Table 2 – Drought and effects on nutrition 2a) General...

Table 2 – Drought and effects on nutrition 2a) General malnutrition and mortality Authors, year Drought exposure

(where, when) Study design/sample Main health outcome

(what, how measured) Main Results

Biellik and Henderson, 1981

Uganda, 1980 Cross sectional cluster survey: • nutritional status of 309

children; interviews in 150 households

Prevalence of child wasting Mortality rate (all ages)

4.8% of children wasted (0.8% severe) Increase in mortality compared to 1969 census, - 607/1000 infant mortality rate (vs. 139/1000) - 212/1000 all age mortality rate (vs. 23/1000)

O'Keefe, 1983 Zululand 1983 Survey of all adult patients admitted to medical wards of four mission hospitals.

Under-nutrition in adults: (Weight, height, % of ideal weight, triceps skinfold thickness, mid-arm circumference)

Main differences were in triceps skinfold (TSF): - 93% of male; 72% of female patients had TSF <60% of normal - Mean TSF significantly lower among rural patients than among urban (p<0.01)

Kustner et al., 1984 South Africa, 1982-3 Cross sectional survey in: • two drought-affected areas • two control areas Random sample of at least 200 children within each

Prevalence of underweight among children aged 1 to 5 years

No difference between drought-affected and control areas. (NB. Authors note inadequate sample size due to unexpectedly low, 2.9%, underweight prevalence

Carnell and Guyon, 1990

Mali 1983-5 Cross sectional survey, May 1985: • 8291 persons (including

1798 children aged <5 years) in 1019 households

Prevalence of wasting and severe wasting among children aged <5 years

28% of children wasted; 0.5% severely wasted: - prevalence greatest in ages 12 to 23 months - nomads significantly more affected than sedentary (43% vs. 20% wasted) - some ethnic groups more affected than others (38% vs 26% vs. 20% vs.19%)

CDC, 1985 Chad, 1985 Cross sectional surveys: • In 7 of the country’s 14

prefectures

Prevalence of wasting and severe wasting among children aged 1 to 5

Wasting ranged between 8% (in an established resettlement site) to 67% (in an unorganized camp with minimal food aid) Severe wasting range: 0% to 18%

CDC, 1986 Burkina Faso, 1984-5 Cross sectional survey in: • Two of 8 drought affected

provinces: 339 children from Soum province; 366 children GnaGna province

Prevalence of wasting and severe wasting in children Clinical signs of micronutrient deficiency

Wasting 10.6% in Soum; 5.7% in GnaGna (no kwashiorkor seen) Severe wasting: 1.8% in Soum; 1.1% in GnaGna Vitamin A and C deficiencies infrequently seen

Authors, year Drought exposure (where, when)

Study design/sample Main health outcome (what, how measured)

Main Results

CDC, 1988a Somalia 1986 Cross sectional survey in: • Four drought-affected

regions (Bakool, Bay, Gedo, Hiraan)

• 10 randomly selected villages in each

• 30 children per village

Prevalence of wasting and severe wasting in children Clinical signs of micronutrient deficiency

Wasting range: 11.5% (Bakool) to 23.5% (Bay) Severe wasting: 0.7% Hiraan, 6.6% Bay - Agro-pastoralists more severely affected Vit. C deficiency: 3.6% (Bay region) Vit A deficiency: 3.1% overall, max 7% Bakool

CDC, 2011 Southern Somalia, 2010

Cross sectional surveys, July 2011 in: 17 different livelihood zones.

Prevalence of global acute malnutrition (GAM) in children aged <5 years Verbally reported: crude mortality rate (CMR); Child mortality

GAM >20% in 15 zones GAM >30% in 11 zones (max 55%) CMR range 2.2 to 6.1deaths/10,000/day Child mortality: 4.1 to 20.3 deaths/10,000/day

CDC, 1991 Haiti 1990 Cross sectional survey: Multistage 30-cluster survey of 967 children aged 3 to 59 months

Prevalence of acute, chronic and mixed under-nutrition in children aged 3 to 59 months

Under-nutrition prevalence: 4.2% acute; 40.6% chronic; 34% mixed Height-for-age (chronic) and weight-for-age (mixed) population distributions shifted to left of reference median by 1.8 standard deviations

Patel 1994 Sudan 1990-1 Summary of 23 cross sectional surveys done during the drought

Prevalence of child wasting

Wasting prevalence >10% in 22/23 surveys; >20% in 7 surveys

Seaman et al., 1978 Ethiopia 1973-4, Harerghe province

Cross sectional survey of 62 randomly selected villages done in 1974 in 5 areas: North, South Ogaden (pastoral); Issa desert (pastoral); mixed economy area; agricultural highlands (unaffected by drought-related livestock loss)

Prevalence of child wasting Reported mortality

Wasting prevalence highest in North Ogaden (most drought-affected) and highland areas (23.4% and 17.5%); lowest in Issa desert (8.2%) Highest mortality in Issa and North Ogaden areas: 615 and 485 deaths/1000 infants; 304 and 278/1000 children aged 1-4 years.

Kidane, 1990 Ethiopia 1984-5 Tigray, Wello Provinces

Retrospective cohort, interviewing household heads from drought areas who have moved to a resettlement camp.

Reported mortality – crude death rate (CDR)

CDR 123/1000 (vs. 23/1000 in normal periods). - Household socioeconomic status pre-drought did not affect mortality - Higher age-specific mortality in larger households



Main Results

Lindtjorn, 1987 Ethiopia 1983-5 Tigray, Wello Provinces

25 cross sectional nutrition surveys from 4 drought-affected regions: Total 37,511 children from 212 communities: 16 surveyed in 1985; 101 in 1984; 95 in 1985

In children aged 1-5 years: Prevalence of kwashiorkor (nutritional oedema) Prevalence of moderate and severe child wasting

Kwashiorkor confined to limited areas only, highest in Sidamo region, 1984 (8.8%) Moderate wasting widespread but prevalence varies: peak 58.6% in Gamu Gofa region, 1984 Severe wasting also widespread: peak prevalence 17.2%, also in Gamu Gofa,1984

Lindtjorn, 1990 Ethiopia 1984-6 Southern areas: - Borana and Arero provinces

Prospective cohort, from 24 food distribution sites: • monthly average of 13,173

and 5334 children under 5 seen in 1985 and 1986 respectively

Mortality Prevalence of wasting (NB families of all children seen had monthly food rations and basic medical care as needed)

Relative risk of death 2.26 (95% CI 1.89 to 2.70) times higher in peak drought year, 1985 compared to 1986 - risk of death significantly higher (p<0.01) among children in sheltered accommodation, - association between wasting and mortality

Ezra and Kiros, 2000 Ethiopia, 1984-5 Tigray, Amhara states

Retrospective questionnaire survey done between Oct 1994-March 1995

Reported mortality over last 10 years Reported household demographics, socioeconomic status

Reported mortality higher in famine/drought years Deaths highest among those aged 1-4 and 5-9 years in famine years In multivariable analysis, significant associations with risk of death included: large household size; uneducated head of household; poorer household; migration;

CDC, 2001 Ethiopia, 1997-2000 Gode District

Cross sectional survey: two stage cluster survey of 595 households comprising 4032 persons

Reported mortality (Crude Mortality Rate, CMR) Reported cause of mortality

CMR 3.2/10,000/day, 95% CI 2.4 to 3.8; Child <5 mortality 6.8/10,000/day, 95% CI 5.3 to 8.0 Reported causes of child <5 death: measles 22%, malnutrition 23%, diarrhoea 37%

De Waal et al., 2006 Ethiopia, 2002-3 Cross sectional survey (2004 Ethiopia Child Survival Survey: • 4816 households including

those in drought affected/ unaffected communities

- Reported under-five (U5) mortality: - infant mortality - child mortality - Under-five nutritional status

Crude mortality rate, per 1000 live births, in drought affected (vs unaffected) rural areas: Infant = 109(86); child =55 (39); U5 =158 (121) On multivariable analysis: drought does not affect mortality (p=0.80). Factors which do (p<0.1) include: household demographics; socioeconomic status; neighbourhood characteristics; receipt of food aid.



Main Results

McDonald et al., 1994 Kenya 1984 Secondary data analysis from a study on mild malnutrition during time of drought: • 247 households, 110

children aged 18-30months and their mothers; 138 schoolchildren

Pre, during and after drought: - weight (kg) and weight-for-age z-score - 48 hour food intake assessed by report and direct observation

During the drought-related food shortage: Weight gain: - caregivers lost 0.5kg on average - rate of gain in schoolchildren decreased - rate of gain in toddlers continued to increase Food intake (kcal/day intake) - declined in carers and schoolchildren - in toddlers, did not change

Mason et al., 2005 Southern Africa, 2001/2

Secondary analysis of child nutrition surveys from Lesotho, Malawi, Mozambique, Swaziland, Zambia, Zimbabwe

Prevalence of underweight, comparing pre-drought to post-drought figures

Child underweight deteriorated everywhere except Lesotho. Substantial worsening in some areas e.g. 5 to 20% in Maputo Mozambique; - Greater deterioration in better-off areas and areas with higher HIV/AIDS prevalence

Renzaho, 2006 Lesotho, 2002-3 Cross sectional two stage cluster survey of 3610 people in three districts. Conducted in 2005 with 2000 as pre-drought baseline

Prevalence of childhood wasting, stunting, underweight Crude mortality rate (CMR) Under-5 mortality rate (u5MR)

From 2000 to 2005, prevalence of - Wasting increased from 5.4% to 12%; Underweight increased from 17.9% to 19.2%; Stunting declined from 45.4% to 36.2%. But nutritional status did not vary by food aid status CMR 0.8/10,000/day: significantly lower among food aid beneficiaries than non-beneficiaries U5MR 3.2/10,000/day (also significantly lower among food aid beneficiaries)

Renzaho, 2007 Mozambique, 2003-4 Cross sectional two stage cluster survey of 838 households, conducted in 2004

Prevalence of childhood wasting, stunting, underweight Crude mortality rate (CMR) Lost pregnancies

Wasting prevalence=8% (95% CI 6.2 to 9.8) Stunting = 37% (95% CI 33.8 to 40.2) Underweight = 26.9% (95% CI 24.0 to 29.9) Boys more likely underweight: OR 1.34, p<0.05 CMR 1.23/10,000/day (95% CI 1.08 to 1.38) U5MR 1.03/10,000day (95% CI 0.71 to 1.35) 7.7% (95% CI 4.5 to 11.0%) of pregnancies lost

Chotard et al., 2010 Horn of Africa (Kenya, Somalia, Sudan, Uganda, Eritrea, Ethiopia), 2000 and 2005-2006

Secondary analysis of 897 cross-sectional surveys (two-stage 30x30 cluster design) done in 2000 to 2006 in different areas

Prevalence of child <5 ( year ) wasting

- Years of drought associated with an increase of up to 8 percentage points in child wasting - Wasting fluctuations greatest among pastoralists (17% to 25% rise and higher);



Main Results

Mason et al., 2010b Horn of Africa (Ethiopia, Kenya, Uganda) and Southern Africa (Lesotho, Malawi, Mozambique, Swaziland, Zambia, Zimbabwe) 2001-3

Secondary data analysis of 45 national nutrition surveys conducted in the affected countries from 1992-2006

Prevalence of underweight in preschool children

Improvements in underweight trends slowed but not stopped by intermittent drought Impact of drought varies in different settings and interacts with HIV: - Drought AND HIV results in highest prevalence of underweight (mean 26.2%) - Drought significantly increases underweight in high-HIV but not in low-HIV SA countries - Drought has greater impact in Horn countries, increasing underweight in both high-HIV and low-HIV areas

Mason et al., 2010a Horn of Africa (Ethiopia, Kenya, Somalia, Sudan, Uganda), Severe drought in 2000; some effects continuing to 2003

Secondary analysis of 897 cross-sectional surveys (two-stage 30x30 cluster design) conducted from 2000 to 2006, in different populations and areas within the Horn.

Prevalence of wasting and oedematous malnutrition in children aged <5 (together = GAM, global acute malnutrition)

Spikes of GAM and child under-5 mortality rates corresponded with drought (and floods) in all areas. Baseline levels of GAM and mortality differ, as does the exact timing and magnitude of association with drought

Assefa et al., 2001 Afghanistan, Kohistan District, 1998-2001

Cross sectional survey conducted in 2001: • cluster design • 378 households comprising

3165 people (including over 700 children)

Prevalence of stunting and wasting in children aged 6 to 59 months. Reported mortality: - Crude Mortality Rate (CMR) - Under 5 child mortality rate (u5MR)

63.7% stunting (95% CI 58.6-68.8%) - of which 34.6% severe(95% CI 29.5-39.7%) 7.0% wasting (95% CI 5.9-9.0%) - of which 1.1% severe (95% CI 0.2-1.5%) CMR = 2.6/10,000/day (95% CI 1.7-3.5) U5MR = 5.9/10,000/day (95% CI 2.0-8.8) Main causes of death = diarrhoea 25%; respiratory tract infection 19.4%; measles 15.7%

Kumar and Bhawani, 2005

India, Rajasthan, 20002

Cross sectional survey: 40 villages, 3206 children

Prevalence of underweight, wasting in children aged <5

63% underweight (28% severe) 27% wasted (5% severe)



Main Results

Singh et al., 2006a India, Western Rajasthan, 2003

Cross sectional survey conducted in 2003 • cluster design • 914 pre-school children

- Prevalence of underweight; stunting; wasting - Clinical signs of nutrient deficit

60% underweight (31% severe) - significantly higher in girls vs. boys (p<0.05) 53% stunted (34% severe) - age group 1-2 years most affected 28% wasted (10% severe) - age group 1-2 years most affected Clinical: anaemia=30%; vitamin A deficiency=0.2% (bitot’s spots); vitamin B complex deficiency=1.6% (glossitis); vitamin C deficiency=0.1% (bleeding gums)

Singh et al., 2006b India, Western Rajasthan, 2003

Cross sectional survey: • 24 villages • 914 pre-school children

Prevalence of underweight, stunting

Significant (p<0.05) boy (girl) differences in: Underweight: Severe=17% (20.6%); mild/mod=19.1%(20.2%) Stunting: 20.4% (boys), 31.2% (girls)

Singh et al., 2008 India, Western Rajasthan, 2003

Cross sectional survey: • 24 villages • 2540 adults aged 15 to 45

years

- Prevalence of chronic energy deficiency (CED) = body mass index (BMI) <18.5.

42.7% CED (WHO suggests a ‘critical’ level if above 40%) Severe deficiency (BMI <16) significantly higher in males (12.7%) than females (8.7%)

Arlappa et al., 2009a India, Western Rajasthan, 2003

Cross sectional survey: • 212 older individuals aged

60 years or more , from 200 households in 20 villages in desert areas

Prevalence of CED ≥40% CED in desert areas overall Higher among: - women (52%) than men (42.4%); scheduled caste/tribe; labourers, artisans; landless people; marginal farmers; families below the poverty line Lower among: Desert-dwellers vs. rural/tribal counterparts

Arlappa et al., 2009b India, Western Rajasthan, 2003

Cross sectional survey • 3147 older individuals aged

60 years on more, from 2628 households in 190 villages

Prevalence of chronic energy deficiency (BMI <18.5)

Prevalence of chronic energy deficiency: - 51.1% among older men; 48.5% among older women - Significantly (p<0.001) higher among those older than 70 years compared to aged 60-69years - Higher in low socioeconomic communities (p<0.01) - Higher among old age pension beneficiaries(p<0.05) - No difference in drought/non-drought periods (p>0.05)



Main Results

Swaminathan et al., 1967

India, Andhra Pradesh, 1965-66

Cross sectional interview study: • Household survey of 168

households in 3 districts. Subareas within each district classified by degree of drought: mild; moderate; severe

• nutritional survey of 150-300 people in each village

Reported mortality Nutritional status assessed by: - clinical examination for specific signs of micronutrient deficiency - anthropometry (not described in detail) Note that no pre-drought baseline comparator data available. Also note that food distribution taking place in some affected areas (not adjusted for in analysis)

No reports of death due to starvation and no reports of epidemics of infectious disease Prevalence of: - Child marasmus = 6%; kwashiorkor = 2% (no differences according to drought severity) - Eye signs of vitamin A deficiency in children= 5 to 7% (no differences according to drought severity) - Clinical Vitamin B deficiency = 6 to 18%, (depending on degree of drought and ages - higher in children) - Anaemia = 15 to 24% (depending on age and degree of drought) - Average height, weight, arm circumference, skinfold thickness (no difference according to drought severity)

Mahapatra et al., 2000

India, Orissa, 1996-7 Cross sectional survey of 15 randomly selected rural areas: • 751 children aged 0-5 years

total surveyed

- Prevalence of: - underweight - stunting - wasting Clinical signs of nutritional deficit

57.1% of children underweight (21.3% severe) 41.8% of children stunted (17.4% severe) 27.7% of children wasted (6.7% severe) Clinical vitamin B complex deficit=5.8%; vitamin A deficit=1.3% (Bitot’s spots)

Katona-Apte and Mokdad, 1998

Democratic People’s Republic of North Korea, 1997 (note multiple other natural disasters also contributed – floods 1995,6, tidal wave 1997)

Cross sectional survey of 3984 children aged <7 years from40 government-selected kindergartens and nurseries

- Prevalence of: - stunting - wasting

38.2% of children stunted (range 0.6% to 74.1% in different institutions) - 16.8% severely stunted 16.5% of children wasted (range 0% to 32.7% in different institutions) - 2.5% severely wasted



Main Results

Soekirman, 2001 Indonesia, 1997-8 Author reports: • National survey data from

the “National Social and Economic Survey”

• Studies on hospital admissions for malnutrition

• Studies on micronutrient prevalence

- Prevalence of underweight among children aged <5 years from 1989 to 1998 - Rates of severe malnutrition among paediatric hospital admissions: - Dr Soetemo Hospital, East Java 1996-8; - Nutrition clinic, West Java 1997-8

Overall prevalence of child underweight declining from 36%% in 1989 to 31% in 1998 (decline more marked in rural areas) - sub-analysis of data for 6-17 month olds also shows overall decline since 1989, but approx.2 percentage point increase in underweight from 1995 to 1998 Malnutrition admissions increased in 1998 in both hospitals compared to previous years

Block et al., 2004 Indonesia 1997-8 Time-age cohort decomposition analysis of 14 rounds of multi-stage cluster surveys, each of 7200 households. Dec 1995 to Jan 2001

Trends in: - Child underweight - maternal body mass index (BMI) - maternal haemoglobin - child micronutrient status

- No significant decline in child underweight - Maternal BMI decreased from 21.4 to 21.1 (p<0.01) - Maternal anaemia prevalence increased from 9 to 12% - Increased child anaemia from 52 to 68%

2b) Micronutrient Malnutrition



Main Results

Desai et al., 1992 India, Rajasthan, 1987

Descriptive report of cases seen at 71 rural eye camps over a 7 year period, 1984 to 1990 - total 11,370 children seen

- Clinically determined prevalence of vitamin A deficiency (night-blindness, clinical examination for specific eye signs)

Overall prevalence 18.9% over the 7 year period: - 11-14% in most years - post-drought peak of 34.3% in 1987 and 20% in 1988

Arlappa et al., 2011 India, 2003 Cross sectional survey of 6

drought affected areas, done in 2003: Total of 3657 pre-school children from 7261 households

- Clinically determined prevalence of vitamin A deficiency (night-blindness, clinical examination for specific eye signs)

Prevalence of Bitot’s spots in drought affected areas = 1.8%. (twice that in non-drought areas). Being affected by drought doubled the odds of Vit A deficiency: OR 2.0 (95% CI 1.6-2.7). Other significant risk factors included female illiteracy; age 3-5 years; larger family size

Wolde-Gebriel et al., 1993

Ethiopia, 1982 Cross sectional survey: 240 children examined, blood collected from 76 children

- Clinical eye signs of Vitamin A deficiency - Blood concentration of retinol (vitamin A), iron, iodine - Prevalence of wasting and stunting

53.2% of boys and 43.1% of girls had night blindness or at least one recognised sign of Vit A deficiency: - 58% of children had low serum retinol; 30.2% had deficiency levels - 15.3% of children had iron-deficient erythropoiesis - Iodine-related levels all normal 33.5% of children wasted; 9.9% stunted; 7.7% both

Gitau et al., 2005 Zambia (and wider Southern Africa, 2001-2)

Longitudinal cohort study originally designed to look at factors associated with subclinical mastitis. Background drought enabled analysis of data collected before, during, after drought

- Plasma micronutrient levels - Maternal weight - Maternal heamoglobin - Infant length

Drought-related maize price increases were associated with: - Decreased vitamin A levels during pregnancy(p=0.028) - Decreased vitamin E levels postpartum (p=0.042) - No significant effects on maternal weight - No significant effect on maternal haemoglobin - marginal effect on infant weight

Cheung, 2003 Western Afghanistan, drought of previous four years

Interviews with key informants, focus groups

Clinical scurvy (painful legs/joints, bleeding gums, or bruising on legs.

Over three month period: 6.3% of population diagnosed with scurvy (4,588 cases); 323 deaths

2c) Anti-nutrient consumption Authors, year Drought exposure

(where, when) Study design/sample Main health outcome


Mohabbat et al., 1976 Afghanistan, 1970-2 Cross sectional study of 7200 inhabitant in affected villages

Veno-occlusive liver disease (form of toxic liver injury produced by pyrrolizidine group of alkaloids)

22.6% of surveyed population had liver disease - liver damaged advanced in 15% Heliotropium, (wild plant growing among wheat) identified as cause: wheat not cleaned before grinding so that seeds were powdered and mixed into flour

Krishnamachari et al., 1977

India, 1974 Survey of affected areas and affected individuals

- Afalotoxicosis (acute onset, symptoms of portal hypertension including jaundice) - Afalotoxin levels in food samples

Disease associate with unseasonal rains prior to harvest and chronic drought conditions: - 400 people affected by afalotoxicosis (22% mortality) - 100% of 1974 grain samples showed presence of A.flavus. Post- drought in 1975, 36% samples affected

Yang et al., 1983 China, 1961, Hebei Province

In an area with high prevalence of selenium toxicity (average incidence in 5 heavy prevalence villages=49.2%), a descriptive study reporting lab analysis of samples from affected individuals (blood, hair, urine) and environment (water, soil)

Selenium toxicity: - Description of the clinical features (including loss of hair and nails; skin lesions; tooth decay; nervous system abnormalities) - Selenium status of residents in affected areas

- Average hair selenium content of residents in affected areas 8x higher than in high-selenium area without clinical disease; - Environmental source identified as coal: selenium entering soil by weathering and available for uptake by crops due to traditional use of lime as fertilizer. Toxicity due to higher intake of selenium rich vegetables and maize in drought years due to rice failure.

Getahun et al., 1999 Ethiopia, 1995-6, Wello area

Interview survey of 228 randomly selected patients from a drought affected area which had an outbreak of 2000 cases of neurolathyrism in 1997-8

Neurolathyrism (an irreversible neurodegenerative spastic paraparesis that can be crippling and lead to complete dependency)

- High proportion of severe disease (18%) compared to previous outbreaks (4.3%) - Significant association between neurolathyrism and reported consumption of drought-resistant) grasspea (both as an unripe green seed and as a roasted ripe seed)

Mlingi et al., 2011 Tanzania: 1985, 1989, 2001-2, 2002-3

Review of published reports and survey of adult and child cases, in collaboration with Konzo treatment programme 2008-9

Clinical Konzo (nervous system disease: sudden onset symmetrical, and permanent spastic paralysis. Caused by dietary intake of large amount of cyanogens from poorly processed cassava)

Four outbreaks related to intake of bitter cassava among poor rural people during drought: 1985: 39 cases (Mara region); 116 cases, 2 deaths in 1989 2001-2002: 24 cases (Ruvuma region) 2002-03: 214 cases (Mtwara region)



Main Results

Cliff et al., 1985 Mozambique, 1981 - northern Nampula province

Two surveys of schoolchildren: a) 1982 • 30 apparently healthy

schoolchildren from Konzo-affected area

• 17 Swedish control children b) 1983: • 31 schoolchildren in ex-

Konzo affected area • control schoolchildren from

cassava eating but non-Konzo area

• control schoolchildren from the city (non-cassava eating)

- Urinary thiocyanate in schoolchildren (mean) – a marker of eating toxic cassava - Urinary sulphur (mean) – a marker of intake of quality foods rich in sulphur amino-acids e.g. beans and fish

a) 1982 survey round: (time of food shortage, people eating suboptimally prepared cassava) - Thiocyanate in healthy children from Konzo-affected areas significantly higher than in Swedish controls - Total sulphur significantly lower than in Konzo-affected areas than in Swedish controls b) 1983 survey round(after both drought and Konzo epidemic over): - Thiocyanate in healthy children from Konzo affected areas decreased from 1982 but still significantly higher than in cassava-eating non-Konzo control areas. Lowest in control areas - Total sulphur lowest in Konzo-affected areas; higher in non-Konzo cassava eating areas and intermediate in control areas

Cliff et al., 2011 Mozambique: 1984-2005 (different episodes of drought during that time)

Review of published literature and unpublished data gathered by authors Adults and children in each area

Clinical Konzo (see above) Measured levels of urinary or serum thiocyanate

Epidemics mostly occurred during agricultural crises: 1984: 1,100 cases (northern Nampula Province) 1992-93: 600 cases (further south in Nampula Province) 2005: 13 cases (Nampula Province) 2000: 10 cases (Zambézia Province) 2005: 100 cases (Zambézia Province)

Cliff, 1994 Mozambique: 1981-1993 (several different drought events)

Review of published literature, including summary of previous studies done by same authors.

Clinical Konzo (see above) in adults and children Measured levels of urinary or serum thiocyanate

1981: 1,102 cases (=34/1000 inhabitants, NE Nampula) 1982-83: 35 cases (south-west Nampula) 1988: 171 cases (north-east Nampula, Erati districts) 1992-93: 600+ cases (south-east Nampula) High thiocyanate levels in affected areas, coinciding with period of cassava harvest

Table 3 Drought and water-related disease Authors, year Drought

exposure (where, when)

Study design/sample Health outcome (what, how measured)

Main Results

Thacker et al., 1980 Haiti, 1976-7 Cross sectional study looking at 4000 households in 2 areas of Haiti which experienced: • Severe water restriction • Some water restriction

Reported diarrhoea Reported scabies, external otitis, conjunctivitis

No significant differences between the two areas. In both areas, morbidity related to: unemployed head of household; household socioeconomic status; large family size; quantity of water (<19 litres/person/day) In families using <19litres/person/day: - More diarrhoea (28.7% vs 25.5%) - More scabies ( 8.4% vs 5%) - More conjunctivitis (8.0% vs 7.2%) - More febrile illness (32.5% vs 27.4%)

Burr et al., 1978 South Wales, 1976 Cohort study: weekly absences returns from infant and nursery schools in: • Area with unrestricted water

(78 schools) • Area with 12hr/day water

cuts (70 schools) • Area with 17hr/day water

cuts (143 schools)

School absence Reported diarrhoea and vomiting

During the first week: - area with l7hr cuts had higher % of affected children than the area with 12-hr cuts (P<0.0001), which in turn had a higher % than the unrestricted area (P<0.001), - 20 schools in restricted areas had 15% or more of their pupils affected compared with only two in the unrestricted area. In eight schools (all restricted) 20% or more of the children affected.

Tauxe et al., 1988 Mali, 1982-4 Case-control study in 4 villages with recent reports of cholera-like illness

Cholera (including microbiological confirmation) Detailed questionnaire to determine routes of transmission

In the affected villages, mean clinical attack rate 1.5 and 29% of affected persons died 2 transmission routes identified: drinking water from one well in a village outside of drought-area; eating left-over millet gruel in a drought-affected village



Main Results

Bradley et al., 1996 Zimbabwe, 1992 Clinical surveillance data from two cholera affected areas: • Refugee camp • Commercial farming area

Cholera (defined according to WHO criteria)

Outbreak of cholera in refugee camps and local rural populations. Different epidemic patterns: - ‘ fast’ epidemic in refugee camp, with initial doubling time 1.2days, peak at 10-14 days. - ‘Slow’ epidemic’ in stable setting, initial doubling 4.3days, peak at 50days. - differential access to protected water supply partially responsible for these differences

Effler et al., 2001 Swaziland, 1992 Surveillance data from: • Clinic in affected area • National Diarrhoeal disease

surveillance system

Clinical and lab reports of E.coli O157

40,912 physician visits for diarrhoea Oct-Nov 92 (sevenfold increase from ‘91) E.coli O157 attack rate 42%. Consuming beef and untreated water were significant risk factors for illness

Jackson et al., 1993 Illinois, USA 1991 Cohort study – focused on outbreak of leptospirosis

Leptospirosis (serovar grippotyphosa) - environmental and source sampling for the organism

High prevalence of L.grippotyphosa isolated from a local swimming hole and nearby animals. Authors note that preceding drought conditions had “created an environment which probably facilitated the transmission of the organsm from area animals to humans”

Pouria et al., 1998 Brazil, 1996 Case reports N= 126 patients in a haemodialysis unit

Microcystin intoxication Clinical examination and microcystin serum levels

All 126 haemodialysis patients who underwent dialysis developed symptoms including severe neurological symptoms and hepatomegaly. Raised concentrations of hepatic enzymes, alkaline phosphatise and bilirubin were recorded. 85% had evidence of liver injury, 60 patients died (not all deaths directly attributable to microcystin toxicity).

Table 4 Drought and airborne/dust related disease Authors, year Drought

exposure (where, when)


Main Results

Gomez et al., 1992 Canada, Old Wives Lake, South Saskatchewan, 1987-9

Cross sectional design comparing 323 individuals exposed to dust from the drought-affected lake with 329 matched controls

Self-administered respiratory health questionnaire Lung function testing

In the dust-affected group, significantly greater (p<0.05, smoking-adjusted): current cough; current and chronic wheeze; chronic nasal irritation, eye irritation. No difference in lung function between groups

Pavelchak et al., 1999 USA, New York State, 1995

Case report Silo gas exposure (oxides of nitrogen and carbon dioxide)

Paper describes four incidents of silo gas exposure involving six farm workers: - All received medical attention; four were admitted to hospitalCo

Pappagianis, 1994 USA, California, 1977 California, 1986-91

Observational data from routine health surveillance systems

Clinical Coccidioidomycosis (Valley Fever): (ranges from no symptoms, to mild flu-like symptoms; to severe infection including rash, chronic pneumonia, meningitis and bone/joint infection

1977 (following dust storm) – 1,095 cases; 1980-1990 – approx. 400-600 cases/year; 1991 – 1,200 cases; 1992 – 4,541 cases Rise in cases followed preceding drought then heavy rains in 1991 and 1992 Some counties much more affected than others – possibly due to soil disruption by building work

CDC, 2003 USA, Arizona, 1997

Cohort data from National Electronic Telecommunication System for Surveillance (NETSS) and Arizona Hospital Discharge Database (AHDD)

Clinical Coccidioidomycosis (Valley Fever)

During 2001, increase of 43/100,000 cases - an increase of 186% since 1995 Drought severity indices associated (p<0.01) with increased disease incidence

Table 5 Drought and vector-borne disease Authors, year Drought exposure

(where, when) Study design/sample Health outcome


Reisen et al., 2009 Kern County, California, USA, 2004-2007

Health department report Kern county population: 801,648 (from 2003 census) Bakersfield population (within Kern county): 481,000

Incidence of West Nile Virus Reported and laboratory-confirmed by Kern County Health Department

313 cases, of which 80% reported from Bakersfield Kern county: 6.4-17.2 per 100,000 annual incidence Bakersfield: 8.9-23.5 per 100,000 annual incidence

Chretien et al., 2007

Coastal Kenya, 2004-2006

Case reports Lamu and Mombasa, n not specified

Prevalence of Chikungunya virus In Lamu: diagnosed by PCR (Polymerase Chain Reaction) or IgM capture enzyme-linked immunosorbent assay (ELISA). In Mombasa: not specified

Lamu: 56 of 88 patients (63%) presenting with symptoms consistent with chikungunya fever tested positive Mombasa: not specified

Trape et al., 1996a; Trape et al., 1996b

Senegal, ongoing drought since 1970

Prevalence study: Cluster design, Keur Moussa, n= 1,340 children; Mlomp, n= 927 patients (adults and children) Incidence study: Cohort study, Dielmo, n= 235 people (adults and children) followed over two years (1990-1992)

Prevalence and incidence of tick-borne borreliosis Thick blood films taken to test for presence of Borrelia crocidurae

Prevalence study: Keur Moussa, 12 cases diagnosed (0.09% prevalence); Mlomp, 0 cases diagnosed. Incidence study: 24 cases diagnosed (5.1% annual incidence), appearing sporadically throughout the study

Vial et al., 2006

Senegal, ongoing drought since 1970

Longitudinal study: Dielmo village, adults and children followed from 1990-2003. 1,286,045 person days of surveillance

Incidence of tick-borne relapsing fever (TBRF) Thick blood films taken to test for presence of Borrelia crocidurae

395 distinct TBRF infections in 235 different people. Average incidence over 14 years was 11 per 100 person-years.



Main Results

Bangs and Subianto, 1999

Irian Jaya, Indonesia, 1997-98

Case reports Jayawijaya, Irian Jaya province population: ~95,000

Malaria-related mortality Blood slides

554 deaths recorded in three months coinciding with severe drought

Mutuku et al., 2011

Coastal Kenya, drought from 2001-2009

Prevalence study Milalani village, two study periods: 2000 and 2009 2000: n= 1,053 2009: n= 777

Prevalence of Schistosoma haematobium, tested by urine samples

2000: 587 (55.7%) positive 2009: 336 (43.2%) positive

Mouchet et al., 1996 Sahel: 1972, 1983, 1991-1992

Case reports Senegal: the Niayes Niger Republic: Niger Valley, Zinder, Diffa

Prevalence and incidence of malaria Niayes: malaria parasite prevalence fell by 84%, incidence fell by 82% in 1991-1992. Niger river: prevalence of 69% in 1969, fell to 23% in 1994 Zinder: prevalence of 89% in 1922, fell to 32% in 1994 Lake Chad: prevalence of 40% in 1967, fell to 7% in 1996.

Table 6 Drought and mental health Authors, year Drought exposure



Carnie et al., 2011 Rural New South Wales, Australia; prolonged drought since 2000

Consultative forums (similar to focus group discussions) 6 forums total: n= 45 in one forum; n= 51 in another forum; n from other forums not reported; included children, young people, adults

‘mental health-related problems’ Mental health impacts on children as reported by adults: worry about family; social isolation; at risk of harm or abuse; unrecognised distress; barriers to accessing services. As identified by children: harm to health and well-being; worry about family, money, their communities and their futures; isolation

Rigby et al., 2011 Rural New South Wales, Australia; prolonged drought over past decade

Consultative forums (similar to focus group discussion) 6 forums total: total n= 166, including Aboriginal adults, service providers and other stakeholders

‘social and emotional well-being’ of Aboriginal people

Three themes identified: impacts on culture; socio-demographic and economic impacts (including loss of livelihood and decrease in ability to buy food); loss and grief (including feelings of despair, helplessness, hopelessness and despondency).

Stain et al., 2008 Rural New South Wales, Australia; prolonged drought over past decade

Postal survey n= 449 adults aged 18+ (FW= farmers or farm workers; FR= farm residents; NF= non-farm persons) from rural and remote communities

Psychological distress (using Kessler-10 scale)

FW: 71.8% report high drought-related stress FR: 67.6% report high drought-related stress NF: 45.8% report high drought-related stress FW more likely than FR or NF to use harmful levels of alcohol (P<0.001).

Sartore et al., 2008a Rural New South Wales, Australia; prolonged drought since 2002

Semi-structured focus groups and subsequent individual interviews N= 30 adults from rural farming communities

‘emotional consequences of drought’ Emotional consequences identified: avoidance, concerns for others (including ability to provide financial support), impacts on hope and community morale. Symptoms identified include disturbed sleep, irritability, worry, negativity. Distress as ‘community-wide problem.’



Main Results

Staniford et al., 2009 Riverland region, South Australia; year??

In-depth interviews N=16 adult citrus growers

Psychological distress Impacts on well-being identified: depressive symptoms, neurotic symptoms, affective symptoms, physical symptoms

Polain et al., 2011 Rural New South Wales, Australia; prolonged drought

Consultative forums (similar to focus group discussions) 5 forums total: total n= 152, adult farmers, their families and related stakeholders.

‘mental health of older farmers’ Issues raised include: feeling marginalised, loss of self esteem, pervasive sense of failure, various experiences of loss, reluctance to seek help or disclose mental health problems

Alston et al., 2004 Rural New South Wales, Australia, 2002-2003

In-depth interviews and focus groups; 3 sites selected. Interviews with farm families: n= 21 site 1; n= 22 site 2; n= 20 site 3. Interviews with key informants: n= 21 site 1; n= 11 site 2; n= 16 site 3. Focus groups: n= 3 site 1.

‘social impacts of drought’ Site 1: stress (includes crying, being tired, stress of children seeing parents suffer, social isolation, financial worry). Site 2: emotional stress (includes loss of income, increasing anxiety, weariness, depression, consuming more alcohol, neglecting health care, somatic complaints, social isolation). Site 3: stress (includes crying, panic attacks in children, trouble paying school fees, social isolation). Other health impacts include depressive and stress-related illnesses.

Stain et al., 2011 Rural New South Wales, Australia; 2008

Postal surveys N= 302 adults in rural New South Wales with high drought exposure in previous 12 months. Note: this is a subset of larger sample (n= 2639) of varying drought exposure.

Drought-related worry (using Worry about Drought Scale); psychological distress or symptoms (using Kessler-10 scale)

23.9% of total sample (n= 2639) report high drought worry; 31.0% of total sample (n= 2639) scored above threshold clinical significance on K-10 for psychological distress. For high drought exposure group, 9.8% report both high drought worry and high K10 scores.



Main Results

Hossain et al., 2008 Rural and remote Queensland, Australia

Focus groups N= 3 (total participants: 23), adult rural landholders, rural organisations/agencies, health professionals

‘incidence and significance of mental health issues’

All FGs raised themes of anxiety, depression, suicide or suicidal thoughts; increased alcohol consumption; increase in hopelessness; social stigma as obstacle to seeking help; increase in depression and anxiety in children and adolescents.

Stehlik et al., 1999 Central Queensland and New South Wales, Australia, 1995-1996

In-depth interviews N= 103 adults on 56 farms in 2 sites: site 1 n= 49, site 2 n= 54

‘Perceived personal stress’ 34% report perceived personal stress “fairly often” or “very often.” 36% report impact of drought on their health (details not provided).

Dean and Stain, 2010 Rural New South Wales, Australia, prolonged drought

Self-report questionnaires and focus groups. N= 111 adolescents aged 11-17 (for questionnaire); of these n= 61 participated in focus groups.

‘Impact of drought on mental health’ data obtained through focus groups. Quantitative data collected in self-report questionnaires using Drought and Community Survey for Children (DACS-C) and Strengths and Difficulties Questionnaire (SDQ)

SDQ: scores were significantly higher for adolescents on Total Difficulties than the normative population (P< 0.01); significant effects were observed for gender and age. DACS-C: in relation to drought effects, results not clear. Focus groups: identified theme of ‘mental health impacts of drought’; topics raised include stress of making difficult decisions, depression, grief, loss.

Kelly et al., 2011 Rural New South Wales, Australia, prolonged drought

Cross sectional analysis of baseline sample of Australian Rural Mental Health Study (ARMHS) N= 2,639 adults from non-metropolitan areas of NSW

‘Psychological distress and well-being’ (using Kessler-10 scale). Individual, individual contextual factors, district/ neighbourhood contextual factors measured with a variety of instruments.

Univariate associations detected between well being and exposure to rural adversity (including greater drought-related worry) Multivariate analysis revealed no effects for district-level variables (including drought severity).



Main Results

Coêlho et al., 2004 North-eastern Brazil, 1995.

Face-to-face oral questionnaires 2 sites: n= 102 in drought-affected community, n= 102 in drought-free control community

Anxiety, emotional distress, PTSD Anxiety measured using State-Trait Anxiety Inventory. Emotional distress measured using Self-Reporting Questionnaire (SRQ-20). PTSD measured using Trauma Sequelae Questionnaire.

Participants in drought communities: significantly higher levels of state anxiety than drought-free participants(P<0.05) Participants in drought communities: significantly higher levels of trait anxiety than drought-free participants (P<0.01) Participants in drought communities scored significantly higher in emotional distress than drought-free participants (P<0.01) PTSD occurrences were infrequent, with no differences between the study sites.

Edwards et al., 2008 Areas of Australia with at least 10% of population employed in agriculture or related service industry, 2007.

Computer-assisted telephone interviews N= 8,000 adults stratified into four groups according to whether they were currently in drought and the severity of the drought

‘Mental health’ using Mental Health Inventory from the Medical Outcomes Study Short Form (SF-36)

People currently in areas of drought: twice the rate of mental health problems than people in areas not in drought over the past three years (12% vs. 7%), based on the social definition of drought. Farmers currently in drought: twice the rate of mental health problems than farmers not currently in drought. Farm workers currently in drought: higher rates of mental health problems than farm workers who had not experienced drought over the past three years. No impact of drought on mental health of people employed but not in agriculture.

Dean and Stain, 2007 Rural and remote New South Wales, Australia, 2002-2006

Self-report questionnaires and semi-structured interviews within focus groups N= 334 children and adolescents aged 11-17 (for questionnaire); of these n= 84 participated in focus groups

‘Emotional health’ data obtained through focus groups Quantitative data collected in self-report questionnaires using items from the Emotional Symptom Scale of the Strength and Difficulties Self-Report Questionnaire (SDQ) and Survey on the Impact of Drought on Children and Young People

Focus groups: themes identified: emotional impacts on family life, overwhelming impacts of loss, no control, loss of friends. SDQ: Emotional Symptoms Scale scores not significantly different for sample of children than Australian norms for same age cohort.



Main Results

Guiney, 2012 Victoria, Australia, 2001-2007

Coroner reports from intentional self-harm fatalities of farmers and ‘primary producers’ (those who earn a living through agricultural activities) between 2001-2007.

Suicide rates in farmers and primary producers

No evidence of a trend of increased numbers of suicides coinciding with the prolonged drought during the period studied.

Table 7 Other drought effects Authors, year Drought exposure



CDC, 1988 Wisconsin, USA, 1988 Case reports N= 7, aged 15-23 years, injured in natural bodies of water

Cervical spinal cord injuries reported to spinal injury centres

5 patients with some degree of quadriplegia with or without fracture; 2 patients with no neurologic deficits or no residual neurologic deficits

Kloos, 1990 Ethiopia, 1984-1985 resettlement programme

Summary of published literature

Multiple health outcomes Mass migration of ~600,000 drought victims as a result of government-sponsored resettlement programme. In settlement communities the following health effects were observed: increased malaria mortality, higher rates intestinal parasites, onchocerciasis, trypanosomiasis, sand flea infestation, non-filarial elephantiasis, severe malnutrition, high mortality rates, mental stress.

Sousa and Pearson, 2009

Ceará, Brazil, 1877-1879 Historical account Smallpox As a result of severe drought, thousands of people migrated to Fortaleza; smallpox was introduced to the community and spread, resulting in the deaths of over 100,000 people

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