q142/random_k2/random_2.md

C H A P T E R   4

Climate Change Impacts
on Human Health

Song Liang1,5, Kristina Kintziger2, Phyllis Reaves3, and Sadie J. Ryan4,5

1Department of Environmental and Global Health, College of Public Health and Health Professions,
University of Florida, Gainesville, FL; 2Department of Public Health, College of Education, Health &
Human Sciences, The University of Tennessee, Knoxville, TN; 3Division of Physical Therapy, School of
Allied Health Sciences, Florida Agricultural & Mechanical University, Tallahassee, FL; 4Department of
Geography, University of Florida, Gainesville, FL; 5Emerging Pathogens Institute, University of Florida,
Gainesville, FL

Climate  change  poses  major  challenges  to  human  society  and  to  Earth  systems,  influencing  the
functioning of many ecosystems and thereby affecting human health. Many climate change/variability-
and extreme weather-associated events, such as sea level rise, hurricanes, and storm surge, as well as
other  weather  extremes,  including  excessive  precipitation  and  heatwaves,  have  direct  and/or  indirect
impacts on human health. These impacts include death/injury, cardiovascular and respiratory diseases,
environmentally-mediated  infectious  diseases,  and  mental  health,  among  others.  Due  to  its  unique
geography,  Florida  is  particularly  vulnerable  to  these  environmental  impacts,  which  have  important
health implications for the state’s more than 20 million residents. In this chapter, we review the health
impacts of climate change and associated weather events, with an emphasis on those relevant to Florida,
and  environmental  hazards,  including  hurricanes  and  storms,  lightning,  sea  level  rise,  excessive
precipitation, extreme heat, and drought. There is clear evidence for significant climate-sensitive hazards
and  human  health  impacts  in  the  state,  despite  uncertainties  associated  with  the  assessment  of  some
effects.  To  address  health  impacts  and  challenges,  policies  focused  on  mitigation  and  adaptation
strategies, health surveillance, and research that could close knowledge gaps on human exposures to the
climate-sensitive hazards and health impacts are needed.

Key Messages

•  Florida is highly vulnerable to climate-sensitive hazards (e.g. sea level rise, heat waves, storm

surge, and hurricanes), which have a wide range of human health effects.

•  The  health  effects  can  be  direct,  such  as  storm/temperature  related  illnesses,  injuries,  and
deaths; or indirect, such as waterborne, food-borne, and vector-borne diseases; or take social
and economic pathways, such as stress and mental illness.

•  The health effects exhibit substantial regional disparities across the state.
•  Policies  focused  on  health  surveillance  and  research  on  knowledge  gaps  between  human

exposure to the hazards and health effects are much needed.

Keywords

Climate change; Environmental hazards; Human health; Florida

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Introduction

C

limate change is well-characterized at the global level using metrics such as the global
mean temperature and sea level. But the manifestations of global climate change and
variability occur at varying geographical scales, causing a variety of weather events,
such as excessive rainfall, drought, severe storm/flooding, sea level rise, and heat waves (Field
et  al.  2014),  all  of  which  are  likely  to  have  direct  and/or  indirect  human  health  impacts
(McMichael and Haines 1997; Colwell et al. 1998; Frumkin et al. 2008). Indeed, there is clear
and increasing evidence that many health outcomes (most adverse) exhibit high sensitivities to
these  varying  weather  events.  The  interface  between  the  climate  change-associated  weather
events  and  human  health  exhibits  a  complex  web  of  relationships  involving  both  natural  and
social environments through direct or indirect impact pathways, social institutional disruption,
or a combinations of these things (Fig. 4.1). Globally, substantial disease burdens are attributable
to hazards that are associated with climate change and related weather events. According to the
World Health Organization’s 2008 estimate, climate change-associated hazards were responsible
for more than 150,000 deaths and 5,517,000 disability-adjusted  life years, which were highly
likely to be underestimated as the estimates were only based on selected risk factors and illnesses
associated  with  climate  change  and  related  weather  events  (WHO  2008).  The  actual  disease
burden might be greater and the adverse health impacts are likely to increase in the years to come,
as  the  Intergovernmental  Panel  on  Climate  Change  (IPCC)  and  US  Global  Change  Research
Program have clearly indicated that the accelerated changing climate poses a substantial threat
to global human health and the risk will continue to become severe if no remediation action is
taken (Field et al. 2014; Balbus et al. 2016).

Due to its unique geography, Florida is highly vulnerable to a variety of hazards associated
with  climate  change  and  variability,  and related  weather  events.  Sea  level  rise,  hurricane  and
storm  surge,  excessive  precipitation,  and  heatwaves  all  pose  threats  to  Florida’s  agriculture,
ecosystems, tourism, and public health. For example, Florida has experienced a greater number
of hurricane landfalls than other states in the country (Knight and Davis 2009), and more intense
hurricanes  are  expected  in  the  future  (Knutson  et  al.  2013).  In  addition,  rising  sea  levels  are
influencing and expected to continue to have significant impacts on communities and residents
along  Florida’s  coastal  areas,  particularly  in  the  southern  part  of  the  state,  making  Floridians
exceptionally vulnerable to these environmental hazards (Elsner et al. 2008).

This  chapter  is  organized  into  sections  addressing  impact  pathways  and  specific
environmental hazards of particular concern in Florida (Fig. 4.1). For direct impacts, we focus
on extreme heat, flooding, storms and lightning, and sea level rise. For indirect impacts on public
health, we focus on water, food, and vector-borne diseases. And lastly, we conclude with our
discussion of impact pathways through social disruption on mental and community health impact
associated  with  climate  change  and  related  weather  events.  Throughout  this  chapter,  health

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impacts and implications, particularly those pertinent to Florida, are reviewed primarily based
on the Building Resilience Against Climate Effects (BRACE) project reports from the Florida
Department of Health (FDH) (FDH 2015b, a) and other relevant publications.

Figure 4.1. Impact pathways by which climate change and variability and related weather events affect
human health.

Direct Impact Pathways – Environmental Hazards
and Human Health

A  number  of  human  health  impacts  come  from  direct  exposure  to  environmental  hazards
associated with climate change and related weather events. Among those of particular concern
in Florida are extreme heat, flooding, storms and lightning, and sea level rise.

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Extreme Heat and Health Impacts

Extreme climate and weather events (e.g., heat, cold, storms, and floods) are expected to occur
more frequently worldwide due to climate change. These extreme events, such as heatwaves and
cold spells (e.g. frequent very hot days and possibly fewer very cold days), have a direct impact
on  human  health  by  compromising  the  body’s  ability  to  regulate  its  internal  temperature.
Increased human morbidity and mortality have been associated with extreme temperatures, both
hot and cold, and documented in both developing and developed countries worldwide (Center
for Disease Control and Prevention 1994; Keatinge et al. 2000a; Keatinge et al. 2000b; Basu and
Samet 2002; Medina-Ramon et al. 2006; Kovats and Hajat 2008; Bandyopadhyay et al. 2012).
The  mechanistic  effects  of  extreme  temperature  on  death  and  illness  are  briefly  summarized
below (Sarofim et al. 2016):
•  Extreme heat may induce heat cramps, heat exhaustion, heatstroke, and hyperthermia.
•  Extreme cold may induce hypothermia and frostbite.
•  Extreme  heat/cold  may  exacerbate  chronic  conditions  related  to  cardiovascular  disease,

respiratory disease, cerebrovascular disease, and diabetes-related illnesses.

•  Extended  exposure  to  high  temperatures  may  induce  increased  hospital  admissions  for

cardiovascular, kidney, and respiratory disorders.

•  Extreme heat may induce or exacerbate mental health and behavioral disorders.

A number of studies have reported associations between high temperatures and human deaths
or  illnesses  around  the  world.  For  example,  a  large  number  of  heat-related  deaths  have  been
reported in the United States (Center for Disease Control and Prevention 1994; Curriero et al.
2002; Hoshiko et al. 2010), Europe (Keatinge et al. 2000a; Keatinge et al. 2000b; Huynen et al.
2001), and Asia (Qian et al. 2008; Chung et al. 2009). A recent study by Berko et al. examined
deaths attributed to extreme weather events from 2006 to 2010 in the United States and found
that each year about 2,000 U.S. residents died from weather-related causes, and among those
31% died due to exposure to excessive heat, heat stroke, and/or sun stroke (Berko et al. 2014).
Mounting  evidence  has  suggested  that  substantial  increases  in  mortality  from  respiratory  and
cardiovascular  diseases,  in  particular  among  the  elderly  and  youth,  are  associated  with  high
temperatures in the United States (Basu and Samet 2002; Medina-Ramon et al. 2006; Kovats and
Hajat 2008). During the 2006 California heat wave, 16,166 excess emergency department visits
and 1,182 excess hospitalizations were reported statewide. This included a significant increase
in  emergency  department  visits  for  acute  renal  failure,  cardiovascular  diseases,  and  diabetes
(Knowlton  et  al.  2009).  The  association  between  heat  and  respiratory  diseases  has  also  been
reported in many studies. In New York state, a significant number of respiratory hospitalizations
were attributable to excessive heat, and a projection suggested that excess respiratory admissions
in the state due to extreme heat will be two to six times higher in 2080–2099 than what was seen
in 1991–2004 (Lin et al. 2012). In another study conducted in Greater London, UK, an analysis

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of historical data suggested that heat-related increases in emergency admissions for respiratory
and renal diseases had been observed in children under five, and for respiratory disease in the
75+ age group (Kovats et al. 2004).

Extreme Heat and Public Health in Florida

Florida has a warm subtropical and tropical climate. Due to continuous summer heat and extreme
weather  events,  temperatures  around  the  state  can  reach  levels  potentially  harmful  to  human
health.  Through  analyses  of  historical  data  (for  the  periods  1895–2009  and  1970–2009),  a
significant  trend  in  Florida’s  mean  temperature  has  been  found  (Martinez  et  al.  2012).  The
average  summer  temperature  (June–August)  has  been  showing  an  overall  increasing  trend,
particularly after the 1980s, which shows a greater upward trend (FDH 2015a), likely due to a
variety of factors ranging from rapid urban development (Martinez et al. 2012; FDH 2015a) to
climate  change  (Ji  et  al.  2014).  Within  the  state,  substantial  spatial  heterogeneities  in  mean,
minimum, and maximum temperature have been reported (Martinez et al. 2012). For example,
the distribution of annual mean number of days with a maximum temperature greater than or
equal to 95 °F and greater than or equal to 75 °F showed that more days with hottest daytime
temperatures occurred in the northern and interior portions of the state (FDH 2015a).

Using statewide information on specific health outcome-related emergency department visits
that occurred May to October from 2005–2012, the BRACE project examined the effects of daily
maximum temperature or daily maximum heat index on emergency department visits through a
two-stage analysis—the first stage involved the analysis on regional (National Weather Service
regions)  scales  using  the  Poisson  regression  model;  the  second  stage  used  a  meta-analysis
technique  to  integrate  regional  estimates  into  a  statewide  estimate  (FDH  2015a).  Rate  ratios,
based on the comparison between the exposure (e.g., hotter days) and the reference (e.g. 88 °F
for temperature and 94 °F for heat index), were used to compare emergency department visits
for specific health conditions (FDH 2015a).
a)  Heat  and  heat-related  illness.  A  strong  association  between  heat-related  illness  and  heat
exposure was observed; the significant increase in emergency department visit rates for heat-
related  illness  was  associated  with  increasing  temperatures  and  a  strong  dose-response
relationship across all regions in Florida was found (FDH 2015a).

b)  Heat and cardiovascular disease. Two types of cardiovascular disease were considered—
myocardial infarction and ischemic stroke. No statistically significant association was found
between  temperature  and  ischemic  stroke  at  the  state  level;  however,  significant  regional
variations  were  identified.  For  example,  the  Tampa  region  showed  a  significant  positive
association between heat index (above the reference level at 94 °F) and stroke (FDH 2015a).
Furthermore,  a  positive,  statistically  significant  relationship  was  observed  between
myocardial  infarction  and  heat  index  despite  remarkable  geographical  variations  (FDH
2015a).

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c)  Heat  and  respiratory  disease.  Overall,  increases  in  the  number  of  emergency  department
visits  for  asthma  were  associated  with  higher  temperatures.  Although  no  significant
association was found at the state level between temperature and emergency department visits
for  asthma,  the  regional  analysis  suggested  that  all  regions  except  Tallahassee  showed  a
statistically significant positive association between temperature and asthma (FDH 2015a).

Flooding, Storms, Lightning, and Sea Level Rise

Excessive  precipitation,  hurricanes,  coastal  storms,  sea  level  rise,  and  thunderstorm-related
lightning, which are all typically accompanied by coastal and inland flooding, have the potential
for substantial direct human health impacts (e.g. injury and death, maternal and child health, and
mental health issues). Natural disasters related to flooding and storms are a significant cause of
mortality and morbidity. For example, according to the International Federation of Red Cross
and  Red  Crescent  Societies  (IFRCRCS),  more  than  3,448  climatic,  hydrological  and
meteorological  disasters  (including  1,751  major  floods  and  988  storms)  resulting  in  339,710
deaths  (59,092  and  177,685  deaths  specifically  tied  to  flooding  and  storms)  were  reported
worldwide  between  2005  and  2014  (IFRCRCS  2015).  Lightning  strike  is  the  second  leading
cause of weather-related mortality at the global scale, with an estimated 0.2-1.7 deaths per million
people, and those who survive lightning strikes often suffer from significant injuries (Aslar et al.
2001; Ritenour et al. 2008). The magnitude and impacts of these extreme weather events, their
severity,  and  the  extent  of  the  effects  are  influenced  by  many  different  factors.  For  example,
short-  and  long-term  averages  and  variability  of  weather  conditions  and  physical  impacts  of
associated extreme events, as well as social environmental factors (e.g. infrastructure, social and
individual vulnerability), are considered important (Bouma et al. 1997, Kovats 2000, Kovats et
al.  2003,  Miranda  2004).  For  projections  of  future  flooding  under  different  climate  change
scenarios,  climate  models  have  consistently  suggested  that  episodes  of  severe  flooding  may
become  more  frequent  in  inland  river  systems  including  flood  plains  (Christensen  and
Christensen 2003,  Booij 2005),  urban  and coastal  environments  in  various parts  of  the  world
(Schreider et al. 2000; Douglas et al. 2008; Kirshen et al. 2008; Thompson et al. 2009, Diez et
al.  2011;  Lyle  and  Mills  2016).  Meanwhile,  climate  models  also  predict  positive  correlations
between lightning and global temperatures, suggesting the likelihood of a greater number of and
more severe lightning episodes (Price and Rind 1994; Reeve and Toumi 1999; Kochtubajda et
al. 2006). These episodes are expected to increase the risk of extreme environmental hazards and
adverse public health impacts.
a)  Natural  disasters  in  Florida.  Due  to  its  geography  (extensive  coastline  and  a  peninsular
shape)  and  its  tropical/subtropical  climate,  Florida  is  particularly  vulnerable  to  tropical
storms, hurricanes, and lightning strikes. Historically the occurrence of hurricanes in the US
has been clustered in Florida and along the Atlantic coastline (Ellis et al. 2015). A total of 67
known  Florida  hurricanes  have  occurred  over  the  108-year  period  (1900-2007)  with  four

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different  hurricanes  occurring  in  one  year  (2004)  in  Florida.  The  climate  change  model
suggests a 46% chance that Florida will be hit by at least one hurricane each year in the future
(Malmstadt et al. 2009), and recent experience seems to support this. Fig. 4.2 illustrates the
distribution of average return time of hurricane landfalls and populations along the coastal
areas of Florida, showing spatial heterogeneities in vulnerability to hurricanes.

b)  Public  health  impacts.  Key  direct  public  health  impacts  associated  with  extreme  weather
events  include  injury  and  death  due  to  trauma,  drowning,  destructive  forces  of  wind,
collapsed building and trees, and lightning strike and carbon monoxide poisoning related to
power outages. Historically, Florida experienced significantly higher mortality in the early
20th century; approximately 3,000 deaths were attributed to extreme weather-related events
(Winsberg  2003)  and  the  largest  number  of  deaths  due  to  lightning  strike  in  the  US  were
reported during this time (Duclos et al. 1990; Ritenour et al. 2008). During 2004 and 2005,
eight hurricanes hit Florida resulting in 213 deaths, over half of which were caused by trauma,
followed by drowning, other injury, electrocution, and carbon monoxide poisoning (Ragan et
al. 2008). Injury is common cause of hurricane-related morbidity and mortality. For example,
in the aftermath of Hurricane Katrina between September 8 and October 14, 2005, 7,543 non-
fatal injuries among residents and relief workers were recorded in the surveillance system
(Sullivent  et  al.  2006).  During  a  2006  flood  event  in  El  Paso  County  in  Texas,  43%  of
individuals (out of 475 surveyed) were reported having physical health issues related to the
flooding episode (Collins et al. 2013).

c)  Injury.  The  BRACE  study  compared  injury-related  emergency  department  visits  and
hospitalizations during impact periods (periods covering tropical cyclone landfall) vs. control
periods  (periods  with  no  such  impact)  between  2004  and  2012.  The  study  found  that
emergency  department  visit  and  hospitalization  rates  were  significantly  higher  during  the
impact periods, with a rate ratio of 1.03 (95% confidence interval (CI): 1.02, 1.05) for the
emergency department visit rate and 1.4 (95% CI: 1.02, 1.05) for the hospitalization rate. The
most common types of injuries during the impact periods included falls, being struck by an
object, being cut or pierced, and motor vehicle transport accidents (FDH 2015b).

d) Carbon monoxide poisoning. Carbon monoxide (CO) is a colorless, odorless, poisonous gas
that can be harmful when inhaled in a large amount. Inhaled CO enters the blood stream and
reduces the delivery of oxygen to the body’s critical organs, such as the heart and brain. The
gas  is  primarily  generated  through  incomplete  combustion.  The  greatest  sources  of  CO
outdoors are usually related to motor vehicles, machinery that burn fossil fuels. Indoors, some
major  sources  include  unvented  kerosene  and  gas  space  heaters,  leaking  chimneys  and
furnaces, and gas stoves. Exposure to CO may cause weakness, headache, dizziness, nausea,
shortness of breath, confusion, and even death at very high concentration levels, which is
more  likely  in  indoor  environments.  A  recent  systematic  review  of  the  health  impacts  of
power  outages  due  to  extreme  events  indicated  that  CO  poisoning  is  an  important  health
concern (Klinger et al. 2014). In Florida, the BRACE study reported that during the study

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period 2004–2012, the rate of CO exposure calls during impact periods was 6.59 times (95%
CI:  4.48,  9.7)  the  rate  of  CO  exposure  calls  to  poison  control  centers  during  the  control
periods. The study also found the rate of CO-poisoning related emergency department visits
was significantly higher for the impact periods than during the control periods with the rate
ratio  3.44  (95%  CI:  2.07,  5.72).  Finally,  the  BRACE  study  revealed  that  rates  of  CO
poisoning-related hospitalizations were also significantly higher during the impact periods
with the rate ratio 4.0 (95% CI: 2.9, 5.51) (FDH 2015b).

Figure 4.2. Historical distribution of hurricane landfalls in Florida.

Indirect Impact Pathways–Infectious Diseases

Climate  change  and  variability  and  associated  variable  weather  conditions  can  affect  human
health  through  indirect  pathways  (Fig.  4.1).  These  indirect  impacts  are  modulated  through
biological  and  ecological processes  that  can  influence  infectious diseases  (in particular,  some
water/food- and vector-borne diseases) and air quality. In this section, we focus on water/food-,
and vector-borne diseases.

Disease Transmission Groupings

The  impact  of  climate  change  and  variability  and  associated  weather  events  on  infectious
diseases has been receiving much attention in the past several decades. Across the globe, high

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human mortality rates and disability have been attributed to infectious diseases; climate change
is  intensifying  and  will  continue  to  exacerbate  transmission  of  infectious  diseases,  poses
increasing concerns (Patz et al. 2005). Indeed, the transmission of many infectious diseases is
closely linked to physical environmental factors, such as water and temperature. Many water-
associated and zoonotic pathogens, for instance, which account for more than 75% of known
pathogens causing human diseases, are associated with hydrological process (WHO 2003). From
a  transmission  perspective,  infectious  diseases  can  be  broadly  classified  into  two  groups:  1)
directly transmitted (i.e., those spread directly from person to person via direct contact or droplet
exposure,  such  as  influenza  and  tuberculosis);  and  2)  indirectly  transmitted,  including  those
mediated  through  an  intermediate  vector  organisms  (vector-borne)  or  through  environmental
media such as water and soil (environmentally-mediated) (Eisenberg et al. 2007). Because the
diseases in the indirectly transmitted group are either directly or indirectly related to water, this
group can be further broken down into the following sub-groups based on water’s role in disease
transmission: waterborne (e.g., cholera typically via fecal-oral transmission), water-based (e.g.
part of the pathogen life cycle requires aquatic environment, such as schistosomiasis), and water-
related (e.g., malaria and dengue, which need water for breeding of insect vectors to fulfill the
transmission cycle) (Yang et al. 2012; Mordecai et al. 2013; Ryan et al. 2015; Johnson et al.
2015; Mordecai et al., 2017) .

Climate-Sensitivity of Microbial Agents and Their Associated Diseases

Table 4.1 lists some of the major pathogens and their associated diseases that are climate sensitive
and associated with water. These disease-causing pathogens, either through infection or toxin-
generating  (e.g.  caused  by  protozoa,  bacteria,  virus,  helminth,  or  algae),  and  their  associated
vectors  (e.g.,  snails,  mosquitoes,  sand  flies)  are  very  small  in  size  and  lack  thermostatic
mechanisms (i.e. lack of function to maintain body temperatures). Their biological (e.g., survival,
reproduction, development/growth, and infectivity) and environmental (e.g., contamination and
movement) processes are determined by environmental conditions, such as rainfall, storm runoff,
temperature,  and  sunlight.  Climate  change  and  variability  and  associated  weather  events  are
expected to affect both fresh and marine water environments thereby changing humans’ exposure
to these water-related contaminants or pathogens that cause ill health.

a) Waterborne Diseases
Waterborne diseases remain an important contributor to the global burden of disease (Pruss et al.
2002; Yang et al. 2012; Pruss-Ustun et al. 2014). Many different viral, bacterial, and parasitic
diseases  have  been  associated  with  waterborne  transmission  (Table  4.1).  Human  exposure  to
waterborne pathogens is primarily through drinking water, recreational water (e.g. via accidental
drinking  and,  for  some  pathogens,  via  dermal  contact),  or  foods.  The  distribution  of  these
pathogens  exhibits  significant  geographical  variations,  depending  on  both  physical

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environmental  and  socio-economic  conditions  (Yang  et  al.  2012).  For  example,  waterborne
cholera,  viral  hepatitis,  and  some  other  water-based  and  water-related  diseases  (e.g.,
schistosomiasis  and  onchocerciasis)  are  largely  confined  to  certain  tropical  areas  where  the
prevalence of such diseases is largely due to lack of access to improved drinking water, sanitation
and  hygiene  (Pruss  et  al.  2002),  while  some  pathogens,  such  as  Cryptosporidium  parvum,
Giardia duodenalis, and Campylobacter spp. have a much wider geographical distribution (Yang
et al. 2012). Regardless of the geographical region, heavy rainfall, flooding, and temperature are
among  the  most  important  factors  associated  with  transmission  and  outbreaks  of  these
waterborne diseases.

There  is  mounting  evidence  that  weather  events  are  often  an  important  factor  triggering
waterborne outbreaks. In developed countries, extreme weather events such as excessive rainfall
and  flooding  can  overwhelm  water  treatment  plants  and/or  increase  runoff  into  recreational
water, leading to water contamination that causes outbreaks (Kistemann et al. 2002). Some recent
studies  have  clearly  indicated  that  excessive  rainfall  has  been  a  significant  contributor  to
waterborne outbreaks. An analysis of historical records of 548 waterborne outbreaks in the US
reported between 1948 and 1994 suggested a significant association between the outbreaks and
rainfall—51% of waterborne disease outbreaks were preceded by precipitation events above the
90th  percentile  and  68%  by  events  above  the  80th  percentile;  the  strongest  association  was
between the outbreaks and surface water contamination due to extreme precipitation (Curriero et
al. 2001). In Canada, Thomas et al. examined extreme rainfall and spring snowmelt in relation to
92 Canadian waterborne disease outbreaks that occurred between 1975 and 2001. They found
that warmer temperatures and extreme rainfall were significant contributing factors to waterborne
disease  outbreaks  in  Canada  (Thomas  et  al.  2006).  Similar  studies  have  been  conducted  in
England (Nichols et al. 2009), the Netherlands (Schijven and de Roda Husman 2005), Finland
(Miettinen et al. 2001), Denmark (Laursen et al. 1994), and Taiwan (Chen et al. 2012). In many
developing countries, lack of access to improved drinking water and sanitation exacerbates the
impact of these extreme precipitation weather events on waterborne diseases. Diarrhea, caused
by  many  waterborne  pathogens,  remains  a  top  killer  of  children  under  five  in  the  developing
world,  particularly  in  Africa  (Pruss-Ustun  et  al.  2014).  A  large  number  of  studies  have  been
carried out in the developing world. For example, cholera outbreaks caused by toxigenic Vibrio
cholerae  have  been  consistently  shown  to  be  correlated  with  excessive  rainfall,  flooding,  and
high  temperatures  in  the  epidemic  areas  of  West  Africa  and  Bangladesh  (Mhalu  et  al.  1987;
Hashizume  et  al.  2008;  Luque  Fernandez  et  al.  2009;  Ngwa  et  al.  2016),  although  the  exact
mechanistic  relationships  that  result  in  this  correlation  remain  elusive  (Colwell  et  al.  1998).
Significant  (positive)  relationships  have  been  reported  between  excessive  rainfall  and/or  high
temperatures and diarrhea in the Pacific Islands (Singh et al. 2001), Ecuador (Carlton et al. 2014),
and  Sub-Saharan  Africa  (Bandyopadhyay  et  al.  2012),  while  evidence  also  suggests  that  low
rainfall  and  even  drought  can  also  be  associated  with  diarrhea,  as  reported  in  Bangladesh
(Hashizume et al. 2008) and Denmark (Senhorst and Zwolsman 2005).

C L I M A T E   C H A N G E   I M P A C T S   O N   H U M A N   H E A L T H   •   1 3 5

b) Waterborne Diseases and Climate Impact in Florida
Across the US, climate change and variability and associated weather events are affecting and
are expected to continue to affect both marine and freshwater resources. These effects extend to
some  water-associated  pathogens  and  related  diseases.  In  Florida,  waterborne  and  foodborne
diseases of major public health concerns are highlighted in Table 1. Enteric bacteria, protozoan
parasites,  enteric  viruses  including  Salmonella  enterica,  Campylobacter  spp.,  toxigenic
Escherichia  coli,  Vibrio  bacteria  species,  Cryptosporidium  and  Giardia  enteroviruses,
rotaviruses, noroviruses, and hepatitis A and E, are among those closely related to drinking and
recreational waters, and shellfish. These pathogens, while in environmental stages, are sensitive
to temperature, precipitation, and water flow. Several important toxin producers of water sources
are of particular public health importance in Florida (Table 4.1) including toxins from harmful
algal blooms, toxigenic marine species of Alexandrium (causing paralytic shellfish poisoning),
Karenia  brevis  (causing  neurotoxic  shellfish  poisoning),  and  Gambierdiscus  spp.  (causing
ciguatera fish poisoning). Human exposure pathways are primarily through the consumption of
contaminated shellfish and fish, and in recreational waters. Cyanobacteria, consisting of multiple
species, can produce toxins (including microcystin), and the primary human exposure is from
drinking water and recreational water. For all of these harmful algal blooms species, temperature,
and  precipitation  are  among  the  important  factors  affecting  their  reproduction,  growth,  and
distribution.

Fig. 4.3 shows yearly distribution of total reported outbreaks and cases of food-borne and
waterborne diseases in Florida from 1989 to 2011 and Fig. 4.4 shows the monthly distribution of
reported outbreaks and cases for 2011, exhibiting marked annual variations and distinct seasonal
distribution. According  to  the  BRACE report for  the  period 2004–2012,  approximately  1,150
cases of campylobacteriosis were reported annually, with the majority of cases reported between
May  and  September.  From  that  same  report,  ~426  cases  of  cryptosporidiosis  were  reported
annually,  with  the  majority  of  cases  reported  between  June  and  October.  Approximately  940
cases of giardiasis were reported annually, with an annual incidence rate of 5.1 cases per 100,000
population  and  the  majority  of  cases  reported  between  May  and  October.  Salmonellosis
accounted for the greatest number of foodborne illnesses reported, with an average of 5,438 cases
reported  each  year  and  ~70%  reported  between  June  and  November.  Finally,  ~101  cases  of
vibriosis  were  reported  annually,  with  81%  of  the  cases  reported  between  April  and  October
(FDH 2015b). Focusing on the five diseases—campylobacteriosis. cryptosporidiosis, giardiasis,
salmonellosis,  and  vibriosis—the  BRACE  study  identified  a  total  of  1,231  follow-up  days  of
interest including 775 control days and 456 impact days—42 associated with hurricanes and 414
with tropical storms (FDH 2015b); the result suggested that the occurrences of cryptosporidiosis
and  salmonellosis  were  significantly  associated  with  the  tropical  cyclones,  with  the  risk  ratio
being 1.26 (95% CI, 1.04, 1.52) and 1.35 (95% CI, 1.29, 1.42), respectively (FDH 2015b).

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Figure  4.3.  Reported  outbreaks  (bar)  and  human  cases  (line)  of  food-borne  and  waterborne  diseases  in
Florida  each  year  from  1989  to  2011  (Source:  Florida  Department  of  Health).  Toxigenic  V.  cholerae
infections are highly unusual in Florida and the first V. cholerae O75 outbreak was detected and reported
in Florida between March 23 and April 13, 2011.

Figure 4.4. Monthly distribution of reported outbreaks and cases of food-borne and waterborne diseases in
Florida, 2011 (Source: Florida Department of Health)

C L I M A T E   C H A N G E   I M P A C T S   O N   H U M A N   H E A L T H   •   1 3 9

c) Vector-Borne Diseases
Vector-borne diseases pose serious public health threats throughout the world. According to the
World  Health  Organization,  vector-borne  diseases  account  for  more  than  17%  of  infectious
diseases, causing more than one million deaths annually from diseases such as malaria, dengue
fever,  yellow  fever,  Japanese  encephalitis,  and  schistosomiasis  (WHO  2016).  Vector-borne
diseases are transmitted through vector organisms including mosquitoes, ticks, flies, fleas, and
snails. The transmission of vector-borne diseases takes two primary transmission pathways. The
first is the human-vector pathway, with transmission through a vector biting a host; pathogens
survive outside hosts in arthropod vectors and humans are typically the only host (Eisenberg et
al. 2007). Diseases in this group include malaria, dengue fever, onchocerciasis, trypanosomiasis,
and  filariasis  (Table  4.1).  The  second  pathway  involves  zoonotic  transmission,  with  a  vector
biting a nonhuman host as the transmission route and humans as the dead-end host (Eisenberg et
al.  2007).  Diseases  in  this  group  include  Lyme  disease,  Yellow  fever,  West  Nile  virus,  and
Japanese  encephalitis  (Table  4.1).  The  transmission  and  spread  of  vector-borne  diseases  are
determined by complex interactions between the host (either human or nonhuman), the vector
(e.g., mosquitos, flies, snails, and ticks), and various pathogens ranging from protozoans, viruses,
bacteria, and helminthes (Table 4.1). Important biological properties underlying the transmission
of vector-borne diseases include survival, development, and reproduction of the vector; also the
pathogens  in  the  vector,  the  vector’s  biting  rate,  and  the  behavior  of  hosts  (human  and
nonhuman), all of which are associated with climatic conditions. The following sections discuss
some specific aspects of the effects of rainfall, temperature, and flooding with regard to vector-
borne diseases.

Temperature Sensitivity
Through the modulating effects on physiological activities and tolerance limits of vectors and
infectivity of pathogens, temperature can affect distribution of the vector and transmission of the
pathogens between vectors and hosts. Some key mechanistic effects of temperature on vectors,
vector-borne pathogens and their transmission are summarized by Gulber et al. (2001).
•  Change in survival of vectors (e.g. increase or decrease depending on species)
•  Change in susceptibility of vectors to pathogens
•  Change in vector population growth
•  Change in feeding behavior and host contact
•  Change  in  incubation  period  of  pathogens  in  vectors  (e.g.  decreased  extrinsic  incubation

period at higher temperatures)

•  Change in pathogen replication and infectivity
•  Change in transmission season

A  large  number  of  studies  on  vector-borne  diseases  at  different  scales  have  provided
empirical evidence and predictions on the climatic factors and vector-borne disease links. For

1 4 0   •   S O N G   L I A N G   E T   A L .

example, studies have shown significant relationships between ambient temperature and malaria
transmission for both mean temperature (Loevinsohn 1994; Lindblade et al. 2000; Thomson et
al. 2005; Tian et al. 2008; Wardrop et al. 2013) and its daily fluctuations (Paaijmans et al. 2010).
Laboratory studies have shown clear temperature-dependent effects on dengue virus infection in
mosquitoes  (Alto  and  Bettinardi  2013).  Fluctuations  at  a  low  mean  temperature  accelerate
dengue  virus  transmission  in  Aedes  aegypti  mosquitoes  (Carrington  et  al.  2013).  A  recent
systematic review and meta-analysis based on 137 studies on the relationship between dengue
risk and temperature suggests that the dengue transmission and risk are sensitive to temperature,
with a positive relationship between them for a minimum range (18.1–24.2 °C) to a maximum
temperature  range (28.0–34.5  °C) (Fan et  al. 2014). A  regional  predictive  study reported  that
increased  temperature  increases  the  likelihood  of  many  vector-borne  diseases,  in  particular
malaria, dengue fever, and Lyme disease in new areas (Githeko et al. 2000). Similar findings are
also reported for West Nile virus (Soverow et al. 2009). These empirical findings have been used
to  parameterize  mechanistic  models  of  temperature  driven  transmission  for  vector-borne
diseases, which can be coupled to projected climate scenarios to anticipate shifting geographies
of transmission risk, e.g. for malaria (Mordecai et al. 2013; Johnson et al. 2014; Johnson et al.
2015; Ryan et al. 2015; Ryan et al. 2015) and for Aedes spp transmitted diseases of concern for
Florida: dengue, chikugunya, and zika viruses (Moedecai et al. 2017; Ryan et al. 2017).

Rainfall
Rainfall can supply water to both transient and persistent environments that can serve as habitats
or breeding sites for vectors and/or for part of pathogens’ lifecycles, critical for transmission of
vector-borne diseases. Meanwhile, rainfall can also have negative impacts on the habitats (for
example, washing away), thereby reducing the transmission risk. Variations in rainfall may have
direct  and  indirect  impacts  on  the  distribution  and  timing  of  transmission  of  vector-borne
diseases. Some key mechanistic effects of rainfall on vectors, vector-borne pathogens, and their
transmission are summarized by Gubler et al. (2001).
•
•  Excess rain (e.g. causing flooding) may eliminate habitat for both vector and hosts.
•
•
•

Increased humidity may increase vector survival and biting rate.
Increased rainfall may facilitate transport of pathogens for certain distance (Liang et al. 2007).
Increased  rain  may  increase  vertebrate  host  size  through  increased  food  availability  (e.g.
vegetation).

Increased rain may increase larval habitat and vector population.

•  Flooding  may  decrease  vertebrate  host  size  (e.g.  reduced  food  availability)  but  increase

interactions (e.g. contacts) with humans.

Such mechanistic links have been reported by many studies including for diseases such as
malaria (van der Hoek et al. 1997; Thomson et al. 2005; Galardo et al. 2009; Gao et al. 2012;
Yang et al. 2012), dengue fever (Li et al. 1985; Su 2008; Johansson et al. 2009; Banu et al. 2011;

C L I M A T E   C H A N G E   I M P A C T S   O N   H U M A N   H E A L T H   •   1 4 1

Hii et al. 2012), West Nile virus (Shaman et al. 2005; Soverow et al. 2009), and Lyme disease
(Ogden et al. 2006; Ostfeld et al. 2006).

Vector-Borne Diseases in Florida
In the United States, 14 vector-borne diseases are of primary public health concern. Table 4.2
lists key notifiable vector-borne diseases and reported cases between 2013 and 2015 in Florida.
Major mosquito-borne diseases include the St. Louis encephalitis virus, West Nile virus, Eastern
equine  encephalitis  virus,  Western  equine  encephalitis  virus,  Venezuelan  equine  encephalitis
virus, Everglades virus, and the California serogroup viruses including La Crosse encephalitis
virus,  all  of  which  are  transmitted  by  mosquitoes.  More  recently,  concern  about  Aedes  spp
transmitted  flavivirus  and  alphaviral  disesaes  have  become  more  prevalent:  dengue  (DENV),
chikungunya (CHIKV), and zika (ZIKV). The 2015-2016 global public health emergency for
Zika declared by the WHO focused attention on Florida as an introduction and establishment
gateway for the U.S.

Table  4.2.  A  summary  of  reported  case  counts  of  notifiable  vector-borne  diseases  in  Florida.  (Source:
Florida Department of Health).

2013-2015 Reported Cases  Number of Counties Reported

Diseases
Tick-borne
Lyme disease
Spotted Fever Rickettsia
Anaplasmosis/Ehrlichiosis
Tularemia
Mosquito-Borne
West Nile virus
Malaria
Dengue
California serogroup viruses  2
3
Eastern equine encephalitis
2
St. Louis encephalitis

459
74
82
2

37
146
331

46
18
30
2

14
24
31
2
3
1

St. Louis Encephalitis. The St. Louis encephalitis virus, a flavivirus, was the most common
mosquito-transmitted human pathogen in the U.S. prior to the introduction of the West Nile virus
in 1999 (FDH 2016). In Florida, the principal vector is Culex nigripalpus, a ubiquitous species
throughout the state. No human case has been reported in Florida since 2003. However, sentinel
chickens testing positive for antibodies to the St. Louis encephalitis virus have been reported in
several counties in Central and South Florida, suggesting the potential for a possible resurgence
(FDH 2014, 2016).

West Nile virus. The peak period of transmission in Florida for the West Nile virus is July
through September. The natural cycle of West Nile virus involves Culex mosquitoes and wild
birds. Between 2001 and 2013, 318 human West Nile virus cases were reported in Florida and

1 4 2   •   S O N G   L I A N G   E T   A L .

West  Nile  virus  activities  have  been  consistently  reported  in  many  counties  around  the  state
(FDH 2014).

Eastern Equine Encephalitis. Eastern equine encephalitis occurs in natural cycles involving
birds and Culiseta melanura in freshwater swampy areas, with a peak in transmission occurring
between  May  and  August.  Historical  and  current  evidence  indicates  limited  human  Eastern
equine encephalitis epidemic potential in Florida (FDH 2014, 2016).

Dengue Fever. In Florida, a historical dengue fever epidemic occurred in 1934-1935 and then
it ceased. It re-emerged in 2009, and since then a small number of cases have been reported each
year among individuals who had previous travel to dengue-endemic countries. In the summer of
2009, local dengue transmission was identified in Key West, Florida. Since then, sporadic local
transmission has been identified in other Central and South Florida counties during 2010, 2011,
2012, and 2013 (FDH 2014, 2016). The presence of the Aedes spp mosquito, both Aedes aegypti,
also  known  as  the  Yellow  Fever  mosquito,  which  has  been  a  persistent  invasive  mosquito  in
Florida for a couple of centuries, and the more recently introduced Asian Tiger Mosquito, Aedes
albopictus, maintain transmission potential in Florida. Aedes mosquitoes are capable of breeding
in as little as a teaspoon of water, and are able to adapt well to urban environments, and exhibit
transmission of dengue, chikungunya, and zika, at temperature ranges found almost year-round
in most of Florida (Mordecai et al. 2017). The optimal transmission temperature range for Aedes
aegypti, in particular, is higher than that for Aedes albopictus, suggesting that future climates
will promote Ae aegypti transmission in Florida, before it becomes too hot for transmission (Ryan
et al. 2017).

Malaria. Malaria is caused by the mosquito-borne parasite Plasmodium falciparum. Endemic
malaria  was  eliminated  in  Florida  in  the  late  1940s.  However,  imported  cases—either  from
travelers returning to the state from malaria-endemic regions or tourists carrying the pathogen—
have been reported. The Anopheles mosquitoes responsible for transmitting the malaria parasite
to humans are common in the state so establishment of local transmission is still possible (FDH
2014, 2016).

Tick-Borne Diseases. The most common tick-borne diseases are ehrlichiosis, anaplasmosis,
Lyme disease, Rocky Mountain spotted fever, and other spotted fever illnesses. Lyme disease is
the most commonly reported vector-borne disease in the United States. It is caused by a bacteria
known  as  Borrelia  burgdorferi.  Lyme  disease  is  reported  in  Florida  year-round.  An  estimate
suggests that about 23% of cases were acquired in Florida and about 77% were acquired while
travelling  to  other  states  or  countries  (FDH  2016).  Ehrlichiosis  and  Anaplasmosis—several
pathogenic species in the genus Ehrlichia and Anaplasma—can cause human illness. The human
illness caused by Ehrlichia chaffeensis is called Human Monocytic Ehrlichiosis, and the illness
caused  by  Anaplasma  phagocytophilum  is  called  Anaplasmosis  or  Human  Granulocytotropic
Anaplasmosis.  In  Florida,  the  majority  of  Human  Monocytic  Ehrlichiosis  cases  (73%)  are
acquired  in  Florida,  primarily  in  the  northern  and  central  parts  of  the  state,  and  Human
Granulocytotropic Anaplasmosis cases are even more likely to be acquired in Florida. Cases are

C L I M A T E   C H A N G E   I M P A C T S   O N   H U M A N   H E A L T H   •   1 4 3

reported year-round, with a peak occurring during the spring and summer months (FDH 2016).
Rocky Mountain Spotted Fever is a disease is caused by the bacterium Rickettsia richerrsii and,
in  Florida,  it  is  transmitted  primarily  by  the  American  dog  tick.  It  can  also  be  caused  by
Dermacentor variabilis and cases of this transmission are reported year-round with more than
70% acquired in Florida, and the majority of cases are reported in the northern and central regions
of the state (FDH 2016).

Drought
Drought  is  considered  a  meteorological  anomaly  characterized  by  a  prolonged  and  abnormal
moisture deficiency. Climate change and variability are progressively increasing the severity and
frequency of drought events. Drought has many possible public health implications (Kalis et al.
2009; Kalis and Curtiss 2016). Drought may:
•  Compromise quantity and quality of water for drinking, sanitation, and hygiene
•  Compromise air quality (e.g. increased particulate matters in the air)
•  Reduce crop yield, food availability and nutrition
•

Increase  or  decrease  risks  to  infectious  pathogens  (e.g.  waterborne,  air-borne,  and  vector-
borne)
Increase risk of non-communicable illness (e.g. respiratory infections and/or illness)

•

Drought  has  been  linked  to  deterioration  of  water  quality  (Golladay  and  Battle  2002;  Al-
Kharabsheh  and  Ta'any  2003)  and  air  quality  (Taylor  and  Davies  1990;  Field  et  al.  2009)  in
various settings in both the developed and developing world. Drought has been implicated for
infectious diseases—waterborne (Lipp et al. 2002; Schuster et al. 2005; Senhorst and Zwolsman
2005), vector-borne (Chretien et al. 2007; Erlanger et al. 2009; Medlock and Leach 2015), and
airborne  (Polymenakou  et  al.  2008).  Drought  conditions  have  also  been  linked  to  increased
incidence of respiratory diseases (Smith et al. 2014).

In  Florida,  the  BRACE  study  examined  associations  between  monthly  drought  conditions
(using the Standardized Precipitation Index), disease rates and emergency department visits for
specific health conditions (e.g. allergic rhinitis, asthma, and all respiratory diseases excluding
asthma)  among  Florida  residents  from  2005  to  2012.  The  results  suggested  that  drought  was
significantly  associated  with  emergency department  visits  for  respiratory  diseases.  It  is  worth
noting  that  the  relationship  between  the  most  extreme  drought  conditions  and  emergency
department visits tended to be protective (e.g. less emergency department visits for respiratory
illness), while more moderate drought appeared to be associated with an increase in emergency
department visits for the health conditions. A similar pattern was also observed for asthma (FDH
2014b).

1 4 4   •   S O N G   L I A N G   E T   A L .

Indirect Impact Pathway – Mental Health, Well-Being,
and Community Health

Mental  health  disorders  and  well-being  are  an  important  aspect  of  the  human  health  impacts
associated  with  climate  change  and  variability,  and  associated  weather  events.  Many  mental
health  consequences,  ranging  from  simple  stress  and  distress  symptoms  to  some  severe
conditions including anxiety, distress, posttraumatic stress disorder (PTSD), and even suicidal
tendency have been the focus of much of the research and public health responses in the past few
decades. Here are some key mental disorders and community health issues that may be related
to  climate  change  and  associated  weather  events,  based  on  the  U.S. Global  Change  Research
Program report (Crimmins et al. 2016).

Experience  with  extreme  weather  events,  such  as  flooding,  drought,  and  hurricanes,  may

cause the following mental disorders:
•
•
•
•

Increased stress, anxiety, depression, grief, and even suicidality;
Increased tensions on social stress and relationships;
Increased substance abuse; and
Increased risk of PTSD.
At the community level (Crimmins et al. 2016), potential impacts may include:
•
Increased interpersonal aggression,
•
Increased violence and crime,
•
Increased social instability, and
•  Decreased community cohesion.

Assessing the impacts of natural disasters on mental or community health and well-being of
affected  populations,  as  well  as  mediation  techniques,  has  been  a  focus  of  much  research,
community and public health responses. In Florida, studies have suggested that anxiety disorder,
major  depressive  episodes,  and  PTSD  among  affected  populations  could  be  significantly
associated with storm exposure and displacement during the occurrence of Hurricane Andrew in
1992 (David et al. 1996), as well as a number of hurricanes in 2004 (Acierno et al. 2007) and
2012  (Neria  and  Shultz  2012).  Studies  have  also  indicated  that  social  support  would  help  to
alleviate such negative impacts (Acierno et al. 2007). Similar impacts have been reported for
community  and  public  health  workers  who  responded  to  these  weather  events.  For  example,
during the 2004 Florida hurricane season, four hurricanes (Charley, Frances, Ivan, and Jean) as
well as one tropical storm (Bonnie) hit Florida during a period of seven weeks. Increased PTSD,
other  mental  health  issues,  and  substance  abuse  were  reported  among  public  health  workers
during  and  after  these  events  (Fullerton  et  al.  2013;  Fullerton  et  al.  2015).  The  studies  also
suggested  that  these  mental  health  outcomes  were  influenced  by  multiple  community
characteristics including the collective efficacy of neighborhood populations in the community.

C L I M A T E   C H A N G E   I M P A C T S   O N   H U M A N   H E A L T H   •   1 4 5

Significantly lower depressive symptoms were associated with communities that had sufficient
resources and received social support (Acierno et al. 2007, Fullerton et al. 2013, Fullerton et al.
2015).

Impacts  on  children  following  natural  disasters  are  of  particular  concern.  For  example,
Hurricane Andrew was a devastating category 5 Atlantic hurricane that struck South Florida in
1992. Studies showed significant impacts of hurricane exposure, stressors occurring during the
hurricane, and recovery periods on children’s persistent posttraumatic stress. In the Miami-Dade
County  area,  35%  to  60%  of  children  surveyed  reported  moderate  to  very  severe  levels  of
posttraumatic  stress  symptoms  (Vernberg  et  al.  1996;  La  Greca  et  al.  2010),  with  hurricane-
related stressors influencing children’s persistent posttraumatic stress symptoms and other life
events in later stages of children’s life (La Greca et al. 2010; Weems et al. 2010; La Greca et al.
2013).  These  findings  have  important  community  health  implications  for  identifying  and
potentially helping youth in the aftermath of natural disasters.

Conclusion

The  current  available  evidence  has  clearly  indicated  increases  in  average  temperature,  total
annual precipitation, frequency of extreme temperature conditions and heavy precipitation in the
United  States  in  the  past  five  decades,  as  well  as  increases  in  the  tropical  cyclone  activity  in
regions along the Atlantic Ocean, the Caribbean, and the Gulf of Mexico. Similar patterns are
expected in the future if no remediation is conducted (USEPA 2016). Florida is likely to face
even greater effects than the rest of the US, particularly effects associated with sea level rise, heat
waves, storm surge, hurricanes, and others (FOCC 2010) that affect human health in a variety of
different ways. Some effects are through direct exposure pathways, such as hurricane/storm and
temperature-related illnesses, injuries, and deaths. Some are through indirect exposure pathways
such as waterborne and vector-borne diseases. And still others are through social and economic
pathways, such as stress and mental illness. In addition to these direct and indirect effects, we
see coupled and compounded effects of climate change, which are anticipated to be exacerbated
in the future. For example, Florida is home to a large elderly population; the warm climate and
housing development capacity made this ideal. However, the elderly are more vulnerable to the
effects of heatwaves, less mobile in the event of hurricanes, and suffer greater impacts of the
symptomology  of  febrile  vectorborne  diseases.  This  puts  the  state  in  a  position  higher  public
health urgency by virtue of an interaction of demographic profile and increased impact of climate
change due to geography. Given the increase in hurricances and storm impacts expected under
climate change, we are likely to also see the added impact of vectorborne disease risk anticipated
in  the  aftermath  of  such  disasters.  For  example,  the  additional  potential  vector  breeding  sites
provided by debris and damaged infrastructure after hurricanes have been noted as concerns for
Zika  transmission  in  the  2016-2017  hurricane  season.  An  additional  component  of  this  is  the

1 4 6   •   S O N G   L I A N G   E T   A L .

unanticipated exposures post-disaster, in which both displaced residents and rescue workers have
radically  increased  outdoor  exposure,  reduced  access  to  air  conditioned  spaces,  and  to  basic
protection measures such as insect repellent and appropriate protective clothing. These are just
two of the compounded scenarios of public health concern that the state of Florida faces in a
changing climate. Despite the comprehensive information reviewed in the chapter, many things
are  still  unknown  or  are  not  well  understood  about  the  health  impacts  of  Florida’s  changing
climate. For instance, what are the impacts of sea level rise, flooding, and other extreme weather
events  on  water  contamination  that  will  ultimately  influence  human  health?  How  will  future
warming  trends  and  other  climate-sensitive  hazards  influence  the  transmission  and  spread  of
existing and/or new waterborne and vector-borne diseases? What are the disease burdens and
their distributions attributable to known climate-sensitive hazards in the state? To address these
challenges,  policies  focused  on  mitigation,  adaptation  strategies,  health  surveillance,  and
research that could close knowledge gaps on human exposures to these climate-sensitive hazards
and associated health impacts are much needed.

Acknowledgments

The authors thank Melissa Jordan for her instrumental discussion on this chapter. Song Liang was supported
in part by grants from NSF/EEID (EF-1015908) and NSF/WSC-Category 3 (1360330). Sadie J. Ryan was
supported in part by grants from NSF/EEID (DEB-1518681), NSF RAPID (DEB-1641145), and an Early
Career Fellowship from the Florida Climate Institute.

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