Climate changes and water borne infections

Karen A Krogfelt Professor , PhD Statens Serum Institut [email protected]

Observations (NASA 2011) and predictions

Global mean land-ocean temperature change from 1880–2011, relative to the 1951–1980 mean. The black line is the annual mean and the red line is the 5-year running mean. The green bars show uncertainty estimates.

Calculations of global warming prepared in or before 2001 from a range of climate models under the SRES A2 emissions).

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Observed changes • Global temperature Index • Climate changes – Extreme weather • • • •

Thunder storms , heavy rain Heat waves Snowfalls in northern Africa Raise in sea water levels

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Climate Change & Health Physical systems (ice, rivers, etc.)

Climate Change Impacts

Food yields Biological & seasonal cycles

Direct health impacts (heat, extreme events, etc.)

Indirect impacts

Economy: infrastructure, output, growth Wealth (and distribution); local environment; etc.

Human Health: • • • • • •

Injuries/deaths Thermal stress Infectious diseases Malnutrition Mental stresses Conflict, drugs, etc.

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Climate changes and society • • • • • •

Traveling and migration Trading of foods and animals Settlements/urbanization Invasion/distraction of ”wild life” Man-made disasters Population demographic changes

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Infectious diseases and climate • Vector-borne infections – Insects prefer heat and moist – Malaria, yellow fever, dengue fever prevail in the tropical regions – No vector-borne diseases in the arctic

• Water-borne infections – Direct (consumption, contact) – Indirect (changes in environment & biodiversity) 6

Malaria in Danmark Latest registered case of malaria acquired in Denmark was in 1945 In 1831, there was an epidemic of malaria by Plasmodium vivax At that time Denmark was covered with wet lands hosting mosquitos • Warmer weather • Draining • Biodiversity changes • Few mosquitos of the malaria carrying species (anopheles) in Denmark (no parasites)

• Surveillance , prevention and control

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Vector-borne infections • “European guidelines for diagnosis of tickborne diseases” CMI 2005 • 15th ECCMID: European Congress of Clinical Microbiology and Infectious Diseases, Copenhagen, April 2-5, 2005

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Tick associated bacterial infections

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Other infections

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Water-borne bacterial infections • Transmission through contact and consumption – Vibrio vulnificus in sea waters – Legionella spp in air-conditioning – Leptospira spp in environment – Polymicrobial infection by sewage waters after heavy rains

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V. vulnificus infection from sea water • Warm summer of 1994 • 11 patients confirmed by culture • All hospitalised, 1 died • Fishing, swimming, handling eels Dalsgaard et al 1996 Eur. J Clin Micr Inf Dis

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Legionella in stagnant water

Cluster of Legionnaires’ disease in a newly built block of flats, Denmark, December 2008 – January 2009 L H Krøjgaard et al 2011, Eurosurveillance 13

Water-borne polymicrobial infections

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Gastrointestinal outbreak after Triathlon in Amager 2010 • 1582 delegates - 1312 completed • 778 (59 %) returned questionnaire • 428 (55 %) had GE Heavy rain on August 14, 2010

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Water-borne bacterial infections

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Leptospirosis –Weil’s disease

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Leptospira in rats in Denmark Area Period N Ørholm (Lyngby-Taarbæk) 07/06 48 Virum (Lyngby-Taarbæk) 03/07 25 Roskildevej (Rødovre) 02/07 19 Damhusdalen (Rødovre) 11/06 31 Østerbro (København) 11/06 35 Nørrebro (København) 11/06 38 Total 196

Prevalens 0% 80% 89% 48% 69% 71% 53%

Krøjgaard et al. Epidemiol Infect 2009; 137: 1586-92 18

Sources of leptospirosis

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Leptospirosis Denmark 1990-2011

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Copenhagen, July 2, 2011

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Objectives • Investigate Personal Protective Equipment (PPE) use and hygiene behaviours of professionals • Describe symptoms of illness associated with the 2 July flood • Identify risk and protective factors associated with becoming ill

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Methods - Case definition • Workers in Copenhagen who experienced diarrhoea, vomiting, common cold/sore throat, allergic reaction, fever, or two or more of the following symptoms: severe muscle ache, headache, abdominal pain, nausea, or rash between July 2-25 • Exclusions: – Not present in Copenhagen July 2-July 9 – Travel history outside of Denmark before illness – History of chronic illness with symptoms similar to reported symptoms 23

Description of ill workers • • • •

56 (22%) of 257 respondents 16% went to GP 7% missed work because of symptoms Symptoms: 54% diarrhoea 45% headache 25% abdominal pain 20% muscle pains 5% rash

45% cold/sore throat 25% allergic reaction 20% nausea 9% fever 5% vomiting 24

Risks among workers Risk factors

Risk Ratio (95% CI)

P-value

No hand hygiene after contact with flood water

1.80 (1.08-2.99)

0.01

Smoking

1.81 (1.13-2.91)

0.03

• An 80% increased risk of illness for persons performing no hand hygiene after contact with flood water/sediment and smokers Wojcik OP et al Epidemiology & Infection Dec 2012 , pp1-8 25

Leptospirosis in residents • Five cases were reported • Two hospitalised - one died • All had been cleaning their basement some had seen rats/mice

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Epi Nyt 2011 33b www.ssi.dk

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Positive effect of warming • Fewer infections (less crowding indoors)

• More vitamin D • White X-mas and Sunny beaches !!!

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In all: • Climate changes influence the spreading of infections • Examples also from Denmark (July 2011) • Challenges for the future

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Thank you