): p. 1205-+, milly, PcD, et al., system sciences, 2008. 12(1): p. 207-221. Nature, 2005. 438(7066): p. 347-350. Karl, T, et al., Weather and climate extremes in a changing climate regions of focus: North america, Hawaii, 317 322 Karl, T, et al., Weather and climate extremes in a changing climate regions of focus: North america, Hawaii, caribbean, and U.s. Pacific islands, in synthesis and assessment product 3.3. 2008, U.s. climate change science caribbean, and U.s. Pacific islands, in synthesis and assessment product 3.3. 2008, U.s. climate change science Program: Washington, Dc. p. x, 162 p, Henderson-sellers, a, et al., Bulletin of the american meteorological society, Program: Washington, Dc. p. x, 162 p. 1998. 79(1): p. 19-38, Knutson, T, et al. in culture extremes and society. 2008, cambridge University Press: cambridge. 323 Planton, s, medecine et maladies infectieuses, 1999. 29(5): p. 267-276. www.niehs.nih.gov/climatereport 58

67 ON CLIMATE CHANGE A Human Health Perspective Weather-Related Morbidity and Mortality 324 There are several adaptation strategies for extreme weather events developing strategies for linking health databases • with that have proven effective, including early warning systems, zoning real-time monitoring and prospective assessment of weather, 325 and planning to avoid building in at-risk areas, reinforcing the built climate, geospatial, and exposure data in order to better environment against hazardous weather events, and evacuation plan ­ characterize the health impacts of extreme weather events ning. While some strategies may be costly, they can be implemented improving the predictive power of probabilistic modeling of health • over extended periods of time, defraying their costs. However, effects of extreme events such as droughts, wildfires, and f loods adaptation could be more difficult in some of the most heavily enhancing predictability, modeling, and ongoing assessment of the • affected areas. For example, the population of many cities along the effects of climate variability and change (seasonal-to-interannual relatively high-risk U.S. Eastern seaboard has been growing in recent and decadal) on extreme events and correlation with short- and years and this growth is likely to continue. High population growth, long-term health outcomes typically associated with concentrations of critical infrastructure, in areas vulnerable to storm surges and sea-level rise will make developing and validating downscaling techniques from global • adaptation difficult. Moreover, some adaptation activities intended climate models to provide regional information for health early to preserve existing infrastructure, such as building levees and other warning systems f lood control measures, may have adverse ecological impacts and be transitioning research advances into operational products and • prohibitively expensive. Alternatively, measures to fortify natural decision support tools for health early warning systems barriers to f looding and erosion and to buffer storm surge, such as wetlands and tidal marshes, will decrease the magnitude of adverse evaluating and improving the effectiveness of health alert warning • exposures and maintain associated ecosystem services such as systems and other health system risk communication tools such as food production and waste assimilation, thereby realizing potential evacuation protocols and National Disaster Management System co-benefits of climate change adaptation. activation, particularly for high-risk populations expanding research on prevention and preparedness for extreme • Research Needs weather events including development of disaster planning tools ­ Due to the complexity of climate change and the health effects associ such as data and communication systems for public health and ated with climate variability and extreme weather, research needs in emergency care, including enhanced access to medical records this area are diverse, and include: and capabilities across hospitals on a regional level exploring the impact of extreme precipitation events on • evaluating and developing new funding and reinsurance strategies • waterborne disease, particularly cholera, and on the ecology of and policies for disaster relief and rebuilding infrastructure vectorborne and zoonotic disease improving understanding of extreme weather events associated • Weather related research intersects with several other areas of with naturally occurring climate phenomena such as El Niño, La - cli mate change research. Examples include waterborne and vector Niña, and monsoons, and their impacts on human health borne illness following f loods and hurricane storm surges, as well as post-traumatic stress disorder and related mental effects that can assessing the ability of health care systems to respond to extreme • result from personal tragedy and displacement after extreme weather weather events and provide uninterrupted access to and delivery events. Studies of marine ecosystems and associated health impacts of health care services under a variety of scenarios also overlap with extreme weather studies. Research in health improving understanding of how to anticipate and address food • communications and early warning systems is clearly applicable security and nutrition issues after extreme weather events, to periods proceeding and following weather disasters, as well as domestically and globally disaster preparedness and critical infrastructure development and protection improving understanding of how to anticipate and address water • quality and availability concerns associated with extreme weather ... events, domestically and globally 324 such as the databases maintained by the National center for Health statistics 325 such as the databases included in the Global earth Observation system of systems initiative and those maintained by the Us ePa and NOaa www.niehs.nih.gov/climatereport 59

68 A Human Health Perspective ON CLIMATE CHANGE Synthesis and Recommendations Synthesis and Recommendations There is abundant evidence that human activities are altering the earth’s climate and that climate change will have significant health impacts both domestically and globally. While all of the changes associated with this process are not predetermined, the actions we take today will certainly help to shape our environment in the decades to come. Some degree of climate change is unavoidable, and we must adapt to its associated health effects; however, aggressive mitigation actions can significantly blunt the worst of the expected exposures. Still, there will be effects on the health of people in the United States, some of which are probably already underway. As great as the domestic risks to U.S. public health are, the global risks are even greater. Climate change and health issues transcend national borders, and climate change health impacts in other countries are likely to affect health in the United States as well. Famine, drought, extreme weather events, and regional conf licts—all likely consequences of climate change—are some of the factors that increase the incidence and severity of disease, as well as contributing to other adverse health impacts, making it imperative to address climate change-related decision making at local, regional, national, and global levels. The complicated interplay of these and other factors must be considered in determining the scope and focus of both basic and applied research on climate change and health. www.niehs.nih.gov/climatereport 60

69 Synthesis and Recommendations ON CLIMATE CHANGE A Human Health Perspective effects of multiple environmental changes and stressors, some caused There are significant research needs to help direct by climate change and some by other factors, facilitating a robust adaptation activities and inform mitigation choices public health and health care response. going forward. Such needs include integrating climate Given the fundamental importance of ecosystems in climate change science with health science; integrating environmental, impacts and the significant roles that environmental factors play in public health, and marine and wildlife surveillance; human health, climate change and health research should also focus applying climate and meteorological observations to on the complex interplay between risk, location, and environmental conditions. Vulnerability and resilience to climate change health real-time public health issues; and down-scaling long­ effects are both heavily determined by locality. A huge amount of term climate models to estimate human exposure risks diverse information will be needed at all governance levels (local, regional, national, global). Understanding local needs will be of and burden of disease. Integrated data systems should greatest importance, given that effective adaptation strategies likely incorporate a breadth of environmental parameters, will not be universally applicable to all locations. However, there is as well as sociodemographic parameters such as also a need to identify common elements of strategies that may be generalized from one community to another. In addition, research is population, income, and education. needed on how to identify common features of locales that will help identify them as having similar responses to climate change, how to Several overarching themes emerged during the creation determine and develop optimal strategies for interventions, and how to develop and implement communication tools that will effectively of this document including: systems and complexity, risk help communities respond to their particular situation. communication and public health education, co-benefits of mitigation and adaptation strategies, and urgency and Risk Communication and Public Health Education. Knowledge is one of the most strategic tools in reducing health scope. These are discussed below. problems in any environment; it allows us to understand what is harmful, why, and possibly how to avoid such harm. Research is The complicated links between human Systems and Complexity. critical, but knowledge that is not effectively communicated to and natural systems need to be better understood so public health appropriate audiences is wasted. Knowledge of the health impacts as ­ agencies can develop evidence-based prevention strategies and the sociated with climate change will have limited value without effective health care community can pursue secondary controls and respond communication and education strategies to increase public awareness to health incidents when prevention is not effective. Research and understanding of the specific risks involved and the complexity of on these links should focus not only on the direct health effects the issues. Communication with particularly vulnerable individuals of climate change but also on the complex relationships between and populations, as well as with health care professionals and public different exposure pathways and health risks. For example, people ­ health officials tasked with protecting communities, is itself deserv with compromised immune systems because of persistent organic ing of further research. For example, public health agencies already pollutant exposure are likely to be at greater risk of infection and warn people with pulmonary diseases to avoid lengthy exposure death from vectorborne, waterborne, and foodborne pathogens and outdoors on days of high ozone. Such warning systems might be disease. Similarly, people with respiratory illnesses such as asthma more effective if delivered through multiple channels and tailored to and chronic obstructive pulmonary disease are far more likely to individual health risks. Warnings on other harmful environmental suffer distress and hospitalization during extreme heat events, dust exposures such as high pollen concentrations and extreme heat storms, or high pollen events than healthy people. Thus, the structure events should be expanded in geographic scope. For at-risk patients, of basic research on health impacts should address the combined www.niehs.nih.gov/climatereport 61

70 A Human Health Perspective Synthesis and Recommendations ON CLIMATE CHANGE and cancer morbidity and mortality associated with vehicular warnings could be integrated into hospital and clinic discharge air pollution will continue and probably increase. This example instructions or distributed with medications to more effectively illustrates the importance of understanding the potential co-benefits prevent exacerbations of environmentally sensitive disease. Public of climate change mitigation efforts so that optimal strategies can be health professionals need to be highly vigilant for opportunities to implemented. Basic research on health and environmental factors ­ increase the range and impact of early warning systems on vulnera and implementation research to develop new models and paradigms ble populations. As our health care system is increasingly integrated for burden-of-disease calculations are needed to allow for a careful and preventive health activities become more robust, there will be use of health and economic cost indicators in the same evaluation. ever more opportunities to prevent adverse health effects associated Health impact assessments are an important tool for evaluating the with harmful environmental exposures. Risk communication efforts health impacts, both positive and negative, of possible mitigation need to be culturally sensitive to provide appropriate and effective strategies prior to widespread implementation. guidance, and potential interventions require testing and evaluation before they are implemented. Similarly, there is considerable need for study of broader adaptation issues that will affect many different groups. Examples of adapta ­ . Considerable discussion currently Mitigation and Adaptation tion include use of air conditioning, weather alerts, and increased focuses on identifying mitigation strategies that balance the numbers of medical facilities. Of key interest are the health effects of economic costs of emission reductions (both direct mitigation adaptation practices in food, water, and chemical use. For example, costs and costs associated with loss of productivity) with the costs regional water shortages will cause a greater intensity of recycling of environmental degradation from continuing business as usual. and reuse of water, with resulting increases in risks of human Examples of mitigation technologies include electric cars, alternative exposure to waterborne pollutants and pathogens. The genetic fuels, and green urban development. Cost-benefit evaluations modification of plants to withstand altered environments and use typically express costs in economic terms rather than in terms of less water could introduce changes in the allergenicity or toxicity of human morbidity and mortality, though these health impacts can be foods that are currently considered harmless. And use of pesticides substantial. Many mitigation and adaptation strategies reach across ­ whose residues may be harmful to both current and future genera health endpoints and may be both beneficial and problematic for a tions may increase as a way of adapting to the effects of increasing wide array of diseases. temperatures and changing precipitation patterns that affect crop yields. Other adaptation efforts may have important health co ­ ­ Climate change health impacts are complicated and not always intui benefits that need to be identified. For example, adaptation efforts tive or unidirectional. For example, reducing reliance on fossil fuels focusing on urban design, such as increasing urban albedo through in the transportation sector will substantially reduce CO emissions, 2 green roofs, increasing urban tree cover, reducing the size of the which over time will reduce the effects of climate change on human urban heat island through compact development, and decreasing health. Thus, consideration of the costs of emissions reductions impervious surface runoff through use of permeable paving surfaces should include reduced health cost due to effective mitigation. have been shown to have multiple co-benefits. Failing to mitigate also carries additional health consequences beyond those associated with climate change itself. For example, By no means a comprehensive list, the strategies discussed above reducing vehicular emissions improves air quality, which may lessen illustrate the diversity in mitigation and adaptation possibilities, incidences of effects such as airway diseases and irritations, cardio ­ and it should be noted that many new ideas and options are being vascular disease, and cancer. However, further research, including developed. As with all emerging technologies, it is important to ho ­ life cycle analyses of batteries and other technologies, and human listically examine their effects on health, both positive and negative, exposure to novel emission mixtures, is needed to avoid unintended so that the best options for society can be identified and adopted. negative consequences. If we choose not to reduce greenhouse gas emissions from transportation, levels of air pollution generated by vehicles will remain high and the cardiovascular, respiratory, www.niehs.nih.gov/climatereport 62

71 Synthesis and Recommendations A Human Health Perspective ON CLIMATE CHANGE The necessary research on climate change Scope and Urgency. health impacts, the health effects of mitigation, and development of appropriate adaptation strategies will not occur spontaneously and cannot occur in isolation. To be successful, an overarching research program needs to be integrated, focused, interdisciplinary, supported, and sustainable, yet f lexible enough to adjust to new information and broad enough to cover the very diverse components described in this document. The effort must also be multinational, multiagency, and multidisciplinary, bringing together the strengths of all partners. The effort also must promote user-driven research that closely aligns future research directions with the needs of decision makers by facilitating multi-directional dialogue among information producers, providers, and end users. This research will require capacity building in a number of areas, especially in climate sciences and disease and ecosystem surveillance necessary to sup ­ port the health sciences as they grapple with these issues. Finally, both the efforts and the outcomes need to be evaluated using clear metrics that are linked to assessment questions and outcome indica ­ tors to ensure they are valid, effective, and achieve the desired goals. Natural systems adapt to environmental changes or they fail. Climate change threatens many of the natural and built systems that protect and preserve our nation’s health. The infrastructure that we have put in place to protect health and provide well being in the United States is extremely diverse and includes hospitals, clinics, public health agencies, trained personnel, roads and transportation systems, the electrical grid, water treatment systems, and many other components. Threats to these systems from climate change range from damage to natural and built physical infrastructure to damage to intangible or ­ ganizational structures (human and social capital) that are required to maintain resilience to environmental threats. Climate change could have grave impacts on public health systems if they are not appropri ­ ately strengthened. Research into the vulnerability of these systems will be critical to identifying areas most in need of attention, avoiding mistakes, limiting human suffering, and ultimately saving lives. www.niehs.nih.gov/climatereport 63

72 A Human Health Perspective ON CLIMATE CHANGE S ummary S tatement Humans have successfully adapted to There is no doubt that we have the capacity to find ways to avoid many of the worst health environmental change over time, from effects of climate change, and indeed, given evolving natural physiological responses to the use of science, technology, and knowledge the universality and potential magnitude of to improve our lives and advance our health. such effects, we have an ethical imperative to From the dawn of the industrial age, people do so. The research needs described in this document should guide the process, helping us have made great strides in improving health, and enjoy a markedly improved quality of life. to develop the proper tools and make informed choices that will ultimately result in better However, these improvements have come at a health and better lives for the citizens of the cost that must now be understood and United States and of the world. addressed. Climate change will force humans to negotiate with their changing environment Interagency Working Group on as never before to find ways to reshape it both Climate Change and Health for short-term protection and long-term alleviation of health consequences.

73

74 ON CLIMATE CHANGE A Human Health Perspective Bibliography Bibliography Bronstein, J. , et al. , Meeting Report: Consensus Statement-Parkinson’s Disease and the Environment: Collaborative Aagaard-Tillery, K.M. , et al., Developmental origins of disease and determinants of chromatin structure: maternal on Health and the Environment and Parkinson’s Action Network (CHE PAN) Conference 26-28 June 2007. Journal of Molecular Endocrinology, 2008. (2): p. 91-102. 41 diet modifies the primate fetal epigenome. Environmental Health Perspectives, 2009. 117 (1): p. 117-121. , et al., Changing pattern of schistosomiasis in Egypt 1935—79. Lancet, 1979. 2 (8136): p. 242-4. Abdel-Wahab, M.F. Cardiovascular effects of air pollution. 115 (6): p. 175-187. Clinical Science, 2008. Brook, R.D., , et al., Effects of inhaled brevetoxins in allergic airways: toxin-allergen interactions and Abraham, W.M. Air pollution and cardiovascular disease: a statement for healthcare professionals from the Expert , et al. , Brook, R.D. Environmental Health Perspectives, 2005. 113 (5): p. 632-637. pharmacologic intervention. Circulation, 2004. (21): p. 109 Panel on Population and Prevention Science of the American Heart Association. The history of arthropod-borne human disease in South Carolina. American Entomologist, Adler, P. and W. Wills, 2655-71. 2003. 49 : p. 216-228. , Dengue fever seroprevalence and risk factors, Texas-Mexico border, 2004. Emerging Infectious , et al. Brunkard, J.M. , et al., Application of satellite infrared data for mapping of thermal plume contamination in coastal Ahn, Y.H. 13 Diseases, 2007. (10): p. 1477-1483. Marine Environmental Research, 2006. (2): p. 186-201. 61 ecosystem of Korea. Regul Toxicol Review of the epidemiological evidence relating toluene to reproductive outcomes. Bukowski, J.A., Int J Cardiol, 1992. , et al., Non-invasive evaluation of cardiac abnormalities in heat stroke pilgrims. al-Harthi, S.S. (2): p. 147-56. 33 Pharmacol, 2001. 37 (2): p. 151-4. 25 Toxicol Ind Health, 2009. Synergistic damage by UVA radiation and pollutants. (4-5): p. Burke, K.E. and H. Wei, 15 Australasian Psychiatry, 2007. , et al., Solastalgia: the distress caused by environmental change. : p. Albrecht, G. 219 -24. S95-S98. Hurricane Katrina: Preliminary estimates of commercial and public sector damages . 2005, Burton, M. and M. Hicks, Constraints on future changes in climate and the hydrologic cycle. Nature, 2002. Allen, M.R. and W.J. Ingram, Center for Business and Economic Research, Marshall University: Huntington, WV. 419 (6903): p. 224-+. Curr Sports Med Rep, 2003. 2 (6): p. 320-4. Heat illness in children. Bytomski, J.R. and D.L. Squire, Autism and the environment: Challenges and opportunities for Altevogt, B.M., S.L. Hanson, and A.I. Leshner, , et al. , Health and climate change: a roadmap for applied research. The Lancet, 2009. Campbell-Lendrum, D. Pediatrics, 2008. (6): p. 1225-1229. 121 research. 373 (9676): p. 1663-1665. . 2009 [cited 2009 July 22]; Available from: http:// Cardiovascular disease cost, 2009 American Heart Association. Climate Change: quantifying the health impactat national and local Campbell-Lendrum, D., R. Woodruff, and WHO, . www.americanheart.org/presenter.jhtml?identifier=4475 . Environmental Burden of Disease Series, ed. A. Pruss-Ustun and C. Corvalan. 2007, Geneva: World Health levels . 2009 [cited 2009 July 22]; Available from: http:// Cardiovascular disease statistics, 2006 American Heart Association. Organization. 66. www.americanheart.org/presenter.jhtml?identifier=4478 . Memorias Do Instituto Oswaldo Cruz, 1999. Climatic factors related to Chagas disease transmission. Carcavallo, R.U., , et al. , The influence of bio-behavioural factors on tumour biology: pathways and mechanisms. Nat Rev Antoni, M.H. 94 : p. 367-369. Cancer, 2006. 6 (3): p. 240-8. Strokes caused by infection in the tropics. Revista De Neurologia, 2007. (12): p. 755-763. 44 Carod-Artal, F.J., Journal of Applied Meteorology and Climatology, Flood fatalities in the United States. Ashley, S.T. and W.S. Ashley, A note on the occurrence of the lone star tick, Amblyomma americanum in the greater Baltimore- Carroll, J.F., (3): p. 805-818. 47 2008. 109 Proc. of the Entomological Society of Washington, 2007. (1): p. 253-256. Washington area. A Demographic-Analysis of Y-Neotricula Aperta (Gastropoda, Pomatiopsidae) Populations in Attwood, S.W., , et al. , Declining vulnerability to temperature-related mortality in London over the 20th century. Am J Carson, C. Journal of Molluscan Studies, Thailand and Southern Laos, in Relation to the Transmission of Schistosomiasis. 164 Epidemiol, 2006. (1): p. 77-84. 1995. : p. 29-42. 61 Assessment of observed changes and responses in natural and managed systems . 2007, , , et al. Cassassa, G. Archives of Internal Exposure to particulate air pollution and risk of deep vein thrombosis. , , et al. Baccarelli, A. Cambridge: Cambridge University Press. Medicine, 2008. 168 (9): p. 920-927. Weather and Climate Extremes in a Changing Climate. Regions of Focus: North America, Hawaii, Caribbean, CC S P, Surveillance for Lyme disease--United States, 1992-2006. MMWR Surveill Bacon, R.M., K.J. Kugeler, and P.S. Mead, and U.S. Pacific Islands. A Report by the U.S. Climate Change Science Program and the Subcommittee on Global 57 (10): p. 1-9. Summ, 2008. , Editors. 2008, Department of Commerce, NOAA’s National Climatic Data Center: , T. Karl , et al. Change Research. Identifying vulnerable subpopulations for climate change health effects in the United Balbus, J.M. and C. Malina, Washington, DC, USA. p. 164. Journal of occupational and environmental medicine / American College of Occupational and Environmental States. . 2009 [cited 2009 July 22]; Available from: http://www.cdc.gov/ncbddd/bd Birth Defects /. CDC. (1): p. 33-37. Medicine, 2009. 51 . 2009 [cited 2009 July 22]; Available from: Leading causes of death, 2006 Centers for Disease Control and Prevention. [Climatic change and public health: scenarios after the coming into force of the Ballester, F., J. Diaz, and J.M. Moreno, http://www.cdc.gov/nchs/FASTATS/lcod.htm . Gac Sanit, 2006. 20 Suppl 1 : p. 160-74. Kyoto Protocol.]. Modeling cardiovascular disease in the zebrafish. Trends Cardiovasc Med, Chico, T.J., P.W. Ingham, and D.C. Crossman, Compilation and discussion of trends in severe storms in the United States: Popular Balling, R.C. and R.S. Cerveny, (4): p. 150-5. 2008. 18 (2): p. 103-112. Natural Hazards, 2003. 29 perception v. climate reality. , in Climate change 2007 : the physical science basis : , , et al. Regional Climate Projections Christensen, J.H. Epidemiology, 2007. Temperature and cardiovascular deaths in the US elderly: changes over time. Barnett, A.G., contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate (3): p. 369-72. 18 , S. Solomon, Intergovernmental Panel on Climate Change., and Intergovernmental Panel on Climate Change , et al. , Temporal and spatial variation of heat-related illness using 911 medical dispatch data. Bassil, K.L. Change. Working Group I., Editors. 2007, Cambridge University Press: Cambridge ; New York. p. 747-845. Environmental Research, 2009. (5): p. 600-606. 109 A framework for examining social stress and susceptibility to air pollution in Clougherty, J.E. and L.D. Kubzansky, , et al. , Climate change and water . 2008, Intergovernmental Panel on Climate Change: Geneva. p. 210. Bates, B. (9): p. 1351-8. Environ Health Perspect, 2009. 117 respiratory health. , Sustainable control of water-related infectious diseases: a review and proposal for , et al. Batterman, S. 361 , Lancet, 2003. (9376): DDT and DDE exposure in mothers and time to pregnancy in daughters. , et al. Cohn, B.A. (7): p. 1023-32. 117 Environ Health Perspect, 2009. interdisciplinary health-based systems research. p. 2205-6. Preparing for climate change: A perspective from local public health officers in California. Bedsworth, L., , et al. , Human Health , in Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution Confalonieri, U. 117 Environmental Health Perspectives, 2009. (4): p. 617-623. , M. of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change (5): , et al. , Long-term exposure to traffic-related air pollution and lung cancer risk. Epidemiology, 2008. 19 Beelen, R. , et al. , Editors. 2007, Cambridge University Press: Cambridge. p. 391-431. Parry p. 702-10. Trans Am Clin Climatol Cholera and climate: a demonstrated relationship. Constantin de Magny, G. and R.R. Colwell, Vital Health Stat 10, Current estimates from the National Health Interview Survey, 1995. Benson, V. and M.A. Marano, 120 Assoc, 2009. : p. 119-28. . p. 1-428. 190 1998. , et al. , The Metropolitan Atlanta Congenital Defects Program: 35 years of birth defects Correa-Villaseñor A. Environmental Health Perspectives, 2008. Unnatural disaster—Human factors in the Mississippi floods. Black, H., (9): 67 Birth Defects Res A Clin Mol Teratol, 2003. surveillance at the Centers for Disease Control and Prevention. 116 (9): p. A390-+. p. 617-24. Stress, inflammation and cardiovascular disease. (1): p. 1-23. J Psychosom Res, 2002. 52 Black, P.H. and L.D. Garbutt, , Ecosystems and human well-being : health synthesis . 2005, [Geneva, Switzerland]: World Health , et al. Corvalán, C. Organization. 53 p. , et al. Rabies surveillance in the United States during 2007. J Am Vet Med Assoc, 2008. 233 (6): p. , Blanton, J.D. 884-97. Environmental impacts and sustainability of degraded water reuse. J Environ Qual, Corwin, D.L. and S.A. Bradford, 2008. 37 (5 Suppl): p. S1-7. (3): p. , , et al. Cardiomyopathy, adult valve disease and heart failure in South America. Heart, 2009. 95 Bocchi, E.A. 181-189. , , et al. Managing the health effects of climate change. Lancet and University College London Institute Costello, A. The Lancet, 2009. 373 (9676): p. 1693-1733. for Global Health Commission. : p. 293-301. 29 Ecological Economics, 1999. Ecosystem services in urban areas. Bolund, P. and S. Hunhammer, , Parkinson’s disease and residential exposure to maneb and paraquat from agricultural , et al. Costello, S. Mercury, food webs, and marine mammals: implications of diet and climate change for Booth, S. and D. Zeller, Am J Epidemiol, 2009. (8): p. 919-26. 169 applications in the central valley of California. Environ Health Perspect, 2005. (5): p. 521-6. 113 human health. (5): p. 122 American Heart Journal, 1991. Cardiovascular Manifestations of Lyme-Disease. Cox, J. and M. Krajden, The effects of roadside structures on the transport and dispersion of ultrafine particles from , et al. , Bowker, G. 14 49 -1455. Atmospheric Environment, 2007. 41 : p. 8128-8139. highways. Observational epidemiologic studies of endemic waterborne risks: cohort, case- Craun, G.F. and R.L. Calderon, , et al. Impacts of climate change on indirect human exposure to pathogens and chemicals from , Boxall, A.B.A. : p. 101-19. 4 Suppl 2 J Water Health, 2006. control, time-series, and ecologic studies. Environmental Health Perspectives, 2009. (4): p. 508-514. 117 agriculture. The mental health needs of refugee children: a review of literature and implications for nurse Crowley, C., , J.E. Oliver, Editor. 2005, , in Urban Climates Encyclopedia of world climatology Brazel, A.J. and D. Quattrochi, J Am Acad Nurse Pract, 2009. 21 (6): p. 322-31. practitioners. Springer: Dordrecht, The Netherlands. p. xx, 854 p. , et al. , Temperature and mortality in 11 cities of the eastern United States. Am J Epidemiol, 2002. Curriero, F.C. , Domoic acid causes reproductive failure in california sea lions (Zalophus californianus). Marine , et al. Brodie, E.C. 155 (1): p. 80-7. (3): p. 700-707. 22 Mammal Science, 2006. www.niehs.nih.gov/climatereport 66

75 A Human Health Perspective Bibliography ON CLIMATE CHANGE , et al. The association between extreme precipitation and waterborne disease outbreaks in the United , et al. Curriero, F.C. (3): p. 98 American Journal of Public Health, 2008. , , Climate change: The public health response. Frumkin, H. 91 (8): p. 1194-9. Am J Public Health, 2001. 435-445. States, 1948-1994. Overview of potential hazards Clinical , Practical handbook of photovoltaics : fundamentals and applications , in Effects of climate change on environmental factors in respiratory allergic diseases. D’Amato G. and L. Cecchi, Fthenakis, V., 38 (8): p. 1264-1274. Markvart and L. Castañer, Editors. 2003, Elsevier Advanced Technology: New York. T. and Experimental Allergy, 2008. , et al. The role of outdoor air pollution and climatic changes on the rising trends in respiratory allergy. (6): p. 42 Environ Sci Technol, 2008. Emissions from photovoltaic life cycles. , D’Amato G. Fthenakis, V.M., H.C. Kim, and E. Alsema, Respiratory Medicine, 2001. 95 2168-74. (7): p. 606-611. 35 Risk factors for heat related death during the August 2003 heat wave in Paris, France, in patients Am J Prev Med, 2008. Climate and vectorborne diseases. , , et al. , , et al. (5): p. 436-50. Davido, A. Gage, K.L. (7): 23 Emerg Med J, 2006. evaluated at the emergency department of the Hopital Europeen Georges Pompidou. Analyses of the effects of global change on human health and welfare and human systems Gamble, J.L. and K.L. Ebi, p. 515-8. : final report, synthesis and assessment product 4.6 : report by the U.S. Climate Change Science Program and the . 2008, Washington, D.C.: U.S. Climate Change Science Program. ix, 204 p. , et al. Environmental Health Perspectives, 2003. Changing heat-related mortality in the United States. , Subcommittee on Global Change Research Davis, R.E. 111 (14): p. 1712-1718. Vitamin D for cancer prevention: global perspective. Ann Epidemiol, 2009. 19 (7): p. 468-83. , et al. , Garland, C.F. , , et al. Decadal changes in heat-related human mortality in the eastern United States. Climate Research, Davis, R.E. Health, economy, and environment: Sustainable energy choices for a Gohlke, J.M., S.H. Hrynkow, and C.J. Portier, 2002. (2): p. 175-184. 22 (6): p. A236-A237. 116 Environmental Health Perspectives, 2008. nation. The First Year After Hurricane Katrina: What the Federal Government Did. . 2009 Department of Homeland Security. American Journal of Respiratory and Cardiovascular effects of ozone exposure in human volunteers. , , et al. Gong, H. [cited 2009 July 22]; Available from: www.dhs.gov/xfoia/archives/gc_1157649340100.shtm . 158 (2): p. 538-546. Critical Care Medicine, 1998. Climate Change, Mortality, and Adaptation: Evidence from Annual Fluctuations in Deschenes, O. and M. Greenstone, , Associations between elevated atmospheric temperature and human mortality: A critical review , et al. Gosling, S.N. , in Center for the Study of Energy Markets Paper . 2007, Center for the Study of Energy Markets: Weather in the US Climatic Change, 2009. 92 (3-4): p. 299-341. of the literature. Santa Barbara, CA. p. 61. Houille Blanche- Twenty-five years of research in hydroecology at the EDF research & development division. Gosse, P., Am J Disaster Med, The influence of global warming on natural disasters and their public health outcomes. Diaz, J.H., (3-4): p. 95-102. Revue Internationale De L Eau, 1999. 54 2 20 07. (1): p. 33-42. , et al. 117 (12): Environ Health Perspect, 2009. , Residential exposure to traffic and spontaneous abortion. Green, R.S. UVA-Induced DNA single-strand cleavage by 1-hydroxypyrene and formation of covalent adducts , et al. , Dong, S. p. 1939-44. 13 (7): p. 585-93. Chem Res Toxicol, 2000. between DNA and 1-hydroxypyrene. The potential impacts of climate variability and change on health impacts of extreme weather , , et al. Greenough, G. State-by-state incidences of hantavirus pulmonary syndrome in the Douglass, R.J., C.H. Calisher, and K.C. Bradley, Environmental Health Perspectives, 2001. 109 : p. 191-198. events in the United States. (2): p. 189-92. 5 Vector Borne Zoonotic Dis, 2005. United States, 1993-2004. , Integrating pests and pathogens into the climate change/food security debate. J Exp Bot, 2009. , et al. Gregory, P.J. On the influence of atmosphere and locality; change of air and climate; seasons; food; clothing; Dunglison, R., (10): p. 2827-38. 60 bathing; exercise; sleep; corporeal and intellectual pursuits, &c. &c. on human health; constituting elements of , et al. Changes in the probability of heavy precipitation: Important indicators of climatic change. , Groisman, P.Y. . 1835, Philadelphia,: Carey, Lea & Blanchard. xi, [13]-514 p. hygiene Climatic Change, 1999. (1): p. 243-283. 42 Health effects associated with recreational coastal water use: Urban versus rural California. , , et al. Dwight, R.H. An assessment of the significance of mercury release from coal fly ash. J Air Waste Manag Gustin, M.S. and K. Ladwig, American Journal of Public Health, 2004. 94 (4): p. 565-567. 54 (3): p. 320-30. Assoc, 2004. Water Association of urban runoff with coastal water quality in Orange County, California. , , et al. Dwight, R.H. , Lancet, 2006. 367 Climate change and human health: impacts, vulnerability, and mitigation. (9528): , et al. Haines, A. Environment Research, 2002. (1): p. 82-90. 74 p. 2101-2109. , , et al. 289 Science, 2000. Climate extremes: Observations, modeling, and impacts. (5487): p. 2068­ Easterling, D.R. Public health benefits of strategies to reduce greenhouse-gas emissions: overview and implications , , et al. Haines, A. 2074. Lancet, 2009. for policy makers. Analyses of the effects of global change on human health , in Effects of Global Change on Human Health , , et al. Ebi, K. , et al. , Epidemiology, Neurobehavioral development in children with potential exposure to pesticides. Handal, A.J. and welfare and human systems. A Report by the U.S. Climate Change Science Program and the Subcommittee on 18 20 07. (3): p. 312-20. , J. Gamble , Editors. 2008, USEPA: Washington, D. C. , et al. Global Change Research Adverse human health effects associated with molds in the indoor Hardin, B.D., B.J. Kelman, and A. Saxon, Weather changes associated with hospitalizations for cardiovascular diseases and stroke in California, , , et al. Ebi, K.L. 45 (5): p. 470-8. J Occup Environ Med, 2003. environment. (1): p. 48-58. Int J Biometeorol, 2004. 49 1983-1998. Proc Natl Acad Sci U S A, 2004. Emissions pathways, climate change, and impacts on California. , , et al. Hayhoe, K. Climate suitability for stable malaria transmission in Zimbabwe under different climate change , , et al. Ebi, K.L. 101 (34): p. 12422-7. Climatic Change, 2005. (3): p. 375-393. 73 scenarios. , et al. , Past and future changes in climate and hydrological indicators in the US Northeast. Climate Hayhoe, K. , , et al. Climate change and human health impacts in the United States: An update on the results of the U.S. Ebi, K.L. 28 Dynamics, 2007. (4): p. 381-407. (9): p. 1318-1324. Environmental Health Perspectives, 2006. 114 National Assessment. (2): p. 170 Am J Epidemiol, 2009. Contact with beach sand among beachgoers and risk of illness. , , et al. Heaney, C.D. Disaster planning and risk communication with vulnerable communities: lessons from Hurricane , , et al. Eisenman, D.P. 164-72. 97 Suppl 1 Am J Public Health, 2007. : p. S109-15. Katrina. , Bulletin of the Tropical cyclones and global climate change: A post-IPCC assessment. , et al. Henderson-Sellers, A. Heat illness. I. Epidemiology. (5-6): p. 402-11. 70 Trans R Soc Trop Med Hyg, 1976. Ellis, F.P., American Meteorological Society, 1998. (1): p. 19-38. 79 Food security and global environmental change: emerging challenges. Ericksen, P.J., J.S.I. Ingram, and D.M. Liverman, , et al. , Alzheimer’s disease, genes, and environment: The value of international studies. Canadian Journal Hendrie, H.C. (4): p. 373-377. 12 Environmental Science and Policy, 2009. 49 (2): p. 92-99. of Psychiatry-Revue Canadienne De Psychiatrie, 2004. , et al. Basic Clin Pharmacol Toxicol, 2008. 102 (2): p. 228-36. Pesticide toxicity and the developing brain. , Eskenazi, B. , et al. , Proc Natl Environmental, economic, and energetic costs and benefits of biodiesel and ethanol biofuels. Hill, J. Increasing habitat suitability in the United States for the tick that transmits Lyme disease: a remote Estrada-Peña A., Acad Sci U S A, 2006. 103 (30): p. 11206-10. (7): p. 635-40. 110 Environ Health Perspect, 2002. sensing approach. Proceedings of the National Climate change and health costs of air emissions from biofuels and gasoline. , , et al. Hill, J. Malariology; a comprehensive survey of all aspects of this group of , in Malaria Incidence in North America Faust, E., (6): p. 2077-2082. 106 Academy of Sciences of the United States of America, 2009. , M.F. Boyd, Editor. 1949, Saunders: Philadelphia,. p. 2 v. (xxi, 1643 p.). diseases from a global standpoint Measuring trauma and health status in refugees: a critical review. Jama, 2002. 288 (5): p. 611-21. , et al. , Hollifield, M. , et al. , Reemergence of Plasmodium vivax malaria in the republic of Korea. Emerg Infect Dis, 1998. 4 (2): Feighner, B.H. Climate change 2001 : the scientific Houghton, J.T. and Intergovernmental Panel on Climate Change. Working Group I., p. 295-7. basis : contribution of Working Group I to the third assessment report of the Intergovernmental Panel on Climate , et al. , Aerosolized red-tide toxins (brevetoxins) and asthma. Chest, 2007. (1): p. 187-194. 131 Fleming, L.E. . 2001, Cambridge ; New York: Cambridge University Press. x, 881 p. Change , et al. , Cancer risk and parental pesticide application in children of Agricultural Health Study participants. Flower, K.B. A fatal waterborne disease epidemic in Walkerton, Ontario: comparison with other waterborne , et al. , Hrudey, S.E. (5): p. 631-5. 112 Environ Health Perspect, 2004. (3): p. 7-14. Water Science and Technology, 2003. 47 outbreaks in the developed world. J Med , et al. , Geographic distribution and ecology of potential malaria vectors in the Republic of Korea. Foley, D.H. Migration and environmental hazards. (4): p. 273-302. 26 Population and Environment, 2005. Hunter, L.M., Entomol, 2009. 46 (3): p. 680-92. Institute of Medicine (U.S.). Committee on Achieving Sustainable Global Capacity for Surveillance and Response to Emerging , et al. Using Satellite Images of Environmental Changes to Predict Infectious Disease Outbreaks. , Ford, T.E. Sustaining global surveillance and response to emerging Emerging Diseases of Zoonotic Origin. and G. Keusch, Infectious Diseases, 2009. 15 (9): p. 1341-1346. . 2009, Washington, DC: National Academies Press. xxv, 312 p. zoonotic diseases , et al. International Archives of Excess mortality related to the August 2003 heat wave in France. , Fouillet, A. Climate change 2007 : impacts, adaptation and Intergovernmental Panel on Climate Change. Working Group II., Occupational and Environmental Health, 2006. 80 (1): p. 16-24. vulnerability : contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel Has the impact of heat waves on mortality changed in France since the European heat wave of . 2007, Cambridge: Cambridge University Press. ix, 976 p. , et al. , on Climate Change Fouillet, A. 37 Int J Epidemiol, 2008. (2): p. 309-17. summer 2003? A study of the 2006 heat wave. , in , World Disaster Report World Disaster Report 2009 International Federation of Red Cross and Red Crescent Societies, , , et al. Residences with anomalous soil concentrations of dioxin-like compounds in two communities in Knight, Editor. 2009, International Federation of Red Cross and Red Crescent Societies: Geneva. p. 210. L. Franzblau, A. Chemosphere, 2009. 74 (3): p. 395-403. Michigan, USA: A case study. Emissions of mercury and other trace elements from coal-fired power plants in Ito, S., T. Yokoyama, and K. Asakura, Sci Total Environ, 2006. 368 (1): p. 397-402. Hope, despair and transformation: Climate change and the promotion of mental health and , , et al. Japan. Fritze, J.G. 2 (1): p. 13. Int J Ment Health Syst, 2008. wellbeing. Research frontiers in climate change: Effects of extreme meteorological events on Jentsch, A. and C. Beierkuhnlein, Urban sprawl and public health : designing, planning, and building for healthy Comptes Rendus Geoscience, 2008. 340 (9-10): p. 621-628. ecosystems. Frumkin, H., L.D. Frank, and R. Jackson, . 2004, Washington, DC: Island Press. xxi, 338 p. communities , et al. , Long-Term Ozone Exposure and Mortality. New England Journal of Medicine, 2009. 360 (11): p. Jerrett, M. 1085-1095. www.niehs.nih.gov/climatereport 67

76 A Human Health Perspective Bibliography ON CLIMATE CHANGE Severe mental disorders in complex emergencies. , , et al. Jones, L. Lancet, 2009. (9690): p. 654-61. Recent climate change in the Arctic and its impact on contaminant pathways 374 Macdonald, R.W., T. Harner, and J. Fyfe, Sci Total Environ, 2005. (1-3): p. 5-86. 342 and interpretation of temporal trend data. An evaluation of climate/mortality relationships in large U.S. cities and the possible Kalkstein, L.S. and J.S. Greene, 105 Environ Health Perspect, 1997. How will global climate change affect risks from long-range transport of persistent organic (1): p. 84-93. , , et al. impacts of a climate change. Macdonald, R.W. (3): p. 643-660. Human and Ecological Risk Assessment, 2003. 9 pollutants? , et al. , Cancer incidence among pesticide applicators exposed to trifluralin in the Agricultural Health Study. Kang, D. , et al. , Fonofos exposure and cancer incidence in the agricultural health study. Environ Health Perspect, (2): p. 271-6. 107 Environ Res, 2008. Mahajan, R. (12): p. 1838-42. 2006. 114 Cognitive development in children with chronic protein energy Kar, B.R., S.L. Rao, and B.A. Chandramouli, Global warming’s six Americas 2009: An audience segmentation Behav Brain Funct, 2008. : p. 31. 4 malnutrition. Maibach, E., C. Roser-Renouf, and A. Leiserowitz, . 2009, George Mason University Center for Climate Change Communication: Washington, DC. p. 140. analysis Global Climate ChangeImpacts in the United States . 2009, New York: Cambridge Karl, T., J. Melilo, and T. Peterson, Air pollution and hospital admissions for ischemic heart disease in persons with congestive heart , , et al. University Press. Mann, J.K. Environmental Health Perspectives, 2002. (12): p. 1247-1252. 110 failure or arrhythmia. , Weather and climate extremes in a changing climate regions of focus: North America, Hawaii, , et al. Karl, T. Surveillance for asthma—United States, 1960-1995. Synthesis and assessment product 3.3 , in 47 . 2008, U.S. Climate Change Science , , et al. MMWR CDC Surveill Summ, 1998. (1): Caribbean, and U.S. Pacific Islands Mannino, D.M. p. 1-27. Program: Washington, DC. p. x, 162 p. Journal Eur Psychiatry, 2007. , , et al. (6): 22 Psychotropic drugs use and risk of heat-related hospitalisation. Alphavirus infection in mosquitoes at the Ross River reservoir, north Queensland, 1990-1993. , , et al. Martin-Latry, K. Kay, B.H. 12 of the American Mosquito Control Association, 1996. p. 335-8. (3): p. 421-428. , , et al. . 2003, [Boston The Future of nuclear power : an interdisciplinary MIT Study Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Kessler, R.C. Massachusetts Institute of Technology., Arch Gen Psychiatry, 2005. 62 (6): p. 617-27. MA]: MIT. x, 170 p. Survey Replication. Am J Prev Med, 1999. 16 Science of the Total Hydrological studies of schistosomiasis transport in Sichuan Province, China. , (4): p. 359-60. , et al. The spectrum of illness during heat waves. Kilbourne, E.M., Maszle, D.R. Environment, 1998. 216 (3): p. 193-203. 247 , Risk factors for heatstroke. A case-control study. (24): p. 3332-6. JAMA, 1982. , et al. Kilbourne, E.M. , . 2008, Geneva, Switzerland: World Health The global burden of disease : 2004 update , et al. Mathers, C. Seasonal variations of marine algal community in the vicinity of Uljin nuclear Kim, Y.S., H.G. Choi, and K.W. Nam, Organization. vii, 146 p. 29 (4): p. 493-499. Journal of Environmental Biology, 2008. power plant, Korea. : p. 42-48. 60 Nutrigenomics - Opportunities in Asia, 2007. Early nutrition: Impact on epigenetics. Mathers, J.C., , , et al. Florida red tide and human health: a pilot beach conditions reporting system to minimize Kirkpatrick, B. Maternal-fetal transfer of domoic acid in rats at two gestational time points. Sci Total Environ, 2008. 402 (1): p. 1-8. human exposure. Maucher, J.M. and J.S. Ramsdell, Environmental Health Perspectives, 2007. 115 (12): p. 1743-1746. , et al. Microbial load of drinking water reservoir tributaries during extreme rainfall and runoff. . , Kistermann, T. Dissecting the relative influences of genes and the environment in Alzheimer’s disease. Annals of 68 (5): p. 2188-2197. Applied and Environmental Microbiology, 2002. Mayeux, R., (2): p. 156-158. 55 Neurology, 2004. Culture Extremes , in ropical cyclones and climate change: revisiting recent studies at GFDL Knutson, T. and R. Tuleya, Wildlife cancer: a conservation perspective. . 2008, Cambridge University Press: Cambridge. (7): p. 517-26. 9 Nat Rev Cancer, 2009. and Society McAloose, D. and A.L. Newton, The impact of biodiesel on pollutant emissions and public health. Increase in coccidioidomycosis - Arizona,1998-2001 (Reprinted from MMWR, vol 52, pg 109, 2003). Inhalation Toxicology, 2007. , , et al. Komatsu, K. McCormick, R.L., 289 (12): p. 1033-1039. Journal of the American Medical Association, 2003. 19 (12): p. 1500-1502. Mg2+ imparts NMDA receptor subtype selectivity to the Alzheimer’s drug The potential impacts of climate variability and change on temperature-related McGeehin, M.A. and M. Mirabelli, Kotermanski, S.E. and J.W. Johnson, Environ Health Perspect, 2001. (9): p. 2774-9. 109 Suppl 2 J Neurosci, 2009. : p. 185-9. 29 morbidity and mortality in the United States. memantine. , Outbreak of Vibrio parahaemolyticus gastroenteritis associated with Alaskan oysters. N Engl . 2008. , in Heat stress and public health: A critical review Annual Review of Public Health , et al. Kovats, R.S. and S. Hajat, McLaughlin, J.B. (14): p. 1463-70. J Med, 2005. p. 41-55. 353 Neonatal toxicity and transient neurodevelopmental deficits following prenatal exposure to lithium: Lancet, Climate change and human health: Present and future risks. Kozma, C., McMichael, A.J., R.E. Woodruff, and S. Hales, (4): p. 441-4. 132 Am J Med Genet A, 2005. 2006. (9513): p. 859-869. Another clinical report and a review of the literature. 367 , et al. , et al. , Quantifying urban forest structure, function, and value: the Chicago Urban Forest Climate , Extended follow-up and spatial analysis of the American Cancer Society study linking particulate Krewski, D. McPherson, E. Res Rep Health Eff Inst, 2009(140): p. 5-114; discussion 115-36. 1 : p. 49-61. Urban Ecosystems, 1997. air pollution and mortality. Project. . National surveillance and the epidemiology of human Q fever in the United States, 1978-2004. Ultrafine particle-lung interactions: does size matter? J Aerosol , et al. , Kreyling, W.G., M. Semmler-Behnke, and W. Moller, McQuiston, J.H. Med, 2006. 19 (1): p. 74-83. (1): p. 36-40. Am J Trop Med Hyg, 2006. 75 , , et al. Emerg Infect Dis, 1999. , (5): p. 607-25. , et al. Food-related illness and death in the United States. Medication adherence in older clinic patients with hypertension after Hurricane Katrina: 5 Krousel-Wood, M.A. Mead, P.S. American Journal of the Medical Sciences, 2008. Implications for clinical practice and disaster management. Science, More intense, more frequent, and longer lasting heat waves in the 21st century. Meehl, G.A. and C. Tebaldi, (2): p. 99-104. 336 2004. 305 (5686): p. 994-7. North American trends in extreme precipitation. (2): p. 291-305. 29 Natural Hazards, 2003. Kunkel, K.E., Me ehl, G.A.a.S., T. F. and Collins, W. D. and Friedlingstein, A. T. and Gaye, A. T. and Gregory, J. M. and Kitoh, A. and Long-term trends in extreme precipitation events over the Kunkel, K.E., K. Andsager, and D.R. Easterling, Knutti, R. and Murphy, J. M. and Noda, A. and Raper, S. C. B. and Watterson, I. G. and Weaver, A. J. and Zhao, Journal of Climate, 1999. 12 Global CLimate Projections (8): p. 2515-2527. , in Climate change 2007 : the physical science basis : contribution of Working conterminous United States and Canada. Z., , S. Solomon, Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change , et al. , Excess cardiovascular mortality associated with cold spells in the Czech Republic. BMC Public Health, Kysely, J. Intergovernmental Panel on Climate Change., and Intergovernmental Panel on Climate Change. Working Group I., 2009 Jan 15; :19. 9 Editors. 2007, Cambridge University Press: Cambridge ; New York. p. 747-845. A re-evaluation of the impact of temperature and climate change on foodborne illness. , et al. , Epidemiol Lake, I.R. Recognizing waterborne disease and the health effects of water contamination: a review of the Meinhardt, P.L., 137 Infect, 2009. , p. 1538–1547. J Water Health, 2006. 4 Suppl 1 : p. 27-34. challenges facing the medical community in the United States. , et al. , The National Children’s Study: a 21-year prospective study of 100,000 American children. Landrigan, P.J. , Eur Arch Psychiatry Clin , et al. Lithium reduces Gsk3b mRNA levels: implications for Alzheimer Disease. Mendes, C.T. Pediatrics, 2006. (5): p. 2173-86. 118 Neurosci, 2009. (1): p. 16-22. 259 , Maternal serum levels of polychlorinated biphenyls and 1,1-dichloro-2,2-bis(p-chlorophenyl) , et al. Law, D.C. Heat-Related Deaths - United-States, 1993 (Reprinted from Mmwr, Vol 42, 558-560, 1993). , et al. , Merchandani, H. (6): p. 523-32. Am J Epidemiol, 2005. 162 ethylene (DDE) and time to pregnancy. (7): p. 810-810. 270 ournal of the American Medical Association, 1993. , , et al. Short-term effects of particulate air pollution on cardiovascular diseases in eight European cities. Le Tertre, A. , et al. , Drug-sensitized zebrafish screen identifies multiple genes, including GINS3, as regulators of Milan, D.J. (10): p. 773-9. 56 J Epidemiol Community Health, 2002. Circulation, 2009. 120 (7): p. 553-9. myocardial repolarization. , Gene expression profiles in zebrafish brain after acute exposure to domoic acid at symptomatic , et al. Lefebvre, K.A. Do early-life insults contribute to the late-life development of Parkinson and Miller, D.B. and J.P. O’Callaghan, (1): p. 65-77. 107 Toxicol Sci, 2009. and asymptomatic doses. Metabolism, 2008. 57 Suppl 2 : p. S44-9. Alzheimer diseases? Haemorrhagic fevers and ecological perturbations. Arch Virol Suppl, 1997. 13 : p. 191-9. LeGuenno, B., Climate Change, Extreme Weather Events, and US Health Impacts: What Can We Say? Journal of Mills, D.M., Climate change in the American mind: Americans’ climate change Leiserowitz, A., E. Maibach, and C. Roser-Renouf, (1): p. 26-32. 51 Occupational and Environmental Medicine, 2009. 2009, Yale Project on Climate Change, Scool of Forestry and beliefs, attitudes, policy preferences, and actions. , et al. , Prevalence of mental disorders and torture among Bhutanese refugees in Nepal: a systemic review Mills, E. Environmental Sciences: New Haven, Connecticut. p. 56. 24 Med Confl Surviv, 2008. (1): p. 5-15. and its policy implications. New England Journal of Sudden cardiac death triggered by an earthquake. Leor, J., W.K. Poole, and R.A. Kloner, Global pattern of trends in streamflow and water availability in a Milly, P.C.D., K.A. Dunne, and A.V. Vecchia, 334 Medicine, 1996. (7): p. 413-419. 438 Nature, 2005. (7066): p. 347-350. changing climate. Maternal serum level of 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene and risk of , , et al. Longnecker, M.P. , , et al. Impacts of climate variability and future climate change on harmful algal blooms and human Moore, S.K. Am J Epidemiol, 2002. 155 (4): p. 313-22. cryptorchidism, hypospadias, and polythelia among male offspring. (SUPPL. 2). 7 Environmental Health: A Global Access Science Source, 2008. health. , , et al. Maternal serum level of the DDT metabolite DDE in relation to fetal loss in previous Longnecker, M.P. , et al. Relationships between weather and myocardial infarction: A biometeorological approach. , Morabito, M. Environ Res, 2005. 97 (2): p. 127-33. pregnancies. 105 (3): p. 288-293. International Journal of Cardiology, 2005. A potential role for alterations of zinc and zinc transport proteins in the progression of Alzheimer’s Lovell, M.A., Chemical and biological pollution contribute to the immunological profiles of free-ranging harbor , et al. , Mos, L. 16 J Alzheimers Dis, 2009. (3): p. 471-83. disease. 25 (12): p. 3110-7. Environ Toxicol Chem, 2006. seals. (5): p. 429-35. Climate change and extreme heat events. Am J Prev Med, 2008. 35 Luber, G. and M. McGeehin, Philos Trans R Soc Lond B Biol Sci, Environmental refugees: a growing phenomenon of the 21st century. Myers, N., , et al. , Cancer incidence among pesticide applicators exposed to butylate in the Agricultural Health Lynch, S.M. (1420): p. 609-13. 2002. 357 (7): p. 860-8. 109 Environ Res, 2009. Study (AHS). , et al. , Psychiatric morbidity among Afghan refugees in Peshawar, Pakistan. J Ayub Med Coll Abbottabad, Naeem, F. , A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the , et al. Mac Kenzie, W.R. 2005. 17 (2): p. 23-5. (3): p. 161-7. 331 N Engl J Med, 1994. public water supply. www.niehs.nih.gov/climatereport 68

77 Bibliography A Human Health Perspective ON CLIMATE CHANGE Investigation on chemical species of arsenic, selenium and antimony in fly ash from coal fuel Prenatal exposure to 1,1-dichloro-2,2-bis (p-chlorophenyl)ethylene (p,p’-DDE) in relation to child , , et al. Narukawa, T. , , et al. Ribas-Fitó N. J Environ Monit, 2005. (4): p. 853-8. 35 Int J Epidemiol, 2006. 7 (12): p. 1342-8. growth. thermal power stations. (3): p. 20 Curr Opin Obstet Gynecol, 2008. http://www.cancer.gov/cancertopics The impact of pesticides on male fertility. . 2009 [cited 2009 July 26]; Available from: / Lung Cancer National Cancer Institute. Roeleveld, N. and R. Bretveld, types/lung. 229-33. Some evidence of effects of environmental chemicals on the endocrine system in What is cancer? 2009 [cited 2009 July 21]; Available from: / http://www.cancer.gov National Cancer Institute. Rogan, W.J. and N.B. Ragan, 210 Int J Hyg Environ Health, 2007. (5): p. 659-67. children. cancertopics/what-is-cancer. Interaction of the onset of spring and elevated atmospheric CO2 on ragweed (Ambrosia , et al. , Ecological impacts of climate Rogers, C.A. National Research Council (U.S.). Committee on Ecological impacts of Climate Change., (6): p. 865-869. . 2008, Washington, D.C.: National Academies Press. xii, 57 p. Environmental Health Perspectives, 2006. 114 change artemisiifolia L.) pollen production. 289 (5485): p. Science, 2000. The global spread of malaria in a future, warmer world. National Research Council (U.S.). Committee On Health, E., And Other External Costs And, Benefits Of Energy Production Rogers, D.J. and S.E. Randolph, Hidden 1763-6. And Consumption., and National Research Council (U.S.). Board on environmental studies and toxicology., . Board on Environmental Studies and Costs of Energy: Unpriced Consequences of Energy Production and Use Pesticides and child neurodevelopment. Curr Opin Pediatr, 2008. 20 (2): p. 191-7. Rosas, L.G. and B. Eskenazi, Toxicology special report. 2009, Washington, D.C.: Board on Environmental Studies and Toxicology. Health care in New Orleans before and after Hurricane Katrina. Health Aff Rudowitz, R., D. Rowland, and A. Shartzer, , , et al. National Research Council (U.S.). Committee on Strategic Advice on the U.S. Climate Change Science Program. (Millwood), 2006. 25 (5): p. w393-406. Restructuring federal climate research to meet the challenges of climate change . 2009, Washington, D.C.: National Ozone air pollution is associated with acute myocardial infarction. , et al. , Circulation, 2005. 111 (5): p. Ruidavets, J.B. Academies Press. xii, 254 p. 563-569. Summary of Natural Hazard Statistics for 2007 in the United States . 2007: Washington. National Weather Service, , Cancer incidence among pesticide applicators exposed to permethrin in the Agricultural Health , et al. Rusiecki, J.A. , et al. , Rationale for a new generation of indicators for coastal waters. Environmental Health Perspectives, Niemi, G. Environ Health Perspect, 2009. (4): p. 581-6. 117 Study. 112 (9): p. 979-986. 2004. Acute Effects of Ambient Particulate Matter on Mortality in Europe and North America: Results from , , et al. Samoli, E. , E.R. Service, Editor. Hosehold food security in the United States, 2008 Nord, M., M. Andrews, and S. Carlson, 116 Environmental Health Perspectives, 2008. (11): p. 1480-1486. the APHENA Study. November, 2009, US Department of Agriculture: Washington, DC. . , et al. Interagency oceans and human health research implementation plan: a prescription for the future , Sandifer, P. Air pollution removal by urban trees and shrubs in the United States. Urban Nowak, D., D. Crane, and J. Stevens, 2007, Interagency Working Group on Harmful Algal Blooms, Hypoxia and Human Health of the Joint Subcommittee on Forestry and Urban Greening, 2006. 4 : p. 115-123. Ocean Science and Technology: Washington, DC, USA. , et al. , The toxicology of climate change: Environmental contaminants in a warming world. Environment Noyes, P.D. Hospital admissions for heart disease - The effects of temperature and Schwartz, J., J.M. Samet, and J.A. Patz, International, 2009. 35 (6): p. 971-986. 15 Epidemiology, 2004. (6): p. 755-761. humidity. Rep Carcinog, 2005(11). NTP Report on Carcinogens. Epidemic typhus fever in Japan and Korea , F.R. Moulton, Rickettsial diseases of man; a symposium , in Scoville, A., , , et al. Occupational and Air pollution and inflammation in type 2 diabetes: a mechanism for susceptibility. Editor. 1948, American Association for the Advancement of Science.: Washington, D.C.,. p. 247 p. O’Neill MS. (6): p. 373-379. 64 Environmental Medicine, 2007. Climate change and infectious diseases in Europe. Lancet Infectious Diseases, 2009. 9 (6): Semenza, J.C. and B. Menne, Health Aff (Millwood), 2005. , et al. , Immunizations in the United States: success, structure, and stress. p. 365-375. Orenstein, W.A. (3): p. 599-610. 24 Water Science Climate change and effects on water quality: a first impression. Senhorst, H.A.J. and J.J.G. Zwolsman, 320 Climate. Blooms like it hot. (5872): p. 57-8. Science, 2008. and Technology, 2005. 51 (5): p. 53-59. Paerl, H.W. and J. Huisman, , et al. 58 Malaria in Korea. Journal of Allergy and Clinical Immunology, 2008. (2): p. 55-66. 122 Jpn J Exp Med, 1988. , (3): p. Climate change and allergic disease. Paik, Y.H., H.I. Ree, and J.C. Shim, Shea, K.M. 443-453. (10): p. RA329-36. , , et al. Lead toxicity update. A brief review. Med Sci Monit, 2005. 11 Papanikolaou, N.C. Trends in heat-related mortality in the United States, 1975-2004. Sheridan, S.C., A.J. Kalkstein, and L.S. Kalkstein, Cancer incidence among paraquat exposed applicators in the agricultural health study: prospective , , et al. Park, S.K. (1): p. 145-160. 50 Natural Hazards, 2009. (3): p. 274-81. 15 Int J Occup Environ Health, 2009. cohort study. , Cholera Outbreak in Kenyan Refugee Camp: Risk Factors for Illness and Importance of Sanitation. , et al. Shultz, A. Health impact assessment of global climate change: Expanding on comparative risk assessment , , et al. Patz, J. 80 American Journal of Tropical Medicine and Hygiene, 2009. (4): p. 640-645. Annual Review of Public Health , in . 2008. p. 27-39. approaches for policy making BMJ, 2008. 336 (7642): p. 471. Floods in southern Africa result in cholera outbreak and displacement. Sidley, P., Impact of regional climate change on human health. , , et al. (7066): p. 310-7. 438 Nature, 2005. Patz, J.A. Understanding community psychosocial needs after disasters: implications for mental health Silove, D. and Z. Steel, , et al. Am J Prev Med, Climate change and waterborne disease risk in the Great Lakes region of the U.S. , Patz, J.A. 52 J Postgrad Med, 2006. (2): p. 121-5. services. 2008. 35 (5): p. 451-8. , et al. 1 (1): p. 3-14. Ultraviolet light and resistance to infectious diseases. , J Immunotoxicol, 2004. Sleijffers, A. Risk of importing zoonotic diseases through wildlife trade, United States. Pavlin, B.I., L.M. Schloegel, and P. Daszak, Am J Respir Crit Care Med, 1997. , et al. , (3 Pt 1): 156 A national estimate of the economic costs of asthma. 15 (11): p. 1721-6. Emerg Infect Dis, 2009. Smith, D.H. p. 787-93. , , et al. Circulation, 2001. Increased particulate air pollution and the triggering of myocardial infarction. Peters, A. , Public health benefits of strategies to reduce greenhouse-gas emissions: health implications of , et al. (23): p. 2810-2815. 103 Smith, K.R. Lancet, 2009. short-lived greenhouse pollutants. 71 (1): p. America in the world: 100 years of tropical medicine and hygiene. Am J Trop Med Hyg, 2004. Petri, W.A., Jr., , et al. , Microbial threats to health : emergence, detection, and response . 2003, Washington, D.C.: 2-16. Smolinski, M.S. National Academies Press. xxviii, 367 p. , Temperature and air pollution as risk factors for heat stroke in Tokyo, July and August 1980-1995. , et al. Piver, W.T. Nat Rev Microbiol, Source-sink dynamics of virulence evolution. (11): p. 911-6. Environ Health Perspect, 1999. 107 Sokurenko, E.V., R. Gomulkiewicz, and D.E. Dykhuizen, (7): p. 548-55. 4 2006. Medecine Et Maladies Infectieuses, 1999. Global warming and El Nino: a review of the current knowledge. Planton, S., Alzheimer Dis Recent trends in Alzheimer disease mortality in the United States, 1999 to 2004. , , et al. 29 (5): p. 267-276. Steenland, K. (2): p. 165-70. Assoc Disord, 2009. 23 , et al. , Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air Pope, C.A., 3rd (9): p. 1132-41. , In harm’s way: toxic threats to child development. J Dev Behav Pediatr, 2002. , et al. (1 Suppl): p. S13-22. 287 JAMA, 2002. 23 pollution. Stein, J. , et al. , The coastal environment and human health: microbial indicators, pathogens, sentinels and Health effects of fine particulate air pollution: Lines that connect. Journal of the Air & Stewart, J.R. Pope, C.A. and D.W. Dockery, 7 Suppl 2 Environ Health, 2008. : p. S3. reservoirs. Waste Management Association, 2006. 56 (6): p. 709-742. The natural life cycle in wild populations of Diatoma moniliformis (Bacillariophyceae) and Rising Co2 Levels and Their Potential Significance for Carbon Flow in Photosynthetic Cells. Plant Cell and Stitt, M., Potapova, M. and P. Snoeijs, 33 Journal of Phycology, 1997. (6): p. 924-937. its disruption in an aberrant environment. (8): p. 741-762. 14 Environment, 1991. First trimester exposure to corticosteroids and oral clefts. , , et al. . 2009, Oxford ; New York: Birth Defects Res A Clin Mol Teratol, 2003. Prevention of bug bites, stings, and disease Pradat, P. Strickman, D., S.P. Frances, and M. Debboun, (12): p. 968-70. Oxford University Press. xviii, 323 p., [8] p. of plates. 67 Dengue and its vectors in Thailand: Calculated transmission risk from total pupal Preventing disease through healthy environments Prüss-Üstün, A., C. Corvalán, and World Health Organization., Strickman, D. and P. Kittayapong, . 2006, Geneva, Switzerland: World Health : towards an estimate of the environmental burden of disease counts of Aedes aegypti and association of wing-length measurements with aspects of the larval habitat. (2): p. 209-217. Organization. 104 p. 68 American Journal of Tropical Medicine and Hygiene, 2003. High temperatures enhanced acute mortality effects of ambient particle pollution in the “Oven” city of , Man’s impact on the global , et al. Study of Critical Environmental Problems. and Massachusetts Institute of Technology., Qian Z (9): p. 1172-1178. Environmental Health Perspectives, 2008. 116 environment; assessment and recommendations for action; report or the Study of Critical Environmental Problems Wuhan, China. . 1970, Cambridge, Mass.,: MIT Press. xxii, 319 p. (SCEP) (5): p. 631-7. , et al. Copper in Alzheimer’s disease: too much or too little? Expert Rev Neurother, 2009. , 9 Quinn, J.F. , et al. Indian J Med Res, 2000. Severe cholera outbreak following floods in a northern district of West Bengal. , Sur, D. In utero domoic acid toxicity: a fetal basis to adult disease in the California sea lion Ramsdell, J.S. and T.S. Zabka, 112 : p. 178-82. Marine Drugs, 2008. (2): p. 262-90. 6 (Zalophus californianus). , et al. , Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care, 2002. Surwit, R.S. Weather and Forecasting, 2009. Advances and Challenges at the National Hurricane Center. , , et al. Rappaport, E.N. (1): p. 30-4. 25 (2): p. 395-419. 24 , et al. American Heart Journal, 1997. Hanshin-Awaji earthquake as a trigger for acute myocardial infarction. , Suzuki, S. Korean J Parasitol, 2000. 38 (3): p. 119-38. Unstable vivax malaria in Korea. Ree, H.I., (5): p. 974-977. 134 9 , et al. , Texas lifestyle limits transmission of dengue virus. Emerging Infectious Diseases, 2003. (1): p. 86-89. Reiter, P. Environmental Biodiesel exhaust: The need for health effects research. Swanson, K.J., M.C. Madden, and A.J. Ghio, , Ozone modifies associations between temperature and cardiovascular mortality: analysis of the , et al. Ren, C. (4): p. 496-499. Health Perspectives, 2007. 115 Occupational and Environmental Medicine, 2008. 65 (4): p. 255-260. NMMAPS data. www.niehs.nih.gov/climatereport 69

78 A Human Health Perspective Bibliography ON CLIMATE CHANGE WHO, , et al. . 2002, Geneva: World Health Organization. xx, 190 p. Monitoring Antimalarial Drug Resistance , Vulnerability to flooding: health and social dimensions. Tapsell, S.M. Philos Transact A Math Phys Eng Sci, 360 2002. (1796): p. 1511-25. World malaria report, 2008 . 2008, Geneva: World Health Organization. xx, 190 p. WHO. Global Malaria Programme., 2007: p. 68. National Security and the Threat of Climate Change. The CNA Corporation, Climate change impacts and adaptation: A science agenda for the Environment Wilby, R., M. Hedger, and H. Orr, Weather, Volume 60, Issue 7. p. 206-211. Trends in Parasitology, The development of malaria early warning systems for Africa. Agency of England and Wales. Thomson, M.C. and S.J. Connor, (9): p. 438-445. 17 2001. , , et al. Public health benefits of strategies to reduce greenhouse-gas emissions: household energy. Wilkinson, P. Effect of Arsenic Exposure during Pregnancy on Infant Development at 7 Months in Rural Matlab, , et al. , Lancet, 2009. (9705): p. 1917-29. 374 Tofail, F. 117 Environmental Health Perspectives, 2009. (2): p. 288-293. Bangladesh. Demographic trends that will shape US policy in the twenty-first century. Research Wilmoth, J.M. and C.F. Longino, , et al. , Survival of epidemic strains of healthcare (HA-MRSA) and community-associated (CA-MRSA) on Aging, 2006. 28 (3): p. 269-288. Tolba, O. Int J Hyg Environ meticillin-resistant Staphylococcus aureus (MRSA) in river-, sea- and swimming pool water. , , et al. Public health benefits of strategies to reduce greenhouse-gas emissions: urban land transport. Woodcock, J. Health, 2008. 211 (3-4): p. 398-402. (9705): p. 1930-43. Lancet, 2009. 374 Coexposure to benzo[a]pyrene and UVA induces DNA damage: first proof of double-strand breaks , , et al. Toyooka, T. , et al. , Effects of temperature and air pollutants on cardiovascular and respiratory diseases for males and Ye, F. 47 Environ Mol Mutagen, 2006. (1): p. 38-47. in a cell-free system. (4): Environ Health Perspect, 2001. 109 females older than 65 years of age in Tokyo, July and August 1980-1995. Bulletin of the American Meteorological Society, 2003. The changing character of precipitation. , , et al. p. 355-9. Trenberth, K.E. (9): p. 1205-+. 84 , et al. , Surveillance for waterborne disease and outbreaks associated with drinking water and water not Yoder, J. Probability change of extreme precipitation observed from 1901 to 2000 in MMWR Surveill Summ, 2008. 57 (9): p. 39-62. intended for drinking--United States, 2005-2006. Tromel, S. and C.D. Schonwiese, (1-4): p. 29-39. Theoretical and Applied Climatology, 2007. 87 Germany. , et al. , Can source reduction of mosquito larval habitat reduce malaria transmission in Tigray, Ethiopia? Yohannes, M. , , et al. Science, 2003. Potential environmental impact of a hydrogen economy on the stratosphere. 10 (12): p. 1274-1285. Tropical Medicine & International Health, 2005. Tromp, T.K. 300 (5626): p. 1740-2. Carbon Development of air conditioning technologies to reduce CO2 emissions in the commercial sector. Yoshida, Y., Melanoma epidemiology. Hematol Oncol Clin North Am, 2009. 23 (3): p. 383-95, vii. 1 : p. 12. Balance Manag, 2006. Tucker, M.A., World Urbanization Prospects: The The temporal pattern of respiratory and heart disease mortality in response to air pollution. , , et al. United Nations Department of Economic and Social Affairs Population Division Zanobetti, A. , P.D. United Nations Department of Economic and Social Affairs, Editor. 2006, United Nations 2005 Revision Environ Health Perspect, 2003. 111 (9): p. 1188-93. Department of Economic and Social Affairs, Population Division: Geneva. Trends Parasitol, 2005. , et al. , Climate variability and malaria epidemics in the highlands of East Africa. Zhou, G. Oceans and Human Health 21 (2): p. 54-6. United States. Congress. Senate. Committee on Commerce Science and Transportation., . 2003, Washington: U.S. Act: report of the Committee on Commerce, Science, and Transportation on S. 1218 Alterations in the production and concentration of selected alkaloids as a function of rising , et al. , Ziska, L.H. G.P.O. ii. 8 p. Global Change Biology, atmospheric carbon dioxide and air temperature: implications for ethno-pharmacology. 11 (10): p. 1798-1807. 2005. US Environmental Protection Agency, Report to Congress: impacts and control of CSOs and SSOs. Office of . 2004, US Environmental Protection Agency,: Washington, DC. Wastewater Management Quantitative risk assessment on the public health impact of pathogenic Vibrio US Food and Drug Administration, 2005. parahaemolyticus in raw oysters. Effects of ozone on lung function and lung diseases. Curr Opin Pulm Med, 2003. 9 (2): Uysal, N. and R.M. Schapira, p. 144-50. Climate change and human skin cancer. Photochem Photobiol Sci, van der Leun, J.C., R.D. Piacentini, and F.R. de Gruijl, 7 (6): p. 730-3. 2008. Am J Public Health, 2004. Mortality in 13 French cities during the August 2003 heat wave. , , et al. Vandentorren, S. (9): p. 1518-20. 94 Influence of recipitation, deforestation and Tucurui reservoir operation on malaria Vasconcelos, C.H. and E. Novo, Igarss 2003: Ieee International Geoscience and Remote Sensing incidence rates in southeast Para, Brazil. Symposium, Vols I - Vii, Proceedings, 2003: p. 4567-4569 Journal of Exposure Analysis , et al. , Assessment of exposure to a flood disaster in a mental-health study. Verger, P. 13 (6): p. 436-442. and Environmental Epidemiology, 2003. 427 (6971): p. 213-214. , Climate - Impact of land-use change on climate. Nature, 2004. , et al. Vose, R.S. , Increase in Coccidioidomycosis-California, 2000-2007 (Reprinted from MMWR, vol 58, pg 105-109, , et al. Vugla, D.J. Journal of the American Medical Association, 2009. 301 (17): p. 1760-1762. 2009). , et al. , Developmental origins of health and disease: brief history of the approach and current focus on Wadhwa, P.D. 27 Semin Reprod Med, 2009. (5): p. 358-68. epigenetic mechanisms. American Cardiovascular Mortality - the Hidden Peril of Heat Waves. Wainwright, S., S. Buchanan, and H. Mainzer, 139 Journal of Epidemiology, 1994. (11): p. S49-S49. , et al. Response of an allergenic species Ambrosia psilostachya (Asteraceae), to experimental warming , Wan, S.Q. American Journal of Botany, 2002. 89 (11): p. 1843-1846. and clipping: Implications for public health. Neurotoxins from marine dinoflagellates: a brief review. Marine Drugs, 2008. (2): p. 349-71. 6 Wang, D.Z., , et al. , Detecting changes in extreme precipitation and extreme streamflow in the Dongjiang River Basin Wang, W. Hydrology and Earth System Sciences, 2008. 12 (1): p. 207-221. in southern China. Journal of the American Medical , , et al. Impact of earthquakes on Takotsubo cardiomyopathy. Watanabe, H. 294 (3): p. 305-307. Association, 2005. Mental health and recovery in the Gulf Coast after Hurricanes Weisler, R.H., J.G.t. Barbee, and M.H. Townsend, JAMA, 2006. 296 (5): p. 585-8. Katrina and Rita. An economic evaluation of asthma in the United States. N Engl J Med, Weiss, K.B., P.J. Gergen, and T.A. Hodgson, 1992. (13): p. 862-6. 326 , et al. Sequestration of carbon dioxide in coal with enhanced coalbed methane recovery - A review. , White, C.M. Energy & Fuels, 2005. 19 (3): p. 659-724. Murine Typhus in Fulton County, Georgia. : p. 386-8. 130 Mil Med, 1965. White, P.C., Jr., www.niehs.nih.gov/climatereport 70

79 PHOTOgrAPHY CrEDITS ACkNOwLEDgmENTS COVER: We would like to thank our colleagues who reviewed versions of the document, The cover image is a composite of an EVEREST (Exploratory Visualization Environment for REsearch in Science and contributed examples and information, and otherwise supported this process. Technology) map of the United States and a group of intertwined hands, symbolizing the need to work together to address the health effects of climate change. Image courtesy EPA: Rona Birnbaum, Carl Mazza, PhD, Al McGartland, PhD, Bruce Rodan, MD, the EPA Climate of the National Center for Computational Sciences, Oak Ridge National Laboratory Change and Health ad hoc working group, the Science Policy Council Steering Committee, the EPA Climate Change Science Program Synthesis 4.6 Reviewers, the Office of Air and Radiation, the Office PAGE 8: Top Right—© Jim Reed/Science Faction/Corbis of Research and Development, and the Office of Policy, Economics, and Innovation. Bottom—© Karen Kasmauski/Corbis PAGE 12: NIEHS: John Balbus, MD, MPH; Tonya Stonham Top Right—© Jim Reed/Science Faction/Corbis Bottom—© Bob Sacha/Corbis Brogan & Partners: Joseph W. Tart (design and layout), Mary Edbrooke (typography and layout) PAGE 16: Bottom—© Simon Jarratt/Corbis PAGE 20: Bottom—© Scott Houston/Sygma/Corbis PAGE 2 4: Bottom—© David Gubernick/AgStock Images/Corbis PAGE 25: http://www.nwfsc.noaa.gov/publications/newsletters/ fishmatters/highlights2004/highlights2004.cfm PAGE 25: © David Gubernick/AgStock Images/Corbis PAGE 28: Bottom—© Corbis PAGE 33: Frank Hadley Collins, Director, Center for Global Health and Infectious Diseases, University of Notre Dame PAGE 36: Top Right—© AP Photos/Stephan Savoia Bottom— Marty Bahamonde/FEMA PAGE 40: Vera Trainer/NOA A Top R ig ht— Bottom—© Brooks Kraft/Corbis PAGE 4 4: Top Right and Bottom—© Karen Kasmauski/Science Faction/Corbis PAGE 45: © Karen Kasmauski/Science Faction/Corbis PAGE 50: Top Right—© Dennis Kunkel Microscopy, Inc. PAGE 51: EPA— http://www.epa.gov/glnpo/atlas/index.html PAGE 56: Bottom—© Jerry McCrea/The Star Ledger

80 :f:'-NIEHS of Institute National ~f Sciences Health Environmental ~ ~ ENVIRONMENTAL HEAL TH e hp TIVES PERSPEC PublISHEd by: Environmental Health Perspectives and the National Institute of Environmental Health Sciences | | 50% POST CONSUMER WASTE 100% DE INKED RECYCLED PrINtEd oN: NEW LEAF SAKURA ® | PROCESSED CHLORINE FREE GREEN E CERTIFIED ANCIENT FOREST FRIENDLY

Related documents