Environmental health indicators of climate change for the United States: findings from the State Environmental Health Indicator Collaborative

Climate-related health impact indicators for public health surveillance in a changing climate: a systematic review and local suitability analysis

Climate change challenges public health. Effective management of climate-related health risks relies on robust public health surveillance (PHS) and population health indicators. Despite existing global and country-specific indicators, their integration into local PHS systems is limited, impacting decision-making. We conducted a systematic review examining population health indicators relevant to climate change impacts and their suitability for national PHS systems. Guided by a registered protocol, we searched multiple databases and included 41 articles. Of these, 35 reported morbidity indicators, and 39 reported mortality indicators. Using Chile as a case study, we identified three sets of indicators for the Chilean PHS. The high-priority set included vector-, food-, and water-borne diseases, as well as temperature-related health outcomes indicators due to their easy integration into existing PHS systems. This review highlights the importance of population health indicators in monitoring climate-related health impacts, emphasising the need for local contextual factors to guide indicator selection.

Funding

This research project was partly funded by ANID Chile and University College London. None of these sources had any involvement in the research conceptualisation, design, or interpretation of the results.

Extramural US Federal Research Grants For Health Outcomes Associated With Climate Change Inadequate, Too Narrow In Focus

Climate change causes and exacerbates disease, creates and worsens health disparities, disrupts health care delivery, and imposes a significant disease burden in the US and globally. Critical knowledge gaps hinder an evidence-based response and are perpetuated by scarce federal research funds. We identified and described extramural US federal research funding (that is, grants provided to organizations and institutions outside of federal agencies) that both addressed health outcomes associated with climate change and was awarded between 2010 and 2020. During this eleven-year period, 102 grants met our criteria, totaling approximately $58.7 million, or approximately $5.3 million per year (2020 adjusted US dollars). Federal investments in climate change and health research during this period failed to address the breadth of climate-sensitive exposures, health outcomes, and impacts on vulnerable populations. Moving forward, in addition to increasing investment in climate and health research across all known hazards, critical attention should be placed on vulnerable populations and health equity. To achieve this, increased federal research coordination and cooperation are needed, as well as a mechanism to track this funding.

Global Warming’s Six MTurks: A Secondary Analysis of a US-Based Online Crowdsourcing Market

Using a global warming audience segmentation tool (Six Americas Super Short Survey (SASSY)) as a case study, we consider how public health can use consumer panels and online crowdsourcing markets (OCMs) in research. Through a secondary analysis, we aim to understand how consumer panels and OCMs are similar to or different from each other on demographics and global warming beliefs through SASSY, and how they compare to US Census estimates. With this information, researchers will understand public opinion of global warming in their sample, which is useful for many climate change initiatives. Neither the consumer panel (Ipsos) or OCM sample (MTurk) matched US estimates of population demographics. Both panels achieved similar SASSY segments, showing that even with diverse sampling frames, SASSY is a useful tool for understanding global warming sentiment. Compared to Ipsos, MTurk was younger (more Millennials and Generation X), had higher educational attainment, and lower income. Both panels were majority White, but Ipsos was more diverse than the unweighted MTurk. Ipsos had more respondents from the South whereas MTurk had more respondents from the West. Across the MTurk SASSY segment, there were no significant differences for the majority of demographic characteristics except for age; younger generations were more Alarmed or Concerned, and older generations were more Doubtful and Dismissive. Researchers interested in understanding their sample’s opinions of global warming should use SASSY and consider oversampling in key demographic variables if they intend to achieve a nationally representative and diverse sample.

Tracking the impacts of climate change on human health via indicators: lessons from the Lancet Countdown

BACKGROUND

In the past decades, climate change has been impacting human lives and health via extreme weather and climate events and alterations in labour capacity, food security, and the prevalence and geographical distribution of infectious diseases across the globe. Climate change and health indicators (CCHIs) are workable tools designed to capture the complex set of interdependent interactions through which climate change is affecting human health. Since 2015, a novel sub-set of CCHIs, focusing on climate change impacts, exposures, and vulnerability indicators (CCIEVIs) has been developed, refined, and integrated by Working Group 1 of the "Lancet Countdown: Tracking Progress on Health and Climate Change", an international collaboration across disciplines that include climate, geography, epidemiology, occupation health, and economics.

DISCUSSION

This research in practice article is a reflective narrative documenting how we have developed CCIEVIs as a discrete set of quantifiable indicators that are updated annually to provide the most recent picture of climate change's impacts on human health. In our experience, the main challenge was to define globally relevant indicators that also have local relevance and as such can support decision making across multiple spatial scales. We found a hazard, exposure, and vulnerability framework to be effective in this regard. We here describe how we used such a framework to define CCIEVIs based on both data availability and the indicators' relevance to climate change and human health. We also report on how CCIEVIs have been improved and added to, detailing the underlying data and methods, and in doing so provide the defining quality criteria for Lancet Countdown CCIEVIs.

CONCLUSIONS

Our experience shows that CCIEVIs can effectively contribute to a world-wide monitoring system that aims to track, communicate, and harness evidence on climate-induced health impacts towards effective intervention strategies. An ongoing challenge is how to improve CCIEVIs so that the description of the linkages between climate change and human health can become more and more comprehensive.

Environmental Displacement and Mental Well-Being in Banjarnegara, Indonesia

BACKGROUND

Residential moves (displacement) owing to climate- and weather-related disasters may significantly impact mental health. Despite the growing risk from climate change, health impacts of environmental-mobility remain understudied.

OBJECTIVES

We assessed the effects of displacement on the association between landslides and changes in perceived mental well-being in Banjarnegara, Indonesia. We also investigated whether sociodemographics (age, sex, level of education, household-level income, or employment in agriculture) and landslide characteristics (number and severity of landslides) were associated with differing odds of relocation after experiencing landslides.

METHODS

In this cross-sectional study, we surveyed 420 individuals who experienced landslides between 2014 and 2018 to assess perceived changes in mental well-being, comparing after landslide exposure to before landslide exposure. We used a novel six-item measure that was created in collaboration with the local community to compare perceived changes between those who were displaced by landslides and those who were not displaced, using logistic and multinomial regressions adjusted for sociodemographic characteristics. We then assessed whether the odds of displacement differed based on sociodemographic characteristics and landslide exposure characteristics, using logistic regressions.

RESULTS

Those who were displaced were more likely than those who were not displaced to report perceived increases in economic stability [odds ratio (OR)=3.06; 95% confidence interval (CI): 1.45, 6.46], optimism (OR=4.01; 95% CI: 1.87, 8.61), safety (OR=2.71; 95% CI: 1.44, 5.10), religiosity (OR=1.92; 95% CI: 1.03, 3.65), and closeness with community (OR=1.90; 95% CI: 1.10, 3.33) after landslides compared with before their first landslide during the study period. More frequent landslide exposures were associated with reduced odds of relocation, but more severe landslides were associated with increased odds of relocation.

DISCUSSION

These findings suggest that landslides affect the mental well-being not only of those who are displaced but also of those who are left behind. Further, this work supports the need for community-based participatory research to fully capture the health impacts of environmental mobility. https://doi.org/10.1289/EHP9391.

Rethinking the design of resilience and adaptation indicators supporting coastal communities

As resilience and adaptation considerations become mainstreamed into public policy, there is an overarching desire to measure and quantify metrics and indicators that seek to evaluate the efficiency, effectiveness, and justness associated with outcomes of such processes. While much research has sought to develop specific indicators that may serve as proxies for these considerations, less research has focused on those normative aspects of indicator design that support a variety of goals associated with the accuracy, reproducibility, proxy value and multi-stakeholder translation of indicators, among various other goals and values. This perspective article sets forth a range of potential considerations that may be useful for those who seek to design and develop novel resilience and adaptation indicators ("RAIs"). These considerations are explored through a range of hypothetical examples that may be applicable to coastal communities that seek to address the practical challenges facing the design, execution, management and modification of RAIs.

Toward an Integrated System of Climate Change and Human Health Indicators: A Conceptual Framework

Environmental health indicators are helpful for tracking and communicating complex health trends, informing science and policy decisions, and evaluating public health actions. When provided on a national scale, they can help inform the general public, policy makers, and public health professionals about important trends in exposures and how well public health systems are preventing those exposures from causing adverse health outcomes. There is a growing need to understand national trends in exposures and health outcomes associated with climate change and the effectiveness of climate adaptation strategies for health. To date, most indicators for health implications of climate change have been designed as independent, individual metrics. This approach fails to take into account how exposure-outcome pathways for climate-attributable health outcomes involve multiple, interconnected components. We propose reframing climate change and health indicators as a linked system of indicators, which can be described as follows: upstream climate drivers affect environmental states, which then determine human exposures, which ultimately lead to health outcomes; these climate-related risks are modified by population vulnerabilities and adaptation strategies. We apply this new conceptual framework to three illustrative climate-sensitive health outcomes and associated exposure-outcome pathways: pollen allergies and asthma, West Nile Virus infection, and vibriosis.

Tracking infectious diseases in a warming world

Using infectious diseases sensitive to climate as indicators of climate change helps stimulate and inform public health responses, write Kris A Murray and colleagues

A Critical Analysis of the Drivers of Human Migration Patterns in the Presence of Climate Change: A New Conceptual Model

Both climate change and migration present key concerns for global health progress. Despite this, a transparent method for identifying and understanding the relationship between climate change, migration and other contextual factors remains a knowledge gap. Existing conceptual models are useful in understanding the complexities of climate migration, but provide varying degrees of applicability to quantitative studies, resulting in non-homogenous transferability of knowledge in this important area. This paper attempts to provide a critical review of climate migration literature, as well as presenting a new conceptual model for the identification of the drivers of migration in the context of climate change. It focuses on the interactions and the dynamics of drivers over time, space and society. Through systematic, pan-disciplinary and homogenous application of theory to different geographical contexts, we aim to improve understanding of the impacts of climate change on migration. A brief case study of Malawi is provided to demonstrate how this global conceptual model can be applied into local contextual scenarios. In doing so, we hope to provide insights that help in the more homogenous applications of conceptual frameworks for this area and more generally.

Critical Analysis of the Value of Drought Information and Impacts on Land Management and Public Health

This paper reviews previous efforts to assign monetary value to climatic or meteorological information, such as public information on drought, climate, early warning systems, and weather forecast information. Methods and tools that have been explored to examine the benefits of climatic and meteorological information include the avoided cost, contingent valuation, choice experiments, benefit transfer, and descriptive approaches using surveys. The second part of this paper discusses specific considerations related to valuing drought information for public health and the Bureau of Land Management. We found a multitude of connections between drought and the land management and health sectors in the literature. The majority of the papers that we summarized only report biophysical change, because the economic losses of drought are not available. Only a few papers reported economic loss associated with drought. To determine the value of drought information, we need to know more about the role it plays in decision making and what sources of drought information are used in different sectors. This inventory of methods and impacts highlights opportunities for further research in valuing drought information in land management and public health.

The Future of Careers at the Intersection of Climate Change and Public Health: What Can Job Postings and an Employer Survey Tell Us?

Climate change is acknowledged to be a major risk to public health. Skills and competencies related to climate change are becoming a part of the curriculum at schools of public health and are now a competency required by schools in Europe and Australia. However, it is unclear whether graduates of public health programs focusing on climate change are in demand in the current job market. The authors analyzed current job postings, 16 years worth of job postings on a public health job board, and survey responses from prospective employers. The current job market appears small but there is evidence from job postings that it may be growing, and 91.7% of survey respondents believe the need for public health professionals with training in climate change may grow in the next 5–10 years. Current employers value skills/competencies such as the knowledge of climate mitigation/adaptation, climate-health justice, direct/indirect and downstream effects of climate on health, health impact assessment, risk assessment, pollution-health consequences and causes, Geographic Information System (GIS) mapping, communication/writing, finance/economics, policy analysis, systems thinking, and interdisciplinary understanding. Ensuring that competencies align with current and future needs is a key aspect of curriculum development. At the same time, we recognize that while we attempt to predict future workforce needs with historical data or surveys, the disruptive reality created by climate change cannot be modeled from prior trends, and we must therefore adopt new paradigms of education for the emerging future.

Indicators to Guide and Monitor Climate Change Adaptation in the US Pacific Northwest

Objectives. To develop a set of indicators to guide and monitor climate change adaptation in US state and local health departments.Methods. We performed a narrative review of literature on indicators of climate change adaptation and public health service capacity, mapped the findings onto activities grouped by the Centers for Disease Control and Prevention's Ten Essential Services, and drafted potential indicators to discuss with practitioners. We then refined the indicators after key informant interviews with 17 health department officials in the US Pacific Northwest in fall 2018.Results. Informants identified a need for clarity regarding state and local public health's role in climate change adaptation, integration of adaptation into existing programs, and strengthening of communication, partnerships, and response capacity to increase resilience. We propose a set of climate change indicators applicable for state and local health departments.Conclusions. With additional context-specific refinement, the proposed indicators can aid agencies in tracking adaptation efforts. The generalizability, robustness, and relevance of the proposed indicators should be explored in other settings with a broader set of stakeholders.

Examination of Human Health Impacts Due to Adverse Climate Events Through the Use of Vulnerability Mapping: A Scoping Review

Government officials, health professionals, and other decision makers are tasked with characterizing vulnerability and understanding how populations experience risks associated with exposure to climate-related hazards. Spatial analyses of vulnerable locations have given rise to climate change vulnerability mapping. While not a new concept, the spatial analyses of specific health outcomes remain limited. This review explores different methodologies and data that are used to assess vulnerability and map population health impacts to climate hazards. The review retrieved scholarly articles and governmental reports concerning vulnerability mapping of human health to the impacts of climate change in the United States, published in the last decade. After review, 37 studies were selected for inclusion. Climate-related exposures were distributed across four main categories, including: high ambient temperatures; flood hazards; vector-borne diseases; and wildfires. A number of different methodologies and measures were used to assess health vulnerability to climate-related hazards, including heat vulnerability indices and regression analyses. Vulnerability maps should exemplify how variables measuring the sensitivity and adaptive capacity of different populations help to determine the potential for climate-related hazards to have an effect on human health. Recommendations address methodologies, data gaps, and communication to assist researchers and stakeholders in directing adaptations to their most efficient and effective use.

Developing environmental health indicators [EHIs] for Iran based on the causal effect model

BACKGROUND

Environmental health monitoring and its effects on health are very important in health systems. Relationship between environment and health can be done by simplifying data in understandable indicators for people and policy-makers. The present study presents the general framework for formulating environmental health quality index for Iran.

METHODS

This study was implemented through expert panel at two levels: indicator domain determination and domain specific variables selection. Domain specific variables were selected based on the Driving force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework from the list of national and international variables.

RESULTS

Seven environmental health issues [air quality, drinking water, sewage disposal, food, radiation management and housing and human settlements] were determined, and three variables were selected for air quality, 8 variables for water quality, 5 variables for sanitation, 1 variable for food quality, 3 variables for housing and human settlements, 4 variables for solid waste management and 3 variables for radiation management.

CONCLUSIONS

Environmental health indicators determination based on the causal effect model leads to a better understanding of the relationship between the environment and health by simplifying data in an understandable format for public and improves prioritization of policy-making in the environmental health. In this study, environmental health indicators for Iran were proposed.

Environmental Health Indicators for China: Data Resources for Chinese Environmental Public Health Tracking

Many developed countries use environmental public health tracking to gain a better understanding of the link between environmental hazards and public health. To respond to complicated environmental health issues, the National Institute of Environmental Health (NIEH), Chinese Center for Disease Control and Prevention (China CDC), has begun to build a Chinese Environmental Public Health Tracking (CEPHT) system. On behalf of the CEPHT, authors provide insight into the CEPHT's development, current status, and future plans. In the initial stage of CEPHT, an indicator framework linking environment and public health that included a list of publicly available data sources regarding environmental hazards, public health outcomes, and risk factors in China was developed. An analysis of data availability, along with a comparison between CEPHT's indicator system and other tracking networks, revealed the existence of barriers and gaps in data integration that affect China's ability to track environmental public health. The lack of access to data, combined with inadequate data quality, has led to difficulties linking environmental hazards to their effects on public health. Current CEPHT efforts will help integrate environmental factors and exposure data with public health outcomes. For the near future, CEPHT plans to focus on increasing collaboration among data tracking agencies, improving data quality, and expanding proper data sharing. https://doi.org/10.1289/EHP4319.

Effect of Health-Related Uncertainty and Natural Variability on Health Impacts and Cobenefits of Climate Policy

Climate policy can mitigate health risks attributed to intensifying air pollution under climate change. However, few studies quantify risks of illness and death, examine their contribution to climate policy benefits, or assess their robustness in light of natural climate variability. We employ an integrated modeling framework of the economy, climate, air quality, and human health to quantify the effect of natural variability on U.S. air pollution impacts under future climate and two global policies (2 and 2.5 °C stabilization scenarios) using 150 year ensemble simulations for each scenario in 2050 and 2100. Climate change yields annual premature deaths related to fine particulate matter and ozone (95CI: 25 000-120 000), heart attacks (900-9400), and lost work days (3.6M-4.9M) in 2100. It raises air pollution health risks by 20%, while policies avert these outcomes by 40-50% in 2050 and 70-88% in 2100. Natural variability introduces "climate noise", yielding some annual estimates with negative cobenefits, and others that reach 100% of annual policy costs. This "noise" is three times the magnitude of uncertainty (95CI) in health and economic responses in 2050. Averaging five annual simulations reduces this factor to two, which is still substantially larger than health-related uncertainty. This study quantifies the potential for inaccuracy in climate impacts projected using too few annual simulations.

Monitoring and Evaluation Indicators for Climate Change-Related Health Impacts, Risks, Adaptation, and Resilience

Climate change poses a range of current and future health risks that health professionals need to understand, track, and manage. However, conventional monitoring and evaluation (M&E) as practiced in the health sector, including the use of indicators, does not adequately serve this purpose. Improved indicators are needed in three broad categories: (1) vulnerability and exposure to climate-related hazards; (2) current impacts and projected risks; and (3) adaptation processes and health system resilience. These indicators are needed at the population level and at the health systems level (including clinical care and public health). Selected indicators must be sensitive, valid, and useful. And they must account for uncertainties about the magnitude and pattern of climate change; the broad range of upstream drivers of climate-sensitive health outcomes; and the complexities of adaptation itself, including institutional learning and knowledge management to inform iterative risk management. Barriers and constraints to implementing such indicators must be addressed, and lessons learned need to be added to the evidence base. This paper describes an approach to climate and health indicators, including characteristics of the indicators, implementation, and research needs.

Climate Change and Public Health Surveillance: Toward a Comprehensive Strategy

CONTEXT

Climate change poses a host of serious threats to human health that robust public health surveillance systems can help address. It is unknown, however, whether existing surveillance systems in the United States have adequate capacity to serve that role, nor what actions may be needed to develop adequate capacity.

OBJECTIVE

Our goals were to review efforts to assess and strengthen the capacity of public health surveillance systems to support health-related adaptation to climate change in the United States and to determine whether additional efforts are warranted.

METHODS

Building on frameworks issued by the Intergovernmental Panel on Climate Change and the Centers for Disease Control and Prevention, we specified 4 core components of public health surveillance capacity relevant to climate change health threats. Using standard methods, we next identified and analyzed multiple assessments of the existing, relevant capacity of public health surveillance systems as well as attempts to improve that capacity. We also received information from selected national public health associations.

FINDINGS

Multiple federal, state, and local public health agencies, professional associations, and researchers have made valuable, initial efforts to assess and strengthen surveillance capacity. These efforts, however, have been made by entities working independently and without the benefit of a shared conceptual framework or strategy. Their principal focus has been on identifying suitable indicators and data sources largely to the exclusion of other core components of surveillance capacity.

CONCLUSIONS

A more comprehensive and strategic approach is needed to build the public health surveillance capacity required to protect the health of Americans in a world of rapidly evolving climate change. Public health practitioners and policy makers at all levels can use the findings and issues reviewed in this article as they lead design and execution of a coordinated, multisector strategic plan to create and sustain that capacity.

Lessons Learned on Health Adaptation to Climate Variability and Change: Experiences Across Low- and Middle-Income Countries

BACKGROUND

There is limited published evidence of the effectiveness of adaptation in managing the health risks of climate variability and change in low- and middle-income countries.

OBJECTIVES

To document lessons learned and good practice examples from health adaptation pilot projects in low- and middle-income countries to facilitate assessing and overcoming barriers to implementation and to scaling up.

METHODS

We evaluated project reports and related materials from the first five years of implementation (2008-2013) of multinational health adaptation projects in Albania, Barbados, Bhutan, China, Fiji, Jordan, Kazakhstan, Kenya, Kyrgyzstan, Philippines, Russian Federation, Tajikistan, and Uzbekistan. We also collected qualitative data through a focus group consultation and 19 key informant interviews.

RESULTS

Our recommendations include that national health plans, policies, and budget processes need to explicitly incorporate the risks of current and projected climate variability and change. Increasing resilience is likely to be achieved through longer-term, multifaceted, and collaborative approaches, with supporting activities (and funding) for capacity building, communication, and institutionalized monitoring and evaluation. Projects should be encouraged to focus not just on shorter-term outputs to address climate variability, but also on establishing processes to address longer-term climate change challenges. Opportunities for capacity development should be created, identified, and reinforced.

CONCLUSIONS

Our analyses highlight that, irrespective of resource constraints, ministries of health and other institutions working on climate-related health issues in low- and middle-income countries need to continue to prepare themselves to prevent additional health burdens in the context of a changing climate and socioeconomic development patterns. https://doi.org/10.1289/EHP405.

Developing Health-Related Indicators of Climate Change: Australian Stakeholder Perspectives

Climate-related health indicators are potentially useful for tracking and predicting the adverse public health effects of climate change, identifying vulnerable populations, and monitoring interventions. However, there is a need to understand stakeholders’ perspectives on the identification, development, and utility of such indicators. A qualitative approach was used, comprising semi-structured interviews with key informants and service providers from government and non-government stakeholder organizations in South Australia. Stakeholders saw a need for indicators that could enable the monitoring of health impacts and time trends, vulnerability to climate change, and those which could also be used as communication tools. Four key criteria for utility were identified, namely robust and credible indicators, specificity, data availability, and being able to be spatially represented. The variability of risk factors in different regions, lack of resources, and data and methodological issues were identified as the main barriers to indicator development. This study demonstrates a high level of stakeholder awareness of the health impacts of climate change, and the need for indicators that can inform policy makers regarding interventions.

Sensitivity of health sector indicators' response to climate change in Ghana

There is accumulating evidence that the emerging burden of global climate change threatens the fidelity of routine indicators for disease detection and management of risks to public health. The threat partially reflects the conservative character of the health sector and the reluctance to adopt new indicators, despite the growing awareness that existing environmental health indicators were developed to respond to risks that may no longer be relevant, and are too simplistic to also act as indicators for newer global-scale risk factors. This study sought to understand the scope of existing health indicators, while aiming to discover new indicators for building resilience against three climate sensitive diseases (cerebro spinal meningitis, malaria and diarrhea). Therefore, new potential indicators derived from human and biophysical origins were developed to complement existing health indicators, thereby creating climate-sensitive battery of robust composite indices of resilience in health planning. Using Ghana's health sector as a case study systematic international literature review, national expert consultation, and focus group outcomes yielded insights into the relevance, sensitivity and impacts of 45 indicators in 11 categories in responding to climate change. In total, 65% of the indicators were sensitive to health impacts of climate change; 24% acted directly; 31% synergistically; and 45% indirectly, with indicator relevance strongly associated with type of health response. Epidemiological indicators (e.g. morbidity) and health demographic indicators (e.g. population structure) require adjustments with external indicators (e.g. biophysical, policy) to be resilient to climate change. Therefore, selective integration of social and ecological indicators with existing public health indicators improves the fidelity of the health sector to adopt more robust planning of interdependent systems to build resilience. The study highlights growing uncertainties in translating research into protective policies when new indicators associated with non-health sources are needed to complement existing health indicators that are expected to respond to climate change.

Iterative management of heat early warning systems in a changing climate

Extreme heat is a leading weather-related cause of morbidity and mortality, with heat exposure becoming more widespread, frequent, and intense as climates change. The use of heat early warning and response systems (HEWSs) that integrate weather forecasts with risk assessment, communication, and reduction activities is increasingly widespread. HEWSs are frequently touted as an adaptation to climate change, but little attention has been paid to the question of how best to ensure effectiveness of HEWSs as climates change further. In this paper, we discuss findings showing that HEWSs satisfy the tenets of an intervention that facilitates adaptation, but climate change poses challenges infrequently addressed in heat action plans, particularly changes in the onset, duration, and intensity of dangerously warm temperatures, and changes over time in the relationships between temperature and health outcomes. Iterative management should be central to a HEWS, and iteration cycles should be of 5 years or less. Climate change adaptation and implementation science research frameworks can be used to identify HEWS modifications to improve their effectiveness as temperature continues to rise, incorporating scientific insights and new understanding of effective interventions. We conclude that, at a minimum, iterative management activities should involve planned reassessment at least every 5 years of hazard distribution, population-level vulnerability, and HEWS effectiveness.

Justice and Equity Implications of Climate Change Adaptation: A Theoretical Evaluation Framework

Climate change affects human health, and climate change adaptation aims to reduce these risks through infrastructural, behavioral, and technological measures. However, attributing direct human health effects to climate change adaptation is difficult, causing an ethical dilemma between the need for evidence of strategies and their precautionary implementation before such evidence has been generated. In the absence of conclusive evidence for individual adaptation strategies, alternative approaches to the measurement of adaptation effectiveness need to be developed. This article proposes a theoretical framework and a set of guiding questions to assess effects of adaptation strategies on seven domains of health determinants, including social, economic, infrastructure, institutional, community, environmental, and cultural determinants of health. Its focus on advancing gender equity and environmental justice concurrently with the implementation of health-related adaptation could serve as a template for policymakers and researchers.

On the Science-Policy Bridge: Do Spatial Heat Vulnerability Assessment Studies Influence Policy?

Human vulnerability to heat varies at a range of spatial scales, especially within cities where there can be noticeable intra-urban differences in heat risk factors. Mapping and visualizing intra-urban heat vulnerability offers opportunities for presenting information to support decision-making. For example the visualization of the spatial variation of heat vulnerability has the potential to enable local governments to identify hot spots of vulnerability and allocate resources and increase assistance to people in areas of greatest need. Recently there has been a proliferation of heat vulnerability mapping studies, all of which, to varying degrees, justify the process of vulnerability mapping in a policy context. However, to date, there has not been a systematic review of the extent to which the results of vulnerability mapping studies have been applied in decision-making. Accordingly we undertook a comprehensive review of 37 recently published papers that use geospatial techniques for assessing human vulnerability to heat. In addition, we conducted an anonymous survey of the lead authors of the 37 papers in order to establish the level of interaction between the researchers as science information producers and local authorities as information users. Both paper review and author survey results show that heat vulnerability mapping has been used in an attempt to communicate policy recommendations, raise awareness and induce institutional networking and learning, but has not as yet had a substantive influence on policymaking or preventive action.

Green Infrastructure, Ecosystem Services, and Human Health

Contemporary ecological models of health prominently feature the natural environment as fundamental to the ecosystem services that support human life, health, and well-being. The natural environment encompasses and permeates all other spheres of influence on health. Reviews of the natural environment and health literature have tended, at times intentionally, to focus on a limited subset of ecosystem services as well as health benefits stemming from the presence, and access and exposure to, green infrastructure. The sweeping influence of green infrastructure on the myriad ecosystem services essential to health has therefore often been underrepresented. This survey of the literature aims to provide a more comprehensive picture—in the form of a primer—of the many simultaneously acting health co-benefits of green infrastructure. It is hoped that a more accurately exhaustive list of benefits will not only instigate further research into the health co-benefits of green infrastructure but also promote consilience in the many fields, including public health, that must be involved in the landscape conservation necessary to protect and improve health and well-being.

Climate Change, Drought and Human Health in Canada

Droughts have been recorded all across Canada and have had significant impacts on individuals and communities. With climate change, projections suggest an increasing risk of drought in Canada, particularly in the south and interior. However, there has been little research on the impacts of drought on human health and the implications of a changing climate. A review of the Canadian, U.S. and international literature relevant to the Canadian context was conducted to better define these impacts and adaptations available to protect health. Drought can impact respiratory health, mental health, illnesses related to exposure to toxins, food/water security, rates of injury and infectious diseases (including food-, water- and vector-borne diseases). A range of direct and indirect adaptation (e.g., agricultural adaptation) options exist to cope with drought. Many have already been employed by public health officials, such as communicable disease monitoring and surveillance and public education and outreach. However, gaps exist in our understanding of the impacts of short-term vs. prolonged drought on the health of Canadians, projections of drought and its characteristics at the regional level and the effectiveness of current adaptations. Further research will be critical to inform adaptation planning to reduce future drought-related risks to health.

Predicting hospitalization for heat-related illness at the census-tract level: accuracy of a generic heat vulnerability index in Phoenix, Arizona (USA)

BACKGROUND

Vulnerability mapping based on vulnerability indices is a pragmatic approach for highlighting the areas in a city where people are at the greatest risk of harm from heat, but the manner in which vulnerability is conceptualized influences the results.

OBJECTIVES

We tested a generic national heat-vulnerability index, based on a 10-variable indicator framework, using data on heat-related hospitalizations in Phoenix, Arizona. We also identified potential local risk factors not included in the generic indicators.

METHODS

To evaluate the accuracy of the generic index in a city-specific context, we used factor scores, derived from a factor analysis using census tract-level characteristics, as independent variables, and heat hospitalizations (with census tracts categorized as zero-, moderate-, or high-incidence) as dependent variables in a multinomial logistic regression model. We also compared the geographical differences between a vulnerability map derived from the generic index and one derived from actual heat-related hospitalizations at the census-tract scale.

RESULTS

We found that the national-indicator framework correctly classified just over half (54%) of census tracts in Phoenix. Compared with all census tracts, high-vulnerability tracts that were misclassified by the index as zero-vulnerability tracts had higher average income and higher proportions of residents with a duration of residency < 5 years.

CONCLUSION

The generic indicators of vulnerability are useful, but they are sensitive to scale, measurement, and context. Decision makers need to consider the characteristics of their cities to determine how closely vulnerability maps based on generic indicators reflect actual risk of harm.

Allergenic pollen season variations in the past two decades under changing climate in the United States

Many diseases are linked with climate trends and variations. In particular, climate change is expected to alter the spatiotemporal dynamics of allergenic airborne pollen and potentially increase occurrence of allergic airway disease. Understanding the spatiotemporal patterns of changes in pollen season timing and levels is thus important in assessing climate impacts on aerobiology and allergy caused by allergenic airborne pollen. Here, we describe the spatiotemporal patterns of changes in the seasonal timing and levels of allergenic airborne pollen for multiple taxa in different climate regions at a continental scale. The allergenic pollen seasons of representative trees, weeds and grass during the past decade (2001-2010) across the contiguous United States have been observed to start 3.0 [95% Confidence Interval (CI), 1.1-4.9] days earlier on average than in the 1990s (1994-2000). The average peak value and annual total of daily counted airborne pollen have increased by 42.4% (95% CI, 21.9-62.9%) and 46.0% (95% CI, 21.5-70.5%), respectively. Changes of pollen season timing and airborne levels depend on latitude, and are associated with changes of growing degree days, frost free days, and precipitation. These changes are likely due to recent climate change and particularly the enhanced warming and precipitation at higher latitudes in the contiguous United States.

Children's health and vulnerability in outdoor microclimates: A comprehensive review

BACKGROUND

Children are routinely identified as a vulnerable population in environmental health risk assessments, experiencing adverse health outcomes due to exposure to a suite of atmospheric constituents.

OBJECTIVE

To provide a substantive overview of the research literature pertaining to biometeorological effects on children. Key information areas within urban environmental health research related to atmospheric variables (heat, air pollution, radiation) are assessed and integrated to better understand health outcomes and vulnerabilities in children. Critical avenues for improvement and understanding of children's health related to such biophysical parameters are also identified.

METHODS

This comprehensive review assesses past and current primary studies, organizational reports, educational books, and review articles. Emphasis is placed on the differential ambient exposures to temperature, air pollution, and radiation within urban microclimates commonly used by children (e.g., schoolyards, urban parks), and the resulting health impacts.

DISCUSSION

Exposure to heat, air pollution, and radiation are often enhanced in urban areas, specifically under the current design of the majority of outdoor child play places. Many heat indices, energy budget models, and health outcome studies fail to adequately parameterize children, yet those that do find enhanced vulnerability to ambient stressors, particularly heat and air pollution. Such environmental exposures relate strongly to behavior, activity, asthma, obesity, and overall child well-being. Current research indicates that a changing climate, growing urban population, and unsustainable design are projected to pose increasing complications.

CONCLUSIONS

Evidence-based research to link children's health, physiology, and behavior to atmospheric extremes is an important future research avenue, underscoring the fact that children are among the population groups disproportionately affected by ambient extremes. However, current methods and population-based models lack child-specific inputs and outputs, as well as designated thresholds for accurate predictions of child health impacts. More substantive evidence is needed for applicable child-specific policies and guidelines.

An evidence-based public health approach to climate change adaptation

BACKGROUND

Public health is committed to evidence-based practice, yet there has been minimal discussion of how to apply an evidence-based practice framework to climate change adaptation.

OBJECTIVES

Our goal was to review the literature on evidence-based public health (EBPH), to determine whether it can be applied to climate change adaptation, and to consider how emphasizing evidence-based practice may influence research and practice decisions related to public health adaptation to climate change.

METHODS

We conducted a substantive review of EBPH, identified a consensus EBPH framework, and modified it to support an EBPH approach to climate change adaptation. We applied the framework to an example and considered implications for stakeholders.

DISCUSSION

A modified EBPH framework can accommodate the wide range of exposures, outcomes, and modes of inquiry associated with climate change adaptation and the variety of settings in which adaptation activities will be pursued. Several factors currently limit application of the framework, including a lack of higher-level evidence of intervention efficacy and a lack of guidelines for reporting climate change health impact projections. To enhance the evidence base, there must be increased attention to designing, evaluating, and reporting adaptation interventions; standardized health impact projection reporting; and increased attention to knowledge translation. This approach has implications for funders, researchers, journal editors, practitioners, and policy makers.

CONCLUSIONS

The current approach to EBPH can, with modifications, support climate change adaptation activities, but there is little evidence regarding interventions and knowledge translation, and guidelines for projecting health impacts are lacking. Realizing the goal of an evidence-based approach will require systematic, coordinated efforts among various stakeholders.

An approach to developing local climate change environmental public health indicators, vulnerability assessments, and projections of future impacts

Environmental public health indicators (EPHIs) are used by local, state, and federal health agencies to track the status of environmental hazards; exposure to those hazards; health effects of exposure; and public health interventions designed to reduce or prevent the hazard, exposure, or resulting health effect. Climate and health EPHIs have been developed at the state, federal, and international levels. However, they are also needed at the local level to track variations in community vulnerability and to evaluate the effectiveness of interventions designed to enhance community resilience. This review draws on a guidance document developed by the U.S. Council of State and Territorial Epidemiologists' State Environmental Health Indicators Collaborative climate change working group to present a three-tiered approach to develop local climate change EPHIs. Local climate change EPHIs can assist local health departments (LHDs) in implementing key steps of the 10 essential public health services and the U.S. Centers for Disease Control and Prevention's Building Resilience Against Climate Effects framework. They also allow LHDs to incorporate climate-related trends into the larger health department planning process and can be used to perform vulnerability assessments which can be leveraged to ensure that interventions designed to address climate change do not exacerbate existing health disparities.

Indicators for tracking European vulnerabilities to the risks of infectious disease transmission due to climate change

A wide range of infectious diseases may change their geographic range, seasonality and incidence due to climate change, but there is limited research exploring health vulnerabilities to climate change. In order to address this gap, pan-European vulnerability indices were developed for 2035 and 2055, based upon the definition vulnerability = impact/adaptive capacity. Future impacts were projected based upon changes in temperature and precipitation patterns, whilst adaptive capacity was developed from the results of a previous pan-European study. The results were plotted via ArcGISTM to EU regional (NUTS2) levels for 2035 and 2055 and ranked according to quintiles. The models demonstrate regional variations with respect to projected climate-related infectious disease challenges that they will face, and with respect to projected vulnerabilities after accounting for regional adaptive capacities. Regions with higher adaptive capacities, such as in Scandinavia and central Europe, will likely be better able to offset any climate change impacts and are thus generally less vulnerable than areas with lower adaptive capacities. The indices developed here provide public health planners with information to guide prioritisation of activities aimed at strengthening regional preparedness for the health impacts of climate change. There are, however, many limitations and uncertainties when modeling health vulnerabilities. To further advance the field, the importance of variables such as coping capacity and governance should be better accounted for, and there is the need to systematically collect and analyse the interlinkages between the numerous and ever-expanding environmental, socioeconomic, demographic and epidemiologic datasets so as to promote the public health capacity to detect, forecast, and prepare for the health threats due to climate change.

Heat waves and health outcomes in Alabama (USA): the importance of heat wave definition

BACKGROUND

A deeper understanding of how heat wave definition affects the relationship between heat exposure and health, especially as a function of rurality, will be useful in developing effective heat wave warning systems.

OBJECTIVE

We compared the relationships between different heat wave index (HI) definitions and preterm birth (PTB) and nonaccidental death (NAD) across urban and rural areas.

METHODS

We used a time-stratified case-crossover design to estimate associations of PTB and NAD with heat wave days (defined using 15 HIs) relative to non-heat wave control days in Alabama, USA (1990-2010). ZIP code-level HIs were derived using data from the North American Land Data Assimilation System. Associations with heat wave days defined using different HIs were compared by bootstrapping. We also examined interactions with rurality.

RESULTS

Associations varied depending on the HI used to define heat wave days. Heat waves defined as having at least 2 consecutive days with mean daily temperatures above the 98th percentile were associated with 32.4% (95% CI: 3.7, 69.1%) higher PTB, and heat waves defined as at least 2 consecutive days with mean daily temperatures above the 90th percentile were associated with 3.7% (95% CI: 1.1, 6.3%) higher NAD. Results suggest that significant positive associations were more common when relative-compared with absolute-HIs were used to define exposure. Both positive and negative associations were found in each rurality stratum. However, all stratum-specific significant associations were positive, and NAD associations with heat waves were consistently positive in urban strata but not in middle or rural strata.

CONCLUSIONS

Based on our findings, we conclude that a relative mean-temperature-only heat wave definition may be the most effective metric for heat wave warning systems in Alabama.

Development of key indicators to quantify the health impacts of climate change on Canadians

OBJECTIVES

This study aimed at developing a list of key human health indicators for quantifying the health impacts of climate change in Canada.

METHODS

A literature review was conducted in OVID Medline to identify health morbidity and mortality indicators currently used to quantify climate change impacts. Public health frameworks and other studies of climate change indicators were reviewed to identify criteria with which to evaluate the list of proposed key indicators and a rating scale was developed. Total scores for each indicator were calculated based on the rating scale.

RESULTS

A total of 77 health indicators were identified from the literature. After evaluation using the chosen criteria, 8 indicators were identified as the best for use. They include excess daily all-cause mortality due to heat, premature deaths due to air pollution (ozone and particulate matter 2.5), preventable deaths from climate change, disability-adjusted life years lost from climate change, daily all-cause mortality, daily non-accidental mortality, West Nile Disease incidence, and Lyme borreliosis incidence.

CONCLUSIONS

There is need for further data and research related to health effect quantification in the area of climate change.

Hispanic health disparities after a flood disaster: results of a population-based survey of individuals experiencing home site damage in El Paso (Texas, USA)

In 2006, El Paso County, a predominantly Hispanic urban area, was affected by a flood disaster; 1,500 homes were damaged. We assessed the health impacts of the disaster upon 475 individuals whose homes were flood-damaged using mail survey data and logistic regression. Substantial proportions of individuals had one or more physical (43 %) or mental (18 %) health problem in the four months following the floods; 28 % had one or more injury or acute effect related to post-flood cleanup. Adverse event experiences, older age, and lower socioeconomic status were significantly associated with negative post-flood health outcomes in all three logistic regression models. A lack of access to healthcare, non-US citizenship, and English proficiency were significant predictors of negative outcomes in both the physical and mental health models, while Hispanic ethnicity (physical), native-birth (mental), and more serious home damage (cleanup) were significant predictors in one model each. The disaster had disproportionate negative health impacts on those who were more exposed, poorer, older, and with constrained resource-access. While a lack of US citizenship and Hispanic ethnicity were associated with higher risks, being less acculturated (i.e., English-deficient, foreign-born) may have protected against health impacts.

Climate change and older Americans: state of the science

BACKGROUND

Older adults make up 13% of the U.S. population, but are projected to account for 20% by 2040. Coinciding with this demographic shift, the rate of climate change is accelerating, bringing rising temperatures; increased risk of floods, droughts, and wildfires; stronger tropical storms and hurricanes; rising sea levels; and other climate-related hazards. Older Americans are expected to be located in places that may be relatively more affected by climate change, including coastal zones and large metropolitan areas.

OBJECTIVE

The objective of this review is to assess the vulnerability of older Americans to climate change and to identify opportunities for adaptation.

METHODS

We performed an extensive literature survey and summarized key findings related to demographics; climate stressors relevant to older adults; factors contributing to exposure, sensitivity, and adaptive capacity; and adaptation strategies.

DISCUSSION

A range of physiological and socioeconomic factors make older adults especially sensitive to and/or at risk for exposure to heat waves and other extreme weather events (e.g., hurricanes, floods, droughts), poor air quality, and infectious diseases. Climate change may increase the frequency or severity of these events.

CONCLUSIONS

Older Americans are likely to be especially vulnerable to stressors associated with climate change. Although a growing body of evidence reports the adverse effects of heat on the health of older adults, research gaps remain for other climate-related risks. We need additional study of the vulnerability of older adults and the interplay of vulnerability, resilience, and adaptive responses to projected climate stressors.

Inequalities in cumulative environmental burdens among three urbanized counties in California

Low-income communities and communities of color often suffer from multiple environmental hazards that pose risks to their health. Here we extended a cumulative environmental hazard inequality index (CEHII) - developed to assess inequalities in air pollution hazards - to compare the inequality among three urban counties in California: Alameda, San Diego, and Los Angeles. We included a metric for heat stress to the analysis because exposure to excessively hot weather is increasingly recognized as a threat to human health and well-being. We determined if inequalities from heat stress differed between the three regions and if this added factor modified the metric for inequality from cumulative exposure to air pollution. This analysis indicated that of the three air pollutants considered, diesel particulate matter had the greatest inequality, followed by nitrogen dioxide (NO(2)) and fine particulate matter (PM(2.5)). As measured by our index, the inequalities from cumulative exposure to air pollution were greater than those of single pollutants. Inequalities were significantly different among single air pollutant hazards within each region and between regions; however, inequalities from the cumulative burdens did not differ significantly between any two regions. Modeled absolute and relative heat stress inequalities were small except for relative heat stress in San Diego which had the second highest inequality. Our analysis, techniques, and results provide useful insights for policy makers to assess inequalities between regions and address factors that contribute to overall environmental inequality within each region.

Integrating climate change adaptation into public health practice: using adaptive management to increase adaptive capacity and build resilience

BACKGROUND

Climate change is expected to have a range of health impacts, some of which are already apparent. Public health adaptation is imperative, but there has been little discussion of how to increase adaptive capacity and resilience in public health systems.

OBJECTIVES

We explored possible explanations for the lack of work on adaptive capacity, outline climate-health challenges that may lie outside public health's coping range, and consider changes in practice that could increase public health's adaptive capacity.

METHODS

We conducted a substantive, interdisciplinary literature review focused on climate change adaptation in public health, social learning, and management of socioeconomic systems exhibiting dynamic complexity.

DISCUSSION

There are two competing views of how public health should engage climate change adaptation. Perspectives differ on whether climate change will primarily amplify existing hazards, requiring enhancement of existing public health functions, or present categorically distinct threats requiring innovative management strategies. In some contexts, distinctly climate-sensitive health threats may overwhelm public health's adaptive capacity. Addressing these threats will require increased emphasis on institutional learning, innovative management strategies, and new and improved tools. Adaptive management, an iterative framework that embraces uncertainty, uses modeling, and integrates learning, may be a useful approach. We illustrate its application to extreme heat in an urban setting.

CONCLUSIONS

Increasing public health capacity will be necessary for certain climate-health threats. Focusing efforts to increase adaptive capacity in specific areas, promoting institutional learning, embracing adaptive management, and developing tools to facilitate these processes are important priorities and can improve the resilience of local public health systems to climate change.

Exposure to hot and cold temperatures and ambulance attendances in Brisbane, Australia: a time-series study

OBJECTIVES

To investigate the effect of hot and cold temperatures on ambulance attendances.

DESIGN

An ecological time-series study.

SETTING AND PARTICIPANTS

The study was conducted in Brisbane, Australia. The authors collected information on 783 935 daily ambulance attendances, along with data of associated meteorological variables and air pollutants, for the period of 2000-2007.

OUTCOME MEASURES

The total number of ambulance attendances was examined, along with those related to cardiovascular, respiratory and other non-traumatic conditions. Generalised additive models were used to assess the relationship between daily mean temperature and the number of ambulance attendances.

RESULTS

There were statistically significant relationships between mean temperature and ambulance attendances for all categories. Acute heat effects were found with a 1.17% (95% CI 0.86% to 1.48%) increase in total attendances for 1°C increase above threshold (0-1 days lag). Cold effects were delayed and longer lasting with a 1.30% (0.87% to 1.73%) increase in total attendances for a 1°C decrease below the threshold (2-15 days lag). Harvesting was observed following initial acute periods of heat effects but not for cold effects.

CONCLUSIONS

This study shows that both hot and cold temperatures led to increases in ambulance attendances for different medical conditions. Our findings support the notion that ambulance attendance records are a valid and timely source of data for use in the development of local weather/health early warning systems.

Resilience to the health risks of extreme weather events in a changing climate in the United States

Current public health strategies, policies, and measures are being modified to enhance current health protection to climate-sensitive health outcomes. These modifications are critical to decrease vulnerability to climate variability, but do not necessarily increase resilience to future (and different) weather patterns. Communities resilient to the health risks of climate change anticipate risks; reduce vulnerability to those risks; prepare for and respond quickly and effectively to threats; and recover faster, with increased capacity to prepare for and respond to the next threat. Increasing resilience includes top-down (e.g., strengthening and maintaining disaster risk management programs) and bottom-up (e.g., increasing social capital) measures, and focuses not only on the risks presented by climate change but also on the underlying socioeconomic, geographic, and other vulnerabilities that affect the extent and magnitude of impacts. Three examples are discussed of public health programs designed for other purposes that provide opportunities for increasing the capacity of communities to avoid, prepare for, and effectively respond to the health risks of extreme weather and climate events. Incorporating elements of adaptive management into public health practice, including a strong and explicit focus on iteratively managing risks, will increase effective management of climate change risks.

A review of frameworks for developing environmental health indicators for climate change and health

The role climate change may play in altering human health, particularly in the emergence and spread of diseases, is an evolving area of research. It is important to understand this relationship because it will compound the already significant burden of diseases on national economies and public health. Authorities need to be able to assess, anticipate, and monitor human health vulnerability to climate change, in order to plan for, or implement action to avoid these eventualities. Environmental health indicators (EHIs) provide a tool to assess, monitor, and quantify human health vulnerability, to aid in the design and targeting of interventions, and measure the effectiveness of climate change adaptation and mitigation activities. Our aim was to identify the most suitable framework for developing EHIs to measure and monitor the impacts of climate change on human health and inform the development of interventions. Using published literature we reviewed the attributes of 11 frameworks. We identified the Driving force-Pressure-State-Exposure-Effect-Action (DPSEEA) framework as the most suitable one for developing EHIs for climate change and health. We propose the use of EHIs as a valuable tool to assess, quantify, and monitor human health vulnerability, design and target interventions, and measure the effectiveness of climate change adaptation and mitigation activities. In this paper, we lay the groundwork for the future development of EHIs as a multidisciplinary approach to link existing environmental and epidemiological data and networks. Analysis of such data will contribute to an enhanced understanding of the relationship between climate change and human health.

Adaptation to impacts of climate change on aeroallergens and allergic respiratory diseases

Climate change has the potential to have many significant impacts on aeroallergens such as pollen and mould spores, and therefore related diseases such as asthma and allergic rhinitis. This paper critically reviews this topic, with a focus on the potential adaptation measures that have been identified to date. These are aeroallergen monitoring; aeroallergen forecasting; allergenic plant management; planting practices and policies; urban/settlement planning; building design and heating, ventilating, and air-conditioning (HVAC); access to health care and medications; education; and research.

Environmental metrics for community health improvement

Environmental factors greatly affect human health. Accordingly, environmental metrics are a key part of the community health information base. We review environmental metrics relevant to community health, including measurements of contaminants in environmental media, such as air, water, and food; measurements of contaminants in people (biomonitoring); measurements of features of the built environment that affect health; and measurements of "upstream" environmental conditions relevant to health. We offer a set of metrics (including unhealthy exposures, such as pollutants, and health-promoting assets, such as parks and green space) selected on the basis of relevance to health outcomes, magnitude of associated health outcomes, corroboration in the peer-reviewed literature, and data availability, especially at the community level, and we recommend ways to use these metrics most effectively.