Global warming ICAN

Climate Change and ID November 2012

Andreas Voss, MD, PhD 1

Andreas Voss iPrevent

UMCN & CWZ Nijmegen, The Netherlands

by far the most terrible talk you will ever hear

by far the most terrifying film you will ever see

Al Gore A Voss

¤ AcceleraKng economic acKvity and fossil fuel combusKon over the past century has precipitated an environmental impact of unprecedented proporKons: ² Ecosystem decline ² Loss of biodiversity ² Stratospheric ozone depleKon ² Climate change

¤ Worldwide mean surface temperature has increased by 0·∙74°C (SD 0·∙18) over the past 100 years

¤ Worldwide sea level has risen by 1·∙8 mm per year since 1961 and oceans are becoming more acidic

¤ ArcKc sea ice is retreaKng by 2.7% (SD 0.6) per decade

¤ Sea surface temperatures are warming ¤ Mountain glaciers are shrinking ¤ Extreme weather events are increasing in frequency and intensity.

Hukme et al. Clim Res 17: 145–168, 2001



Hukme et al. Clim Res 17: 145–168, 2001

2020s 2050s 2080s

¤  Heat waves

¤  Storms ¤  Floods

¤  Fires

¤  Droughts

¤  Infectious diseases

¤ higher proliferaKon and reproducKon rates at higher temperatures

¤ extended transmission season

¤ changes in ecological balances

¤ climate-‐related migraKon of vectors, reservoir hosts, or human populaKons



¤ Vector-‐borne diseases

¤ Rodent-‐borne diseases

¤ Water-‐borne diseases

¤ Air-‐borne diseases

¤ Food-‐borne diseases

¤  = infecKons transmiged by the bite of infected arthropod species, such as mosquitoes, )cks, sandflies, and blackflies.

¤  Arthropod vectors are cold-‐blooded and thus especially sensiKve to climaKc factors.

¤ Weather influences: -‐ survival and reproducKon rates -‐ habitat suitability/distribuKon -‐ intensity and temporal pagern of vector acKvity (parKcularly biKng rates) throughout the year -‐ rates of development, survival and reproducKon of pathogens -‐ changes in human behaviour

Culex spp mosquito

¤ West Nile virus, a virus of the family Flaviviridae that is part of the Japanese encephaliKs anKgenic group.

¤ West Nile fever mainly infects birds and infrequently human beings through the bite of an infected Culex spp mosquito.

¤ In numerous European countries the virus has been isolated in mosquitoes, wild rodents, migraKng birds, hard Kcks, horses, and human beings.

¤ Roughly 80% of cases are asymptoma)c, the rate of West-‐Nile virus infecKons in human beings remains largely unknown

¤  France 2000 -‐ Aggressiveness of the vector (Culex modestus) was posiKvely correlated with temperature and humidity, and linked to rainfall and sunshine, which were parKcularly high during the epidemic period

¤ Romenia 1996 and Israel 2000 -‐ associated with a heat wave early in the summer with high minimum temperatures

¤ Clima)c model for West-‐Nile virus with mild winters, dry springs and summers, heat waves early in the season, and wet autumns.



¤ Italy: reported 5 new cases, from the Veneteo region (n=4) and Emilia Romagna (n=1). Cases are age 62 tot 82, admiged to the hospital with neurological symptoms.

¤ France: reports a 41-‐year-‐old paKent in Var (South-‐France). The last cases of WNF in France was in 2003 (same region, 7 humans, 4 horses).

¤ Hungary: 2 paKents from central Hungary. ¤ All three countries started control measures, WNF-‐surveillance, public informa)on campaigns and screening of blood donors.

Weekly public health rapport, 1 October 2009

¤  Dengue is the most important worldwide arboviral human disease

¤  Due to nearly universal use of piped water, the disease has disappeared from Europe.

¤  Dengue is frequently introduced into Europe by travellers returning from dengue-‐endemic countries, but no local transmission has been reported since it would also depend on the reintroduc)on of its principal vector, the mosquito Aedes aegyp*

¤  However, over the past 15 years another competent vector Aedes albopictus (Asian Kger mosquito) has been introduced into Europe and expanded into several countries, raising the possibility of dengue transmission

¤ Temperature is a factor in dengue transmission in urban areas!

¤ Climate change projecKons on the basis of humidity for 2085 suggests dengue transmission to shiG the la)tudinal and al)tudinal range.

¤ Climate change could further increase the length of the transmission season in endemic loca)ons

¤ Increase in mean temperature could result in seasonal dengue transmission in southern Europe if principal vector A. aegyp2 infected with the virus were to become established.

Aedes aegyp2-‐ en Aedes albopictus mosquito

¤  IncubaKon period 2-‐3 (–7) days ¤  Symptoms

²  fever up to 39°C ²  spot bleeding and rash (arms and legs) ²  painful joints ²  headache, photophobia, …

¤  Mostly self-‐limiKng, someKmes chronic joint pain



¤  Three genotypes: West-‐African, Central-‐East-‐ African, and Asian

¤  UnKl 2007 only in tropical countries

¤  Sporadic, mostly travel-‐related cases (Central-‐ East-‐African type) in Europe

¤  Augustus 2007, Ravenna Italy: first epidemic in Europe

¤ In 2009 hundreds of cases in Italy and France

¤ Vector surveillance in the vicinity of the cases idenKfied large numbers of Aedes albopictus mosquitoes in traps

¤ IntroducKons of A albopictus and Chikungunya virus into Italy were accidental events

¤ SKll, a clima)c model predicts establishment of A. albopictus in Europe with main variables such as mild winters, mean annual rainfall exceeding 50 cm, and mean summer temperatures exceeding 20°C.

¤ Caused by Plasmodium spp transmiged by female Anopheles spp mosquitoes.

¤ Historically malaria was endemic in Europe, including Scandinavia, but it was eventually eliminated in 1975 through a number of factors related to socio-‐economic development.

¤ Any role that climate played in malaria reduc)on would have been small. Nevertheless, the potenKal for malaria transmission is intricately connected to meteorological condiKons such as temperature and precipitaKon.

¤ Condi)ons for transmission in Europe have remained favourable as documented by sporadic autochthonous transmission of a tropical malaria strain by local vectors to a suscepKble person.

¤ The potenKal for malaria and other tropical diseases to invade southern Europe is commonly cited as an example of the territorial expansion of risk due to climate change

¤ Portugal projected an increase in the number of days per year suitable for malaria transmission; however, transmission would depend on infected vectors being present

¤ For the UK, an increase in risk of local malaria transmission based on changes in temperature projected to occur by 2050 was esKmated to be 8–14%, but malaria re-‐establishment is highly unlikely.

¤ Thus, while climaKc factors may favour autochthonous transmission, increased vector density, and accelerated parasite development, ...

¤ ... other factors (socio-‐economic, building codes, land use, treatment, capacity of health-‐care system, etc) limit the likelyhood of climate-‐related re-‐emergence of malaria in Europe



¤ Protozoan parasi)c infecKon caused by Leishmania infantum that is transmiged to human beings through the bite of an infected female sandfly.

¤ Temperature influences the biKng acKvity rates of the vector, and maturaKon of the protozoan parasite in the vector.

¤ Sandfly distribuKon in Europe is south of la)tude 45°N and less than 800 m above sea level, although it has recently shiGed to a laKtude of 49°N

45° 49°

¤  Historically, sandflies are from the Mediterranean, but more recently, have been reported in northern Germany.

¤  The bi)ng ac)vity of European sandflies is strongly seasonal, and in most areas is restricted to summer months.

¤ Once condiKons make transmission suitable in northern la)tudes, imported cases could act as sources of infecKons, permiong new endemic foci.

¤  Conversely, if climaKc condiKons become too hot and dry for vector survival, the disease may disappear in the South.



Ixodes ricinus

¤ Arbovirus infecKon, transmiged by Kcks (predominantly Ixodes ricinus) that act both as vectors and as reservoirs.

¤ Temperature accelerates the Kcks’ developmental cycle, egg producKon, populaKon density, and distribuKon.

¤ Climate change (increased temperature) already led to changes in the distribuKon of Ixodes ricinus populaKons in Europe, expending into higher al)tudes in the Czech Republic over the past two decades.

¤ In Sweden, since the late 1950s all cases of encephaliKs admiged in Stockholm County have been serologically tested for TBE.

¤ 1960–98 = increase in TBE incidence since the mid-‐1980s related to milder and shorter winters, resulKng in longer Kck-‐acKvity seasons.

¤ The distribuKon-‐limit shired to higher laKtude;

¤ DistribuKon has also shired in Norway and Germany.

Endemic in 27 European countries

¤ ClimaKc changes alone are unlikely to explain the surge in TBE incidence over the past three decades, ...

¤ Poten)al causal pathways include: ² changing land-‐use pagerns ² increased density of large hosts for Kcks (eg. deer) ² habitat expansion of rodent hosts ² alteraKons in recreaKonal and occupaKonal human acKvity (habitat encroachment)



¤ InfecKon with the bacterial spirochete Borrelia burgdorferi, which is transmiged to human beings during the blood feeding of hard )cks of the genus Ixodes.

¤ In Europe, the primary vector is I. ricinus, also known as the deer )ck, and Ixodes persulcatus from Estonia to far eastern Russia.

¤ Lyme borreliosis is the most common )ck-‐borne disease in Europe with at least 85 000 cases yearly

¤ Increasing incidence in several European countries such as Finland, Germany, The Netherlands, Russia, Scotland, Slovenia, Sweden ….

¤ A shir toward milder winter temperatures due to climate change may enable expansion of Lyme borreliosis into higher laKtudes and alKtudes, but only if all of the vertebrate host species required by Kck vectors are equally able to shiG their populaKon distribu)on.

¤ In contrast, droughts and severe floods will nega)vely affect the distribuKon, at least temporarily.

¤ Caused by an RNA virus of the Bunyaviridae family and transmiged by Hyalomma spp )cks from domesKc and wild animals.

¤ Most widespread Kck-‐borne arbovirus and is found in the eastern Mediterranean where there have been a series of outbreaks in Bulgaria in 2002 and 2003, and in Albania and Kosovo in 2001.

¤ Milder weather condiKons, favouring Kck reproducKon may influence CCHF distribuKon: ² outbreak in Turkey was linked to a milder spring season



¤ Rodents can act as both intermediate infected hosts and as hosts for arthropod vectors such as fleas and Kcks.

¤ Rodent populaKons are affected by weather condiKons. In parKcular, warm, wet winters and springs increase rodent popula)ons.

¤ Under climate change scenarios, rodent populaKons could be anKcipated to increase in temperate zones, resulKng in greater interacKon between human beings and rodents and a higher risk of disease transmission, especially in urban areas.

¤ In some European countries breakdown in sanita)on and inadequate hygiene are contribuKng to serious rat infestaKons.

¤ Plague is a zoonosis caused by the bacterium Yersinia pes*s that is spread by fleas feeding on black rats (Ragus ragus).

¤  Since the last major plague outbreak in 1720, plague is no longer circulaKng in Europe—neither in human beings nor in rodent populaKons.

¤ Milder weather condiKons are favourable to rodent popula)ons, while harsh weather condiKons such as heat waves might drive rodents indoors in search of water and thus increase contact with human beings.

¤ Central Asia: a 1°C increase in spring temperatures could result in a 50% increase in Y. pes*s prevalence in its reservoir host.

¤ Hantaviruses are rodent-‐borne viruses with four genotypes circulaKng in Europe, of which at least Puumala, Dobrava, and Saaremaa viruses are human pathogens.

¤ Human beings are at risk of exposure through the inhala)on of virus aerosols from the excreta of infected rodents.

Belgium – tree seeds



¤ Excess prolifera)on of rodent popula)ons related to climaKc changes is of considerable internaKonal public health concern.

¤ Hantavirus infecKon is sensiKve to clima)c condi)ons; rat populaKons in Belgium are linked to tree-‐seed producKon that in turn has been linked to high summer and autumn temperatures.

¤ It is anKcipated that general warming of the European climate will increase the risk of infecKon.

¤ altering mean meteorological measures but also by increasing the frequency of extreme events such as excessive precipitaKon, storm surges, floods, and droughts

¤ two major exposure pathways: drinking water and recrea)onal water use.

¤ Increased mean temperature of water bodies, which can be favourable for micro-‐organism reproducKon cycles and algal blooms.

¤ For example, Vibrio spp bacteria indigenous to the Bal)c and the North Sea, have displayed increased growth rates during unusually hot summers (eg, 2006) and infected open wounds that can necroKse and cause severe sepsis.

¤ Water-‐borne outbreaks have the potenKal to be rather large and of mixed aeKology, but the actual disease burden in Europe is difficult to approximate and most likely underesKmated.

¤ In 2006, only 17 water-‐borne outbreaks were reported by five countries.

¤ These outbreaks involved 3952 pa)ents, of whom 181 were hospitalised, afflicted by a number of causaKve agents including campylobacter, calicivirus, giardia, and cryptosporidium

¤ Extreme precipitaKon events can overwhelm water treatment plants and lead to cryptosporidium outbreaks due to oocysts infiltraKng drinking-‐water reservoirs from springs and lakes

¤ A study from England and Wales found that 20% of water-‐borne outbreaks in the past century were associated with a sustained period of low rainfall, compared with 10% associated with heavy rainfall.



¤  storms and floods can cause a lot of other trouble resulKng in …

Displacement of rodents !

Displacement of paKents à overcrowded waiKng room at “open” hospitals

¤ ClimaKc factors such as absolute humidity have been associated with the risk of lower respiratory tract infecKons.

¤ The epidemic acKvity of RSV infecKon is related to meteorological condiKons and thus to laKtude: persistently high temperature and humidity results in epidemic peaks in summer and early autumn, while in temperate climates RSV infec)on peaks in the winter.

¤ A causal link with temperature seems inconsistent based on these climaKc data, but the RSV infecKon season in England and Wales has ended earlier and its dura)on has shortened as the climate has become warmer.

¤ Increased use of cooling towers during heat waves might increase the risk for exposure to Legionella spp

¤  Increased use of whirlpools in The Netherlands ...



¤ Higher ambient temperatures increase replicaKon cycles of food-‐borne pathogens, and prolonged seasons may augment the opportunity for food handling mistakes

¤ In 32% of invesKgated food-‐borne outbreaks in Europe “temperature misuse” is considered a contribuKng factor.

¤ ... most commonly reported GI bacterial disease, and is caused by thermophilic Campylobacter spp bacteria.

¤ In 2007, the European Union incidence was 45·∙2 cases per 100 000 people (200507 confirmed cases) and broiler meat and fresh poultry meat were the biggest idenKfied sources of infecKons.

¤ Colonisa)on of broiler-‐chicken flocks with Campylobacter increases rapidly with rising temperatures. The risk of campylobacteriosis is posi)vely associated with mean weekly temperatures.

¤ The second largest number of human food-‐borne diseases is caused by Salmonella spp.

¤ In 2007, the European Union incidence was 31·∙1 cases per 100 000 populaKon (151995 confirmed cases) with eggs being the biggest contributors to these outbreaks followed by fresh poultry and pig meat.

¤ Higher ambient temperatures have been associated with 5–10% higher salmonellosis noKficaKons for each degree increase in weekly temperature, for ambient temperatures above 5°C.

¤ Roughly one-‐third of the transmission of salmonellosis (populaKon agributable fracKon) in England and Wales, Poland, the Netherlands, the Czech Republic, Switzerland, and Spain can be agributed to temperature influences.

¤ Despite a considerable body of research on the relaKon between climate and infecKous diseases, substan)al informa)on gaps remain, such as the impact of climate change on the geographical distribuKon of vectors, vector–host relaKonships, new or re-‐emerging pathogens, transmission of food-‐borne pathogens, or the vulnerability of drinking water supplies.

ECDC has recognised the need to develop an

infrastructure coined the European

Environment Epidemiology (E³) Network �

�

E³ �



Dutch North-‐Sea coast 2050?

Global warming: mistake of the Royal Dutch Meteorological Ins)tute

June 25-‐28, 2013 Geneva Switzerland

www.icpic2013.com



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