The Possible Effect of Climate Change on Selected Infectious Diseases in South Florida

The Possible Effect of Climate Change on The Possible Effect of Climate Change on Selected Infectious Diseases in South Selected Infectious Diseases in South

FloridaFloridaOffice of Epidemiology and Disease ControlOffice of Epidemiology and Disease Control

Miami-Dade County Health DepartmentMiami-Dade County Health Department

Juan A. SuarezJuan A. Suarez

Regional Environmental EpidemiologistRegional Environmental Epidemiologist

Presentation at the Medical Campus ofPresentation at the Medical Campus of

Miami Dade CollegeMiami Dade College

January 28, 2008January 28, 2008

ContributorsContributors

This presentation was adapted from This presentation was adapted from a November 2007 version prepared a November 2007 version prepared by:by:

Fermin Leguen, MD, MPH, DirectorFermin Leguen, MD, MPH, DirectorOffice of Epidemiology and Disease ControlOffice of Epidemiology and Disease ControlJuan A. SuarezJuan A. SuarezRegional Environmental EpidemiologistRegional Environmental EpidemiologistMenhel Kinno, MPH candidate, Intern OEDCMenhel Kinno, MPH candidate, Intern OEDCSome additional data slides from the Bureau of Some additional data slides from the Bureau of

Community Environmental Health-FDOHCommunity Environmental Health-FDOH

IntroductionIntroduction

Climate change in the form of global Climate change in the form of global warming and extreme weather are warming and extreme weather are increasingly mentioned in the media and increasingly mentioned in the media and journal articles as issues to be dealt with journal articles as issues to be dealt with in the next decades.in the next decades.

Human health will be affected by changes Human health will be affected by changes in the environment of insects and in the environment of insects and microorganisms that in turn are vectors or microorganisms that in turn are vectors or agents for disease in man. agents for disease in man.

AssumptionsAssumptions The following discussion assumes rise in The following discussion assumes rise in

sea levels, global increase in temperature, sea levels, global increase in temperature, and intrusion of the ocean water on fresh and intrusion of the ocean water on fresh bodies of water and drinking water wells.bodies of water and drinking water wells.

The science behind these assumptions is The science behind these assumptions is based on observations but also on based on observations but also on predictions.predictions.

Causes of these effects remain Causes of these effects remain controversial. Anthropogenic vs. natural controversial. Anthropogenic vs. natural variations.variations.

The physical results are based on the The physical results are based on the Intergovernmental Panel on Climate Intergovernmental Panel on Climate Change’s report.Change’s report.

Selected Infectious DiseasesSelected Infectious Diseases

Vector borne diseasesVector borne diseases Water borne diseasesWater borne diseases Rodent borne diseasesRodent borne diseases RabiesRabies

Vector-borne diseases:Vector-borne diseases:

Mosquito transmitted diseases:Mosquito transmitted diseases: Dengue & Dengue Hemorrhagic FeverDengue & Dengue Hemorrhagic Fever Yellow FeverYellow Fever West Nile FeverWest Nile Fever MalariaMalaria Other insects transmitted diseases:Other insects transmitted diseases: Lyme diseaseLyme disease TularemiaTularemia Chagas diseaseChagas disease

Source: CDC, 2007Source: CDC, 2007

Dengue Fever & Dengue Dengue Fever & Dengue Hemorrhagic FeverHemorrhagic Fever

genus genus FlavivirusFlavivirus There are four serotypes of the virus that cause the There are four serotypes of the virus that cause the

disease.disease. Transmitted by Transmitted by Aedes aegyptiAedes aegypti (a domestic, day-biting (a domestic, day-biting

mosquito, has a world wide distribution in tropical area)mosquito, has a world wide distribution in tropical area) Clinical features:Clinical features: High Fever, headache, High Fever, headache, Backache, joint pain, eye pain,Backache, joint pain, eye pain, RashRash Nausea and vomitingNausea and vomiting Hemorrhagic manifestation (DHF) which is potentially Hemorrhagic manifestation (DHF) which is potentially

lethal.lethal. No specific treatment is available.No specific treatment is available. No vaccination is available.No vaccination is available. Mosquito control.Mosquito control.


Dengue Fever & Dengue Dengue Fever & Dengue Hemorrhagic FeverHemorrhagic Fever

In 2005, 2.5 In 2005, 2.5 billion people at billion people at risk of Degue risk of Degue fever.fever.

The Aedes The Aedes mosquito has a mosquito has a worldwide worldwide distribution in the distribution in the tropical and sub-tropical and sub-tropical areas.tropical areas.

WHO, Fact Sheet, 2001WHO, Fact Sheet, 2001

Yellow FeverYellow Fever

Genus Genus FlavivirusFlavivirus It is also transmitted by It is also transmitted by Aedes Aedes mosquito.mosquito. This virus is restricted to only 2 regions: Africa and South America.This virus is restricted to only 2 regions: Africa and South America. Clinical Features (incubation period of 3-6 days):Clinical Features (incubation period of 3-6 days): Asymptomatic.Asymptomatic. Acute phase: Fever (sometimes Paradoxical fever with low pulse Acute phase: Fever (sometimes Paradoxical fever with low pulse

rate), aches, Nausea and vomiting, rate), aches, Nausea and vomiting, 15% Toxic phase: jaundice, abdominal pain with vomiting. Bleeding 15% Toxic phase: jaundice, abdominal pain with vomiting. Bleeding

can occur from the mouth, nose, eyes and/or stomach. ½ die within can occur from the mouth, nose, eyes and/or stomach. ½ die within 10-14 days.10-14 days.

Three types of transmission cycle:Three types of transmission cycle: Sylvatic (jungle): sporadic cases in forest.Sylvatic (jungle): sporadic cases in forest. Intermediate yellow fever: in Africa only.Intermediate yellow fever: in Africa only. Urban yellow fever: epidemics.Urban yellow fever: epidemics. No specific treatment is available.No specific treatment is available. Prevention: Vaccination and mosquito controlPrevention: Vaccination and mosquito control

CDC, 2007CDC, 2007

West Nile Fever:West Nile Fever:

Genus Genus FlavivirusFlavivirus Transmitted by female Transmitted by female Culex pipiensCulex pipiens mosquitoes mosquitoes Clinical Features:Clinical Features: Incubation period: 2-15 daysIncubation period: 2-15 days fever, headache, tiredness, and body aches, fever, headache, tiredness, and body aches,

occasionally with a skin rash and swollen lymph occasionally with a skin rash and swollen lymph glandsglands

1 in 150 ( Neuro-invasive disease, West Nile 1 in 150 ( Neuro-invasive disease, West Nile encephalitis or meningitis or West Nile encephalitis or meningitis or West Nile poliomyelitis)poliomyelitis)

Treatment: no specific treatment (antiviral Treatment: no specific treatment (antiviral “Ribravirin”)“Ribravirin”)

Prevention: mosquito control, vaccination only Prevention: mosquito control, vaccination only available for horses.available for horses.


2007 West Nile Virus Activity in the United 2007 West Nile Virus Activity in the United StatesStates

(Reported to CDC as of November 6, 2007)(Reported to CDC as of November 6, 2007)

WHO, 2007; CDC, 2007WHO, 2007; CDC, 2007

MalariaMalaria

Parasitic infection by Parasitic infection by PlasmodiumPlasmodium Human malaria is caused by four species:Human malaria is caused by four species: Plasmodium Plasmodium vivaxvivax & & ovaleovale P. P. malariaemalariae P. P. falciparumfalciparum 41% of the global population lives in area at risk of malaria.41% of the global population lives in area at risk of malaria. Malaria is transmitted by female Malaria is transmitted by female anophelesanopheles mosquito. mosquito. Clinical Feature (incubation period of 10-14 days):Clinical Feature (incubation period of 10-14 days): FeverFever RigorRigor SweatingSweating Treatment: anti-malarial medication and supportive therapyTreatment: anti-malarial medication and supportive therapy Prevention: prophylactic treatment and mosquito control.Prevention: prophylactic treatment and mosquito control.

Lyme diseaseLyme disease Bacterial infection by Bacterial infection by Borrelia burgdorferi.Borrelia burgdorferi. It usually lives in small animals (mice, squirrels, It usually lives in small animals (mice, squirrels, Transmitted by: Transmitted by: Ixodes scapularis, Ixodes pacificusIxodes scapularis, Ixodes pacificus

(blacklegged ticks)(blacklegged ticks) Clinical Feature (incubation period 3-30 days):Clinical Feature (incubation period 3-30 days): fever, headache, fatigue fever, headache, fatigue Erythema migrans (characteristic rash in 70-80%).Erythema migrans (characteristic rash in 70-80%). In untreated patient it can cause a wide ray of symptoms In untreated patient it can cause a wide ray of symptoms

(Nervous system, heart, and joint).(Nervous system, heart, and joint). Treatment: oral antibiotics, intravenous AB in severe cases Treatment: oral antibiotics, intravenous AB in severe cases Prevention: vaccine is no longer available, tick controlPrevention: vaccine is no longer available, tick control This disease may be more of an issue in the Northeast/Central This disease may be more of an issue in the Northeast/Central

states, unclear if South Florida would be affected.states, unclear if South Florida would be affected.


Reported Cases of Lyme Disease by Reported Cases of Lyme Disease by Year, United States, 1991-2005Year, United States, 1991-2005

CDC, 2007CDC, 2007

Chagas diseaseChagas disease

It is a parasitic infection by It is a parasitic infection by Trypanosoma cruziTrypanosoma cruzi Transmitted by kissing bud (Transmitted by kissing bud (triatominetriatomine vector). vector). Clinical Feature:Clinical Feature: Acute: occurs after infection and it is Acute: occurs after infection and it is

characterized by fever or swelling around the site characterized by fever or swelling around the site of inoculation of inoculation

Chronic Intermediate: asymptomatic stage.Chronic Intermediate: asymptomatic stage. Chronic (30%): life-threatening chronic Chronic (30%): life-threatening chronic

complications (dilated cardiomyopathy, dilated complications (dilated cardiomyopathy, dilated esophagus, toxic megacolon)esophagus, toxic megacolon)

Treatment:Treatment: Prevention: insect control.Prevention: insect control.

WHO, 2007WHO, 2007

Why there will be an increase in Why there will be an increase in Vector Transmitted disease?Vector Transmitted disease?

Warm temperature and surface water are essential for Warm temperature and surface water are essential for insect breeding (especially mosquito)insect breeding (especially mosquito)

Stagnant water with humid condition are both necessary for Stagnant water with humid condition are both necessary for breeding.breeding.

Warmer temperature leads to: Warmer temperature leads to: Enhance vector breeding, Enhance vector breeding, Increase vector survival, Increase vector survival, Increase vector biting rate,Increase vector biting rate, Reaching higher altitude, Reaching higher altitude, and reduce the pathogen’s maturation period with the and reduce the pathogen’s maturation period with the

vector.vector. Very hot temperature with dry condition can reduce the Very hot temperature with dry condition can reduce the

survival of insects.survival of insects.

Water & Food borne diseases:Water & Food borne diseases:

GiardiasisGiardiasis Cholera and other VibriosCholera and other Vibrios SalmonellaSalmonella

CDC, 2007CDC, 2007

GiardiasisGiardiasis Parasitic infection by Parasitic infection by Giardia lambliaGiardia lamblia Transmitted mainly through contaminated Transmitted mainly through contaminated

water.water. Clinical Feature (incubation period 1-2 weeks):Clinical Feature (incubation period 1-2 weeks): Asymptomatic.Asymptomatic. Diarrhea, Nausea and Vomiting, gas and Diarrhea, Nausea and Vomiting, gas and

flatulence, abdominal crampsflatulence, abdominal cramps Chronic diarrhea and malabsorption and weight Chronic diarrhea and malabsorption and weight

loss.loss. Treatment: oral antibioticsTreatment: oral antibiotics Prevention: good hygiene, avoidance of Prevention: good hygiene, avoidance of

contaminated water and food.contaminated water and food.

WHO, 2007WHO, 2007

CholeraCholera Causative agent: Causative agent: Vibrio choleraVibrio cholera It is mainly a water-borne diseaseIt is mainly a water-borne disease Clinical symptoms:Clinical symptoms: Acute, watery (rice water like) diarrhea.Acute, watery (rice water like) diarrhea. Vomiting Vomiting Leg crampsLeg cramps Rapid loss of body fluids and dehydration that Rapid loss of body fluids and dehydration that

might lead to death within hours without might lead to death within hours without treatment.treatment.

Treatment: antibiotics and IV fluidsTreatment: antibiotics and IV fluids Prevention: oral vaccine, avoid contaminated Prevention: oral vaccine, avoid contaminated

water and food.water and food.

WHO, 2007WHO, 2007

SalmonellaSalmonella Bacterial infection by Bacterial infection by SalmonellaSalmonella Water & food borne diseaseWater & food borne disease Clinical features:Clinical features: FeverFever Diarrhea, and abdominal crampsDiarrhea, and abdominal cramps Reiter's syndrome Reiter's syndrome Chronic carriersChronic carriers Treatment: oral antibioticsTreatment: oral antibiotics Prevention: avoidance of raw or Prevention: avoidance of raw or

undercooked eggs, poultry, or meat. undercooked eggs, poultry, or meat.

Vibrio vulnificusVibrio vulnificus Causative agent: marine bacterium Causative agent: marine bacterium Vibrio vulnificusVibrio vulnificus Water-borne (wounds) and consumption of raw oysters and Water-borne (wounds) and consumption of raw oysters and

shellfishshellfish Incubation: 12-72 hoursIncubation: 12-72 hours Clinical picture:Clinical picture: Septicemia in immunosuppressed, or chronic liver disease, Septicemia in immunosuppressed, or chronic liver disease,

or hemochromatosis, or cirrhosis or hemochromatosis, or cirrhosis Case fatality from 50-90%Case fatality from 50-90% Cellulitis, myositis, shock, hypotension, bullous skin lesions, Cellulitis, myositis, shock, hypotension, bullous skin lesions,

intravascular coagulation, thrombocytopeniaintravascular coagulation, thrombocytopenia Treatment: antibioticsTreatment: antibiotics Prevention: avoid contact of wounds with seawater and Prevention: avoid contact of wounds with seawater and

avoid eating raw or undercooked oysters and shellfishavoid eating raw or undercooked oysters and shellfish

Vibrio vulnificus in Florida, 1990-2006Vibrio vulnificus in Florida, 1990-2006

ExposureExposure # Cases# Cases

WoundWound 211211

OystersOysters 156156

UnknownUnknown 5555

CrabCrab 77

ClamsClams 33

ShrimpShrimp 11

TotalTotal 433433

Deaths from Vibrio vulnificus in Florida, Deaths from Vibrio vulnificus in Florida, 1990-20061990-2006

ExposureExposure # Deaths# Deaths % Total % Total CasesCases

OystersOysters 6666 15.215.2

WoundWound 2424 5.55.5

UnknownUnknown 2020 5.25.2

CrabCrab 22 0.50.5

ShrimpShrimp 11 0.30.3

ClamsClams 11 0.30.3

TotalTotal 114114 26.426.4

ExposureExposure # Cases# Cases # # DeathsDeaths

Deaths % Total Deaths % Total CasesCases

WoundWound 211211 2424 5.5%5.5%

OystersOysters 156156 6666 15.3%15.3%

UnknownUnknown 5555 2020 4.6%4.6%

CrabCrab 77 22 0.5%0.5%

ClamsClams 33 11 0.2%0.2%

ShrimpShrimp 11 11 0.2%0.2%

TotalTotal 433433 114114 26.4%26.4%

Vibrio vulnificus Cases and Deaths from Various Vibrio vulnificus Cases and Deaths from Various Exposures, Florida 1990-2006Exposures, Florida 1990-2006

Rodent-Borne Disease:Rodent-Borne Disease:

PlaguePlague


PlaguePlague Bacterial infection Bacterial infection Yersinia pestisYersinia pestis Transmitted by:Transmitted by: Flea biteFlea bite Contact with infected rodentContact with infected rodent Inhalation or ingestion of infected material.Inhalation or ingestion of infected material. It is still widely distributed in the tropics and subtropics and in It is still widely distributed in the tropics and subtropics and in

warmer areas of temperate countries. warmer areas of temperate countries. Clinical Feature:Clinical Feature: Bubonic form (most common type in which the disease is Bubonic form (most common type in which the disease is

transmitted by flea and it mainly affects the lymph nodes transmitted by flea and it mainly affects the lymph nodes (bubo) which became painful and may suppurate) (bubo) which became painful and may suppurate)

Septicaemic form Septicaemic form Pneumonic form (least common but most virulent)Pneumonic form (least common but most virulent) Treatment: antibiotics and supportive therapyTreatment: antibiotics and supportive therapy Prevention: rodent control, flea control, vaccination only for Prevention: rodent control, flea control, vaccination only for

high risk group.high risk group.


RabiesRabies Viral infection by Viral infection by Animal bite (domestic and wild animals). Animal bite (domestic and wild animals). Clinical Feature:Clinical Feature: Initially, non-specific symptoms Initially, non-specific symptoms Acute stage, signs of hyperactivity (furious rabies) or Acute stage, signs of hyperactivity (furious rabies) or

paralysis (dumb rabies) predominate.paralysis (dumb rabies) predominate. paralysis eventually progresses to complete paralysis paralysis eventually progresses to complete paralysis

followed by coma and death in all cases, usually due to followed by coma and death in all cases, usually due to respiratory failure. respiratory failure.

Without intensive care, death occurs during the first seven Without intensive care, death occurs during the first seven days of illness.days of illness.

Treatment: immediate cleaning of the wound, and post-Treatment: immediate cleaning of the wound, and post-exposure vaccinationexposure vaccination

Prevention: vaccination of domestic animals, vaccination Prevention: vaccination of domestic animals, vaccination of individuals at high risk, avoidance and control of wild of individuals at high risk, avoidance and control of wild animals.animals.

Control MeasuresControl Measures

Control measures for these diseases Control measures for these diseases and their vectors are well known and and their vectors are well known and established. However, new established. However, new challenges will be encountered in the challenges will be encountered in the control of insects and control of insects and microorganisms under the new microorganisms under the new environmental conditions and new environmental conditions and new methods must be researched and methods must be researched and implemented.implemented.

SummarySummary

The true effects that climate change will The true effects that climate change will have on infectious diseases will be hard to have on infectious diseases will be hard to predict but we can, with the present predict but we can, with the present knowledge, estimate which of these will be knowledge, estimate which of these will be more of a problem.more of a problem.

We must also not forget that today’s We must also not forget that today’s challenges with other issues in infectious challenges with other issues in infectious diseases, not related to climate change, diseases, not related to climate change, may also continue. Examples include may also continue. Examples include antibiotic resistance, limited resources, antibiotic resistance, limited resources, and new emerging pathogens. and new emerging pathogens.

UN Millennium Development GoalsUN Millennium Development Goals

Goal # 7Goal # 7Ensure environmental sustainability:Ensure environmental sustainability:

Integrate the principles of sustainable development Integrate the principles of sustainable development into country policies and programmes; reverse loss into country policies and programmes; reverse loss of environmental resources of environmental resources

Reduce by half the proportion of people without Reduce by half the proportion of people without sustainable access to safe drinking watersustainable access to safe drinking water

Achieve significant improvement in lives of at least Achieve significant improvement in lives of at least 100 million slum dwellers, by 2020 100 million slum dwellers, by 2020

Dr. Julie Gerberding, Dr. Julie Gerberding, CDC Oct 2007CDC Oct 2007

Many of the activities needed to protect Many of the activities needed to protect

Americans from the health effects of Americans from the health effects of

climate change are mutually beneficial for climate change are mutually beneficial for

overall public health….it is also important overall public health….it is also important

that potential health effects of that potential health effects of

environmental solutions be fully environmental solutions be fully

considered. considered.

I am persuaded that global climate change is one of

the most important issues that we will face this

century. With almost 1,200 miles of coastline and the

majority of our citizens living near that coastline,

Florida is more vulnerable to rising ocean levels and

violent weather patterns than any other state…Florida

will provide not only the policy and technological

advances, but the moral leadership, to allow us to

overcome this monumental challenge."

ReferencesReferences

IPCC, 2007: Summary for Policymakers. In: IPCC, 2007: Summary for Policymakers. In: Climate Change 2007: The Physical Climate Change 2007: The Physical Science Basis. Contribution of Working Science Basis. Contribution of Working Group I to the Fourth Assessment Report Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate of the Intergovernmental Panel on Climate Change Change [Solomon, S., D. Qin, M. Manning,[Solomon, S., D. Qin, M. Manning,Z. Chen, M. Marquis, K.B. Averyt, M.Tignor Z. Chen, M. Marquis, K.B. Averyt, M.Tignor and H.L. Miller (eds.)]. Cambridge and H.L. Miller (eds.)]. Cambridge University Press, Cambridge, United University Press, Cambridge, United Kingdom and New York, NY, USA.Kingdom and New York, NY, USA.

http://ipcc-wg1.ucar.edu/wg1/Report/AR4WG1_Print_SPM.pdfhttp://ipcc-wg1.ucar.edu/wg1/Report/AR4WG1_Print_SPM.pdf

ReferencesReferences Control of Communicable Diseases Manual, 18Control of Communicable Diseases Manual, 18thth

Ed. David L. Heymann, MD, Editor, APHA, WHO.Ed. David L. Heymann, MD, Editor, APHA, WHO. Centers for Disease Control and Prevention Centers for Disease Control and Prevention

http://www.cdc.gov/http://www.cdc.gov/ Environmental Protection Agency Environmental Protection Agency

http://www.epa.gov/climatechange/effects/health.htmlhttp://www.epa.gov/climatechange/effects/health.html World Health OrganizationWorld Health Organization

http://http://www.who.intwww.who.int/en//en/ United Nations. UN Millennium Development United Nations. UN Millennium Development

Goals. Goals. http://http://www.un.org/millenniumgoalswww.un.org/millenniumgoals//

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The Possible Effect of Climate Change on Selected Infectious Diseases in South Florida