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SUBMISSION BY THE SLOVAK REPUBLIC AND THE EUROPEAN COMMISSION ON BEHALF OF THE EUROPEAN UNION AND ITS MEMBER STATES This submission is supported by Bosnia and Herzegovina and Serbia. Bratislava, 8 September 2016 Subject: Submission under the Nairobi work programme on recent work in the

area of climate impacts on human health 1. Introduction SBSTA 44 invited Parties and NWP partner organizations and other relevant organizations to submit to the secretariat, by 29th August 2016, information on their recent work in the area of climate impacts on:

- human health, including changes in the geographical distribution of diseases; - new and emerging health issues, including tropical diseases and their impacts on

social and economic structures, as well as the issues of malnutrition, waterborne diseases, vector-borne diseases and disaster impacts; and the

- effects of climate change on health and productivity in the workplace, with implications for occupational health, safety and social protection.

The EU and its Member States welcome this opportunity to share with others its experiences and lessons learned. The first part of the submission provides some insights at the European level, the second part - and the corresponding annex - provides insights by selected Member States and the third part summarizes the lessons learned from the perspective of the EU. The EU hopes that this submission together with the follow-up activities by the secretariat will help to foster national adaptation planning in the area of health in all Party´s countries and strengthening the linkages not only among those participating at UNFCCC meetings but of practitioners being engaged in domestic adaptation activities at all levels. Therefore this submission provides links in order to allow for convenient and quick direct communication if the information provided is accessible in one of the UN languages. Promoting health and well-being is one of 17 Global Goals (SDG 3) that make up the 2030 Agenda for Sustainable Development. An integrated approach is crucial for progress across the multiple goals, including Climate Change (SDG 13).

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2. The EU Adaptation Strategy – 2016 update1

Climate change is continuing in Europe as well as globally. Land and sea temperatures are increasing; precipitation patterns are changing, generally making wet regions in Europe wetter and dry regions drier; sea ice, glaciers and snow cover are decreasing; sea levels are rising; and climate-related extremes such as heat waves, floods and droughts are increasing in frequency and intensity in many regions. Climate change will continue for many decades to come, causing further impacts on ecosystems and society. Some of the climatic changes in recent years have established new record levels, such as for global and European temperature, winter Arctic sea ice extent, and sea level. Some climatic changes have accelerated recently, e.g. sea level rise. Furthermore, various recent extreme weather and climate events in Europe have become much more likely as a result of global climate change. Past changes in climate have had wide-ranging impacts on ecosystems, economic sectors and human health in Europe. Ecosystems and protected areas are under pressure; land-based animal and plant species, including vector borne diseases, are changing their life cycle and are migrating northwards and to higher altitudes, and regional extinctions have been observed; invasive alien species have established themselves or have expanded their range; and marine species, including commercially important fish stocks, are migrating northwards. These environmental changes threaten biodiversity in Europe, but they also affect forestry, fishery, agriculture and human health, mostly adversely. The rise in sea level has increased flood risks and contributed to erosion along European coasts. The observed increase in heat waves had large effects on human health, in particular in cities. It is also increasing the risk of electricity black-outs and forest fires. Transport and tourism have also been affected by climate change with large regional differences. The majority of impacts across Europe are adverse, although some impacts of climate change have been beneficial, such as a decrease in heating demand. Climate change vulnerability is increasingly assessed taking into account socio-economic changes, including projected decreases in population size in the eastern parts of Europe, ageing of the population and increasing urbanization across Europe, and a narrowing economic gap between eastern and western parts of Europe. Multi-sectoral impacts and vulnerabilities vary across European regions. The water, agriculture, forestry and biodiversity sectors show strong interdependencies, also with changing land use patterns and population change. South-eastern and southern Europe are projected to be hotspot regions with the highest number of sectors severely affected by climate change. Regarding ecosystem services the Alps and the Iberian Peninsula are additional hotspots. Also coastal areas and floodplains in the western parts of Europe are multi-sectoral hotspots. Arctic

1 For more details: see “Climate change, impacts and vulnerability in Europe” (EEA Report, September 2016)

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ecosystems and human activities will be much affected due to the particularly fast increase in air and sea temperatures. Estimates of the projected economic impacts of climate change in Europe have partial coverage and show considerable uncertainty. Economic costs can potentially be high, even for modest levels of climate change, and these costs rise significantly for higher warming scenarios. Projected damage costs from climate change are highest in southern Europe. More information has become available on costs and benefits, at national scale, of adaptation for coastal areas, water management, floods, agriculture and the built environment. Europe is also vulnerable to climate change impacts outside Europe through six major potential pathways: trade of agricultural commodities, trade of non-agricultural commodities, infrastructure and transport, geopolitics and security risks, human mobility related to migration, and finance. European vulnerability to cross-border effects is expected to increase in the coming decades, though quantitative projections are not available yet. Climate change adaptation strategies, policies and actions, including mainstreaming into other policies, are progressing at all governance levels (EU, transnational, national and local). Further actions might include enhancing policy coherence across EU environmental and sectoral policies; effective and efficient action across all levels of governance, through multi-level governance; enhancing flexible 'adaptive management' approaches; combining technological solutions, ecosystem based approaches and 'soft' measures; involving the private sector; and using a balanced approach between ‘incremental’ and ‘transformative’ adaptation actions. The knowledge base can be enhanced regarding EU wide climate change impact, vulnerability and risk assessments, e.g. through better reporting of assessments; enhanced national and sectoral assessments; and further monitoring, reporting and evaluation of adaptation actions at national level.

The magnitude of future climate change and its impacts depends on the effectiveness of global climate mitigation efforts. It can be substantially reduced by an ambitious global mitigation policy compatible with the mitigation goal of the 2015 Paris agreement of holding the increase in global average temperature to well below 2°C above pre-industrial levels. 3. Current efforts in adaptation planning on human health in the EU Member States

The main health effects from climate change are related to extreme weather events, changes in the distribution of climate-sensitive diseases, and changes in environmental and social conditions. River and coastal flooding have affected millions of people in Europe in the last decade. Health effects include drowning, injuries, infections, exposure to chemical hazards, and mental health consequences. Heat waves have caused tens of thousands of premature deaths in Europe since 2000. Since length, frequency and intensity of heat waves are

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projected to increase in the future associated health effects are projected to increase, unless adaptation measures are taken. Cold-related mortality is projected to decrease due to better social, economic and housing conditions in many countries in Europe. There is inconclusive evidence whether the projected warming will lead to a further substantial decrease in cold-related mortality. Observations show a move to higher latitudes and altitudes of specific tick species and the associated vector-borne diseases (Lyme borreliosis and tick-borne encephalitis). Climate change is projected to lead to further northward and upward shifts of tick species. Despite the increased concern about the upward incidence of Lyme Borreliosis (LB), effective measures to control tick populations or vaccines for LB are not yet available. Therefore, behavioral measures including avoidance of areas inhabited by ticks, performing routine body checks, using protective clothing, and the application of tick repellents are of great importance. Unfortunately, acceptance and uptake of many of these preventive behaviors are currently low. Hence, effective health education and public health communication aimed at promoting the uptake of preventive behaviors regarding tick bites and LB are urgently needed. Climate change was (and is projected to be) a factor in the expansion of the Asian tiger mosquito and a sand-fly species, which can disseminate several diseases (respectively dengue and chikungunya; and leishmaniosis). Recent outbreaks of vibriosis infections in Baltic Sea states have been linked to increases in sea surface temperature. The emergence of vibriosis in high-latitude regions requires improved diagnostic detection and clinical awareness of these emerging pathogens. Quantitative projections of future climate-sensitive health risks are difficult due to the complex relationship between climatic and non-climatic factors, climate-sensitive disease and other health outcomes and future adaptation measures.

4. Lessons learned

The State of the Environment Report 20152 identified “avoiding harm to people’s health and

well-being and ecosystems by precautionary and preventive action” as one of the four key approaches to achieve the vision of the Seventh EU Environment Action Programme

(7EAP)3. The other three approaches being: mitigation of GHG emissions through resource-

efficient technological innovations; adaptation to impacts of climate change by increasing resilience; and restoring and enhancing natural resources.

Adapting to the many changes European society faces, as mentioned above, is a challenge but also an opportunity for synergies and benefits if Europe implements adaptation measures in a coherent way, by ensuring that policies are integrated and working toward similar goals. Such policy coherence will be needed across many environmental and sectoral policies, both

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http://www.eea.europa.eu/soer 3 http://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32013D1386&from=EN

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regarding policy development and implementation. A related challenge is to ensure the effectiveness, efficiency and coherence of action across the various levels of governance, through multi-level governance. EU adaptation policy should take into account national strategies and plans as well as actions at transnational and city levels.

Adaptation policy responses ought to be flexible and tailor‑made to address regional and local conditions and needs and also taking into account the progress made in the scientific understanding of disaster risks, decadal climate variability, and long-term climate and socio-economic changes. This understanding is evolving and lessons are being learned from implementing actions. It is important to adopt an 'adaptive management' approach, which means adjusting plans to these conditions as they unfold, taking account of uncertainty over future developments, and constantly updating adaptation policy with new information from monitoring, evaluation and learning.

Flexibility can also be advanced by using different types of adaptation measures. Implementing a combination of 'grey' (i.e. technological and engineering solutions), 'green' (i.e. ecosystem-based approaches) and 'soft' (i.e. managerial, legal and policy approaches) adaptation options is often a good way to deal with the inter-connections between natural systems and social systems.

The involvement of stakeholders is important in creating a sense of 'ownership' in adaptation policy, a critical factor in the success of adaptation implementation. Stakeholder involvement also helps to improve the coherence of adaptation actions and builds adaptive capacity in the wider society. Multi-level governance bridges the gaps between the different levels of policy and decision-making and provides opportunities for ensuring key actors are involved.

In most Member States, the private sector does not yet seem to be fully integrated into adaptation policy processes. There is therefore limited information about vulnerability and risks of businesses and about adaptation measures being taken by the private sector. This challenge could be addressed further by adaptation policies and actions.

Incremental adaptation builds on existing adaptation measures and known solutions by improving these, often based on proven knowledge gained over decades. Incremental adaptation often focuses on individual measures. Measures are relatively quick to put in place and can often deal sufficiently and effectively with short- and medium-term challenges.

When incremental adaptation is no longer sufficient, transformational adaptation is needed. Transformational adaptation involves managing more radical change rather than protecting or restoring a certain environmental or social state. Transformative adaptation follows a broader and systemic approach and addresses the root causes of vulnerability to climate change, which is often the result of human actions, such as settling in risk-prone areas, inadequate building design or other behavior that aggravate the impact of climate change. For example, the design of cities, its buildings and its infrastructures are supposed to last for decades or even centuries.

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Transformative adaptation requires rethinking city planning and building in order to prepare for future climatic conditions. It may involve e.g. redesign of parks and other open spaces to accommodate storm water, new building design to better cope with heat waves and developing transport infrastructure that is robust against extreme events. The transformative approach seeks to integrate adaptation with other aspects of urban development with the

opportunity of a better functioning city and improved quality of life4.

Member States and cities, with few exceptions, have not yet implemented comprehensive adaptation approaches that combine incremental and transformative actions, although some have taken transformative steps. In future further actions can be expected combining different types of actions and learning from experiences that are accumulating across EU, transnational, national and urban levels. Such learning will benefit from increasing activities at various governance levels in monitoring, reporting and evaluation. Sharing experiences and learning about the use of monitoring and evaluation results will further improve

adaptation policy and practice; see also5.

In national adaptation strategies across Europe, human health is fourth in the order of priorities, after water, agriculture and forestry. There is no long-term sustainable development without appropriately considering climate change effects. Consequently, although integrated climate change mitigation and adaptation is still a new approach, some cities are already exploring the opportunities. Mainstreaming the need to adapt into other policy areas, such as climate change mitigation, water management, biodiversity, disaster risk management or health, can be an effective way to

implement adaptation. It is sometimes even the only way decision-makers accept6.

4Urban adaptation to climate change in Europe 2016 — Transforming cities in a changing climate (EEA Report 12/2016) 5National monitoring, reporting and evaluation of climate change adaptation in Europe (EEA Technical Report 20/2015) 6Urban adaptation to climate change in Europe 2016 — Transforming cities in a changing climate (EEA Report 12/2016)

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ANNEX Examples at the EU Level

i. European Union Policy Framework The European Commission's 2013 EU strategy on adaptation to climate change is accompanied by a Staff

Working Document7 which sets out what the EU is doing as regards impacts of climate change on health. The

strategy provides a framework and mechanisms to improve the preparedness of the EU for current and future impacts of climate change, thus contributing to a more climate-resilient. It is structured around three strategic objectives: promoting action by Member States; better informed decision making; and "climate-proofing" EU action by mainstreaming adaptation measures into EU policies and programmes and promoting adaptation in key vulnerable sectors. It thus also encourages the mainstreaming of climate change impacts and responsive measures also in the health sector, including prevention and health determinants such as nutrition. The EU health strategy, 'Together for Health' recognizes climate change as a threat to health in the EU, the Community's role to coordinate and respond rapidly to health threats globally and to enhance Member States capacities to do so. The EU Health Programme (2014-2020) includes among its goals the need to protect Union citizens from serious cross-border health threats, including those caused by climate change. In 2013, the European Union adopted the Decision on serious cross-border threats to health (Decision 1082/2013/EU). This decision strengthens preparedness in the EU and the coordination of responses to health threats. It helps Member States prepare for and protect citizens against possible future pandemics and serious cross-border threats caused by communicable diseases, chemical, biological or environmental events, including climate change. The Covenant of Mayors for Climate and Energy, an initiative of the European Commission, empowers local and regional authorities, stakeholders and citizens to define their transition to low carbon and climate resilient future. New signatories commit to implementing EU climate and energy objectives on their territory, including climate-resilient action. Addressing impacts of climate change on health is explicitly encouraged, and several good examples already exist, in particular in relation to heat wave response planning, drought management, and enhancing health benefits of adaptation actions, particularly ecosystem based solutions. The European Centre for Disease Prevention and Control (ECDC) is in charge of scientific evidence and risk assessments on communicable diseases. ECDC developed the 'European Environment and Epidemiology' (E3) Network, which provides real-time monitoring tools of meteorological conditions to assess the risk of water-borne diseases, climate change risk maps of vector-borne diseases, a Handbook for National Vulnerability Impact and Adaptation Assessments from climate change for communicable diseases, and geospatial datasets for analysing the impacts of global change on infectious disease transmission, as well as other tools for risk

assessments8. In addition, ECDC and EFSA (European Food Safety Authority) host VectorNet

9, a platform for

exchanging data on the geographical distribution of arthropod disease vectors in Europe, and have produced a wide range of studies focused on assessing European impacts and vulnerabilities to climate change.

Relevant information on health and climate change adaptation is available on Climate-Adapt10.

7http://ec.europa.eu/clima/policies/adaptation/what/docs/swd_2013_136_en.pdf

8https://e3geoportal.ecdc.europa.eu/SitePages/General%20Description.aspx

9http://ecdc.europa.eu/en/activities/diseaseprogrammes/emerging_and_vector_borne_diseases/Pages/VBORNET.aspx

10http://climate-adapt.eea.europa.eu/eu-adaptation-policy/mainstreaming/health

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ii. Studies and Research

A 2016 study11 commissioned by DG Environment highlights the health and social benefits of nature and

biodiversity, including on combatting heat waves. The PESETA set of projects has addressed certain aspects of quantifying the impacts of climate change on

health, with a study published in 201412. Current work of PESETA includes assessment of human health impacts

and effects on labour productivity, in particular heat stress. There is a number of FP7 or H2020 research projects which are dealing with health impacts, such as:

- ARCRISK13: Impacts on health in the Arctic and Europe owing to climate-induced changes in

contaminant cycling (completed in 2015),

- HEAT-SHIELD14: Integrated inter-sector framework to increase the thermal resilience of European

workers in the context of global warming (ongoing),

- BlueHealth15: Investigating the relationship between blue infrastructure and health and well-being

in Europe (ongoing).

iii. Climate Action Funding - LIFE LIFE funding for climate change adaptation includes projects awarded through annual calls that test or demonstrate approaches to addressing issues of climate impacts on human health, i.e. through projects on urban resilience, disaster risk reduction or development of adaptation strategies or vulnerability assessments. Some completed projects include:

- Development of adaptation strategies with public health aspects for countries (Cyprus) or cities (Helsinki region (Finland), Warsaw (Poland), Bologna (Italy),

- Development of green infrastructure to better cope with floods and coastal storm surges or heat waves: green roofs, permeable surfaces, green alleys and streets, urban forestry, green open spaces such as parks and wetlands, and adapted buildings,

- Development of flood or fire early warning systems.

For more examples, please consult the LIFE website16 or the 2015 brochure on LIFE and climate change

adaptation17.

iv. Health and climate change in development cooperation

With regard to the EU's development assistance in health, it needs to be considered that the disease burden due to climate change is highly variable for each country and each sub-region, and there is no universal single-best adaptation measure. Therefore the EU contribution to help countries to adapt to climate change in health consists in strengthening of comprehensive health systems, including strengthening countries' public health capacities to assess disease burden and design adaptation measures, and prioritize interventions based on the estimated disease burden and the potential effectiveness and efficiency of these interventions.

11http://ec.europa.eu/environment/nature/biodiversity/intro/docs/Health%20and%20Social%20Benefits%20of%20Nature%20

-%20Final%20Report%20Main%20sent.pdf 12https://ec.europa.eu/jrc/en/publication/eur-scientific-and-technical-research-reports/climate-impacts-europe-jrc-peseta-ii-

project 13http://cordis.europa.eu/result/rcn/161281_en.html

14http://cordis.europa.eu/project/rcn/200678_en.html

15http://cordis.europa.eu/project/rcn/199715_en.html

16http://ec.europa.eu/environment/life/index.htm

17http://ec.europa.eu/environment/life/publications/lifepublications/lifefocus/documents/climatechangeadaptation.pdf

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The EU development cooperation has identified health as one of the sectors affected by climate change in different ways. It has therefore developed a guidance note on integrating climate change in the health sector. The note is used by officers in charge of programming actions in the sector in order to ensure that potential climate-related elements are fully identified and integrated if relevant. As regards specific climate action, the EU flagship initiative Global Climate Change Alliance (GCCA+) has supported several country programmes which do include health related components, often under the form of support to fuel-efficient and improved cooking stoves, with a clear positive impact on indoor-air pollution and the related respiratory and ocular diseases. Other GCCA+ actions include drinking water management and

sanitation under an adaptation focus, with a clear direct impact on the related diseases.18

Finally, and still under the GCCA+ initiative, several countries benefitted from support to their national institutional set-up and sector strategies with the view to integrate climate change in the relevant areas. An example of such action is Belize, where the capacity building support to the national government to coordinate a national response to the threats of climate change has led, among other, to the undertaking of integrated vulnerability and adaptation assessments, one of which focussing on water and health sector, aimed at the development of national adaptation response strategies.

Examples at EU Member State Level Belgium In 2010, Belgium adopted its national adaptation strategy. To implement this Strategy regional plans have been adopted and national and federal adaptation plans have been developed on the base of vulnerability assessment studies. Those plans address different sectors, like health.

In terms of health, some examples of health adaptation measures are:

- The Federal and regional heat wave and ozone plans. Last May 15, the 2016 heat wave and ozone federal plan was issued. This plan is the result of one decade of experience in the management of heat waves in Belgium. It explicitly refer to climate change, as one of the main risk factors that will leads us in the coming years, to warmer and more frequent, episodes of heat waves.

- The MODIRISK project, dedicated to the monitoring of specific vectors like aedes mosquitoes, has been finalized and mosquitoes eradication programs have been conducted on our territory

- A system of identification and surveillance of infectious and vector borne diseases is in place which can be for instance, linked to climate change. This system is coupled to a reportable disease list which includes new or unusual diseases like: Lyme disease, malaria, zika, etc.)

- We support research on climate change and health. For example, within BELSPO (The Belgian Science Policy Office), we started a project called cordex.be aiming at developing national climate scenario with some case studies, inter alia on climate change and health. This project on climate change will allow us to :

o address specific climate-related issues using local climate-impact models

o and produce high-resolution climate runs over Belgium.

This will be a strategic tool of anticipation, preparedness and response.

Future adaptation actions foreseen include inter alia the promotion of education and training of health professionals on environment and health with a focus on linkages between climate change and health (master degree in environmental health)

18www.gcca.eu

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Bulgaria In order to reduce the country's vulnerability to the effects of climate change and improve the capacity to adapt natural, social and economic systems to the inevitable adverse impacts of climate change, the Ministry of Environment and Water initiated a process towards development of a National Adaptation Strategy to Climate Change and Action Plan (NAS).

The NAS will be a package of strategic documents, a set of a risk and vulnerability assessment, a number of other documents with sectoral measures and economic analysis. The Ministry of Environment and Water as a body coordinating the development of the NAS is guided by the EU adaptation strategy.

Taking into account that the development of such a strategic document is subject to substantial expertise and significant data collection, a stepwise approach was adopted.

As a first step a Framework document “Risk and Vulnerability Analysis and Assessment of the Bulgarian Economic Sectors to Climate Change” was prepared. The document was finalized in early June 2014.

The Framework document should serve as a basis for the further development of a National Adaptation Strategy. Therefore all the collected and evaluated information will provide the ground for the development of specific measures which should present strategic actions that reduce the vulnerability of the country from the effects of climate change. The competent authorities will be involved in the development of measures for each sector, as well as NGOs and the scientific community.

In the section of the Risk and Vulnerability Analysis and Assessment of the Bulgarian Economic Sectors to Climate Change a special part aims to analyze and assess the potential risks for public health in the Republic of Bulgaria and its vulnerability to climate change.

In the "Health" sector, the effect of changes in temperatures, precipitation and extremes for the health of the population may manifest in a different manner for different scenarios, as well as with a varying degree of probability for the different effects of climate change.

Possible negative health effects of rising temperatures are defined as follows:

- Increased mortality from cardiovascular diseases and strokes in large cities during the summer period, due to heat waves in urban heat islands;

- Increase in the incidence of vector-transmitted diseases due to prolongation of the vegetative cycle of the vectors and in particular ticks I. Ricinus, which carry Borrelia burgdorferi;

- Increased number of cases of Salmonella infection due to the longer vegetative period and more favorable conditions;

- Increased campylobacteriosis, due to the longer vegetative period and more favorable conditions. Additionally the risk of kamrilobakterioza increases with the combination of higher temperatures with high humidity;

- Increase and exacerbation of respiratory diseases due to the increased concentration of carbon dioxide (CO2), dust and small particles in the air;

- Increased number of allergic diseases due to early flowering and increased concentration of pollen, spores and other allergens in the air.

Possible negative health effects of changes in precipitation are defined as follows:

- Increased number of cases of Cryptosporidiosis in northwestern Bulgaria because of the more frequent and heavy rainfall;

- Increased number of cases of campylobacteriosis in northwestern Bulgaria because of more frequent rainfall combined with increased average annual temperatures;

- Increased number of cases of diarrheal caused by non-cholera vibrios due to heavy rainfall and high

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humidity in northwestern Bulgaria and the Black Sea.

Health consequences of expected changes in extreme climate events are:

- Increase in mortality due to extreme climate events and fires (by 10%), over-representation among vulnerable groups;

- Increase in the number of water and food-borne diseases, because of disruptions of the infrastructure;

- Increasing cases of post-traumatic stress.

Based on the analyses the sector’s vulnerability can be defined as moderate and the adaptation capacity as insufficient. Considering the results from the analysis the NAS will include a dedicated sector “Human Health” and specific measures for the sector will be planned.

Czech Republic In October 2015 the Czech Government adopted the Strategy on Adaptation to Climate Change in the Czech Republic. This document represents a national adaptation strategy of the Czech Republic and includes assessment of the climate change impacts and proposals for specific adaptation measures, legislative and partial economic analysis. Health and hygiene is one of its ten priority areas. Strategy will be implemented by the National Action Plan on Adaptation to Climate Change, which is currently under development (foreseen to be adopted in the end of 2016). Monitoring the activity of ticks (Ixodes ricinus) The Czech Republic has a long history of ticks monitoring. The tick activity forecast is published every Monday and Thursday in cooperation with the National Health Institute and supported by the Ministry of Health. The higher level of activity, the higher the risk of attack by human or animal tick, and if infected, the probability of contracting tick-borne encephalitis and Lyme disease. This risk is expressed in ten stages (1 = low risk – 10 = the highest risk) complete with recommendations on how to behave in a situation predicted when visiting sites with an expected incidence of ticks. The forecast is provided for the period from April to October, a specific start and end dates depend on current weather conditions and can therefore be shifted into March or November.

Table: Example of the tick activity forecast (Source: CHMI19)

Day Tuesday Wednesday Thursday Friday Saturday Sunday

Date 2. 8. 2016 3. 8. 2016 4. 8. 2016 5. 8. 2016 6. 8. 2016 7. 8. 2016

Level of Activity

5 5 5 4 4 4

Monitoring tick-borne diseases There are many scientific studies dealing with the issue of tick-borne diseases, such as tick-borne encephalitis (TBE) and Lyme borreliosis. Research has demonstrated an important role of climate-linked conditions in the ecology of the vector Ixodes ricinus, connected with changes in its population. The seasonal pattern of TBE has changed markedly over time. The proportion of cases occurring in April, May, October, and November increased from 9% in the 1970s to 23% in 2000-2008. TBE occurrence in new areas (or higher incidences in places of formerly sporadic occurrence) is closely associated with wider distribution of I. ricinus (from the former 700 m to today’s 1200 m a.s.l. These changes in incidence patterns appear to be linked with changes in climatic and meteorological conditions. The link between climate change and TBE incidence is plausible, since TBE is a recreation-related infection associated with outdoor activities, and since climatic changes affect the life cycle of the vector.

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Further information (available in Czech Language only): http://portal.chmi.cz/predpovedi/predpovedi-pocasi/ceska-republika/predpoved-aktivity-klistat

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Figure: Tick-borne encephalitis, Czech Republic, 1970–2008, reported cases by district of infection and period.20

France The main website to access information on health and climate related activities in France is http://social-sante.gouv.fr/sante-et-environnement/risques-climatiques/article/changement-climatique-et-sante Current initiatives France is involved in France is participating in the Pan-European Programme on Transport, Health and Environment developed under the aegis of the United Nations and the WHO. In this regard, political commitment is essential and Ministers of

Health, Transport and Environment from 56 countries adopted the Paris Declaration21 in April 2014 that

encourages and supports the development of more sustainable and healthier transport systems in cities. Moreover, French cities are involved in the WHO network of cities that committed themselves to promote transportation means which are beneficial to citizens’ health but also sustainable urbanization, increase of parks

and green areas of Carbon Dioxide captors.22

Ministry of Health’s response to Climate Change The ministry is actively participating in the French National Plan on adaptation to Climate Change (Plan national d’adaptation au changement climatique) which includes specific measures such as monitoring of extreme temperature or surveillance of vector risks. The first plan, in 2010, contains a set of 84 actions

expressed in 230 measures and is available online.23

Given the uncertainty surrounding climate change predictions and evaluations of the anticipated impacts of climate change, several priorities have been highlighted

- increasing current knowledge in all fields, including the use of a socio-economic approach;

- defining methodologies for mainstreaming adaptation;

- reinforcing observation and alert mechanisms. The second plan, which will be launched in 2017 will aim to reinforce health-related actions and strengthen the role of health professionals. This forthcoming plan will also have a territorial dimension including oversees departments that have specific needs. The National Plan on Health and Environment (2015-2019) also includes provisions on management of risks linked to vector borne diseases.

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http://www.ncbi.nlm.nih.gov/pubmed/23025693 21https://www.unece.org/fileadmin/DAM/thepep/Publications/2015/Paris_Declaration_in_English_Final.pdf

22 For example HEAT http://www.heatwalkingcycling.org/ and http://www.villes-sante.com/heat/

23 http://www.developpement-durable.gouv.fr/The-national-climate-change.html

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Example 1: The summer 2015 heat wave With regard to the heat wave that occurred in France over the summer 2015 the lessons from the precedent one in 2003 were essential. Combined with improved knowledge of meteorological factors, it enabled us to adapt our response and implement prevention measures that saved lives. In 2014, the Public Health Council (Haut Conseil de la Santé Publique) updated the health recommendation of the National Plan on Heat Waves to adapt to target populations taking into consideration their physiopathology (Recommendations to health

professionals, mobilization of hospitals, mass information campaign)24.

Example 2: Tiger Mosquito Climate change favors the development of insects and especially the Tiger Mosquitos (Aedes albopictus) in France. The Ministry of Health is monitoring the evolution of the presence of Tiger Mosquito and established a surveillance network. We have developed a dedicated website for citizens to notify the presence of Mosquitos

and took several measures to prevent Mosquitoes from invading other parts of France25.

Germany

i. Examples of impacts of climate change on health

Vector-borne, food-borne and water-borne infectious diseases According to the German climate change and health assessment report, increased risks are expected for vector-, food- and water-borne infectious diseases through:

- Pathogens that are native to Germany (e.g. hanta virus, TBEvirus and borrelia infections, which are transmitted by ticks, salmonella, campylobacter), and

- Emerging infectious diseases (e.g. dengue fever or chikungunya and leishmaniasis).

Lyme Borreliosis, transmitted by ticks, is the most common notifiable vector-borne disease in Germany, with 16,461 cases in the eastern federal states between 2007 and 2009. Influence of heat waves on ischemic heart diseases in Germany A study of the German Meteorological Service funded by the German Environment Agency and the Federal Environment Ministry analyzed the impact of heat waves on ischemic heart disease (IHD) mortality and morbidity in Germany during 2001–2010. Heat waves were defined as periods of at least three consecutive days with daily mean temperature above the 97.5th percentile of the temperature distribution. The results show that IHD mortality during heat waves was significantly increased (+15.2% more deaths on heat wave days). In contrast, no heat wave influence on hospital admissions due to IHD could be observed. Regional differences in heat wave IHD mortality were present, with the strongest impact in Western Germany and weaker than average effects in the Southeastern and Northwestern regions. The increase in mortality during heat waves is generally stronger for females (+18.7%) than for males (+11.4%), and for chronic ischemic diseases (+18.4%) than for myocardial infarctions (+12.2%). Longer and more intense heat waves feature stronger effects on IHD mortality, while timing in season seems to be less important. Source: Zacharias S, Koppe C, Mücke HG (2014): Influence of Heat Waves on Ischemic Heart Diseases in Germany. Climate, 133-152; doi: 10.3390/cli2030133

UV-radiation According to the Federal Statistical Office, melanoma and other malignant skin lesions alone cost health services 311 million euros in 2002 and even 503 million euros in 2008. These costs may rise even further as a result of climate change. In 2006, the WHO published an assessment of the health risks of UV radiation.

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http://social-sante.gouv.fr/sante-et-environnement/risques-climatiques/canicule 25

http://social-sante.gouv.fr/sante-et-environnement/risques-microbiologiques-physiques-et-chimiques/especes-nuisibles-et-parasites/article/moustiques-vecteurs-de-maladies

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Pursuant to the assessment, excessive exposure to UV radiation caused a worldwide loss of around 1.5 million DALYs (0.1% of the total global disease burden) and resulted in 60,000 untimely deaths. Sensitivity to weather In 2012, working people called in sick due to weather sensitivity for an average of 1.7 days. Assuming that the workforce in Germany is around 40 million people strong and that around 45 % are sensitive to weather, around 31 million work days were lost due to sensitivity to weather. Assuming furthermore an annual gross domestic product of 40,000 euros per citizen, this would add up to 80,000 euros per working person or, based on 250 work days that year, 320 euros per working person and day. Calculating with 31 million work days lost due to weather sensitivity, this translates into economic damages of almost 10 billion euros for 2012.

ii. Activities in Germany

Adaptation to climate change associated health risks as a task of environmental health protection An Analysis of a nationwide survey by the Federal Environment Agency The Federal Environment Agency (UBA) and the Robert Koch Institute jointly elaborated guidelines for decision makers and stakeholders. Building on these, in 2013/2014, UBA has conducted a nationwide survey, collecting data on completed, ongoing and planned adaptation measures. UBA also analysed 32 adaptation strategies of the Federal States. Selected best practice examples of potential health-related prevention and adaptation measures concerning heat stress, UV radiation exposure and the spread of Ambrosia artemisiifolia are presented in this article. The data collection with more than 330 activities can be found on the website of the German National Environment and Health Action Plan (APUG; www.apug.de, in German only). In the course of this project, the APUG website was also significantly extended with comprehensive information and overviews on health risks of climate change, hence creating a central platform for this particular topic. The investigation was financed by the German Ministry of Health and the Federal Environment Agency. Health heat warning system In Germany, DWD has been operating a nation-wide Heat Health Warning System (HHWS) since 2005. The HHWS provides information for the general public and the public health authorities in order to be prepared for heat waves and to minimize their negative health impacts. The combination of weather forecast, thermal indices (Perceived Temperature) and their specific thresholds, short time acclimatization of people during summer conditions, nocturnal minimum temperature and indoor conditions are used to predict specific conditions such as heat episodes, which are associated with consequences like an increased mortality and morbidity among human population. In addition, information about the expected duration of these conditions is important and provided. These specific thresholds and approaches used have thermo-physiological background and are used to assess the levels of heat stress to which humans are exposed. The HHWS leads to a reduction of the heat related mortality and in general to protection of human life. Research centre in human biometeorology

The DWD operates a Research Centre in Human Biometeorology26, which is responsible for weather, climate

and health issues. Daily forecasts for cold/heat conditions (based on Perceived Temperature) for Germany and Europe, UV-index for all Europe, Pollen for Germany and weather sensitivity are provided. In addition research is performed in the context of effect of climate conditions on mortality and morbidity including climate change scenarios. Climate information service Germany is also participating in the Global Framework for Climate Services (GFCS), where “health” is one of

the priority areas27. The Deutscher Klimadienst (DKD) has been established as national implementation of the

GFCS28.

26 http://www.dwd.de/DE/klimaumwelt/ku_beratung/gesundheit/gesundheit_node.html

27 http://gfcs-climate.org/health

15

iii. International activities

Protecting health from climate change - A seven-country initiative Recognizing that global climate change is posing ever growing threats to public health security, in 2008 the WHO Regional Office for Europe started a two-year project funded through the International Climate Initiative of the German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety. “Protecting health from climate change. A seven-country initiative” focuses on taking action against the health effects of climate change in seven European countries: Albania, Kazakhstan, Kyrgyzstan, the Russian Federation, Tajikistan, the Former Yugoslav Republic of Macedonia and Uzbekistan. The project supports actions and pilot-tests some interventions in countries that are already experiencing climate-related problems (such as extreme events, water scarcity, glacier melting, permafrost thawing) that are projected to have severe health effects. All countries ratified the United Nations Framework Convention on Climate Change and are committed to do more to protect health from climate change by increasing awareness and improving intersectoral cooperation. Activities are carried out by national Governments through bilateral agreements with the WHO Regional Office for Europe in the framework of the WHO global workplan on climate change and health. Italy In Italy, the surveillance of infectious diseases is entrusted mainly to the Information System for Infectious Diseases (SIMI) based on notifications of human cases. Regarding diseases most affected by climate change, the main vector-borne diseases are: Yellow fever and viral hemorrhagic fevers (Lassa fever, Marburg, Ebola); cutaneous and visceral leishmaniasis, rickettsial diseases and tularemia; and malaria, and special monitoring and surveillance systems have been enhanced for the following:

o Arbovirus transmitted by Aedes mosquitoes (chikungunya, dengue and Zika virus): a national surveillance plan and integrated response that includes epidemiological surveillance of human cases, entomological surveillance and evaluation of the different levels of risk of transmission, and risk communication is annually issued.

o West Nile Disease: a national integrated surveillance and Response Plan that includes the monitoring of non-migratory birds belonging to the target species, clinical and serological surveillance in equines, entomological surveillance, monitoring of carcasses of wild birds and surveillance of human cases is issued each year.

These two surveillance systems are prepared and implemented in a cross-sectoral way. Waterborne diseases because of their very nature are more frequent in the countries of the Southern Hemisphere and fall in the register of the so-called "communicable diseases". They are even more difficult to control in the current contingency of high pressure from migratory flows which Italy and Europe are facing. With regard to health issues associated with migration, because of the North African crisis in 2011, Italy had to face complex situations impacting the health system. For this reason a close collaboration between the Ministry of Health and the WHO Regional Office for Europe has been started with the aim, among others, to examine the preparedness of regional and local health system to manage related health problems due to the influx of people arriving in Italy through irregular migration channels.

28

www.dkd-netzwerk.de

16

The Italian Ministry of Health issued the document: “Recommendations for the management of health problems

associated with the influx of migrants on the small islands29” to allow timely detection and reporting, using

syndromic surveillance of potentially risky events to public health. The aim is to take the positive aspects and lessons learned, in terms of public health, of the past experience in the south of Italy (Island of Lampedusa) and translate it in a virtuous model applicable, mutatis mutandis, to other similar realities, not only of small islands but also of "continental contexts". Prevention of heat effects on health The National Plan for the prevention of heat effects on health30 was launched by the Ministry of Health in 2005, through specific projects of the National Centre for Disease Prevention and Control (Ccm)31, and it is coordinated by the Center of national competence Department of Epidemiology SSR Lazio Region (DEP Lazio)32. The goal is to encourage inter-institutional coordination at all levels and provide operational guidelines for the creation of a centralized system for the forecasting and prevention of heat effects on health. Since 2009, the Plan is included in the Central Tasks of the Programs and Projects of the CCM. The main activities developed every summer according to the Plan are: Alarm systems, called Heat Health Watch Warning Systems (HHWWS) They are city-specific systems, using weather forecasts and are capable of forecasting, up to 72 hours in advance, the occurrence of unsafe conditions for the health of population. The results are reported in newsletters on heat waves33 that contain the summary forecasts and a graded warning level (level 1, 2, and 3) to allow the modulation of prevention interventions based on the level of the expected risk. The HHWW alarm systems have been extended to major urban areas (which are those most at risk for the presence of so-called "urban heat island"), reaching a good national coverage. Currently, the plan involves 34 cities with over 200,000 inhabitants, of which 27 with a daily city-specific forecasting alarm system. In all cities there exists a quick surveillance system of daily mortality associated with heat waves. Activation of the national daily mortality detection system for a rapid monitoring of the impact of heat waves on health: The system is active in 34 cities, covering about 20% of the national population, in collaboration with the Municipality of Civil Status Offices. This system allows a timely monitoring of the impact of heat waves and other extreme weather events (e.g. intense cold and floods). Monitoring of heat waves impact on the admissions to emergency department of some major Italian hospitals: The system is active during summer (May to September) in collaboration with hospitals in 8 sentinel cities (Rome, Milan, Genoa, Verona, Palermo, Bologna, Trieste, Venice). The acquisition of data is using procedures similar to those of the detection system in daily mortality. Development of the so-called "Registry of susceptibility": It regards the creation at local level of a list of names of the people susceptible to heat waves. Such a tool enables identifying the persons to whom priority protection measures and assistance should be provided in case of climate emergency, and it constitutes an important preliminary phase of a prevention plan that allows programming interventions at specifically targeted subgroups of populations most at risk, thus increasing the efficiency and effectiveness of preventive action.

29

http://www.euro.who.int/__data/assets/pdf_file/0003/280992/Promoting-intersectoral-public-health-responses-Eng.pdf 30http://www.salute.gov.it/portale/caldo/dettaglioContenutiCaldo.jsp?lingua=italiano&id=408&area=emergenzaCaldo&menu

=vuoto 31http://www.ccm-network.it/home.html

32http://www.deplazio.net/

33http://www.salute.gov.it/portale/caldo/bollettiniCaldo.jsp?lingua=italiano&id=4542&area=emergenzaCaldo&menu=vuoto

&btnBollettino=ULTIMO+BOLLETTINO

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Survey of interventions for the prevention of heat effects on health put in place in Italian cities: The results include an updated list of toll-free numbers and other services dedicated to vulnerable persons activated in the area during the summer in case of emergency and the local response plans. The results are updated every year and made available on the ministry website. Training activities/update: organization of training courses for health workers, technicians of prevention and other staff involved in prevention activities both locally and centrally, including the internal staff of the Ministry of Health. "Safe Summer" Information / communication campaign: an important goal of the campaign promoted by the Ministry every summer is to make the population aware of the risks to health related to heat, on the possibility of preventing them. The campaign includes the activation of a dedicated webpage on the institutional web site and an emergency phone number. Lithuania

Lithuania’s “The Strategy of National Climate Change Management Police for 2013-205034” was approved in

2012. The Strategy sets climate change mitigation and adaptation targets and objectives in all economy sectors. The strategic goal of the Lithuanian adaptation to climate change is to reduce vulnerability of the natural ecosystems and national economy sectors by implementing measures which preserve and increase the resilience to climate change, and maintain beneficial conditions of social life and economic activity. The implementation of this strategic goal is assessed according to the achievement of the special adaptation to climate change targets in the most vulnerable national economic sectors (agriculture, soil, landscape, forestry, biodiversity conservation, water resource management, energy, transport, industry, public health and etc.). The main principle of the Strategy is that adaptation targets and objectives are being integrated into the normal planning and operational work in different sectors. The Inter-institutional Action Plan for the implementation of the goals and objectives for the period of 2013-2020 of the Strategy was approved by the Government and is updated annually.

Public health In 2014 a Study identifying the climate change threats to human health including the recommendations on

adaptation to climate change was developed35. The main vulnerabilities were identified as the following: allergic

diseases, tick-borne diseases, UV radiation, air pollution, extreme heat, sudden frost, floods and impacts from extreme weather events. The introduction of additional vaccines and the existing vaccination practices is being assessed. In 2015 a Study identifying the vulnerability to climate change of most vulnerable national economic sectors (agriculture, forestry and biodiversity conservation, water resource management, energy, transport,

industry and waste management), risk assessment and opportunities to adapt to climate change was conducted36.

Integrated flood risk management Within the last decade Lithuania has been hit by a number of extreme weather events which led to an intense effort to further improve and develop the integrated approach in flood risk management. Information on the

flood risk management in Lithuania is presented in the webpage of the Environmental Protection Agency37.

Prevention of heat action plan Lithuania have developed National Public health and prevention of heat 2016-2020 annual plan as contingency measure in particular for population groups sensitive to heat stress. Lithuania has developed a “National Public

34

http://www.am.lt/VI/en/VI/index.php#a/717 35

http://www.am.lt/VI/files/File/Klimato%20kaita/Galutine%20ataskaita-2014-09-17.pdf 36

http://www.am.lt/VI/files/File/Klimato%20kaita/Klimato%20kaita_galutine%20ataskaita_2015_08_31.pdf 37

http://vanduo.gamta.lt/cms/index?rubricId=57ed5b04-d0bf-49b0-878b-28dc16ac8571

18

health and prevention of heat 2016-2020 annual plan38” as contingency measure in particular for population

groups sensitive to heat stress. The prevention of heat action plan identifies gaps and specific adaptation measures that need to be taken at

national level in order to strengthen cooperation39.

Regarding lessons learnt:

- The Strategy of National Climate Change Management Police (2012) and its implementation Action Plan

(2013)40 are the main framework policy for carrying out actions to assess impacts, vulnerability and plan

measures for the adaptation to climate change in Lithuania.

- “The Strategy of National Climate Change Management Police41 (2012)

- A significant share of the adaptation measures are implemented at the regional and local level. Various measures promoting the adaptation to climate change, such as flood protection, have already been taken on at the regional or municipal level for quite a long time, though they have not been seen as adaptation measures as such. In order to be able to advance effective adaptation measures, local and regional institutions should be further promoted and guidance on adaptation to climate change for municipalities shall be developed.

Sweden Integrating disaster risk management, adaptation and health in Karlstad 'In our city, we work towards integrating planning for the management of disaster risk, such as flood risk, climate change adaptation, green infrastructure and related health aspects because we think that can save us a significant amount of money. Current and future flood levels are considered in the design of the new levee for the General Hospital with an elevated bicycle path. The levee will integrate both mitigation and adaptation measures and also adds better traffic safety and a more secure environment for people who work at the hospital. Also, looking at climate change mitigation that calls for a dense city development and adaptation that calls for green urban areas at the same time enables us to find better solutions serving both, rather than maximising the benefits for one area now and having to invest a lot to solve the problems with the other area at a later date. Thinking and working across departments opens up new perspectives, better and more cost-effective solutions.' Anna Sjödin, Karlstad City Administration. Karlstad has 89 000 inhabitants. It is on the largest delta in northern Europe, where the River Klarälven flows into Lake Vänern. Its location helps make the city attractive but also puts it at significant risk of flooding, which is expected to increase as the climate changes. Karlstad has employed a flood risk manager since 2007 and has had a flood risk management plan since 2010. That year, it also became a role model in UNISR's Making Cities Resilient campaign. In contrast to many other risk management plans, Karlstad integrated climate change impacts in its plan. In the meantime, the package is growing: a climate change adaptation plan, a green infrastructure plan and a plan for stormwater management are also under development. Cross-department project teams are developing them, thus ensuring proper

integration42.

Cleaner drinking water in the city of Östersund Sweden’s supply of drinking water is facing great challenges. With a changing climate large parts of Sweden are expected to get a changing quality of raw water. The municipality of Östersund is actively working with drinking water supply issues, and ensures present and future conditions with a plan to install further steps in the purification-process of the drinking water.

38https://www.etar.lt/portal/lt/legalActPrint?documentId=78ffb580a97511e5be7fbe3f919a1ebe

39

https://www.etar.lt/portal/lt/legalActPrint?documentId=78ffb580a97511e5be7fbe3f919a1ebe 40

http://www.am.lt/VI/en/VI/index.php#a/717 41

http://www.am.lt/VI/index.php#a/12869 42

Source: Direct communication from Anna Sjödin, Karlstad City Administration, November 2015.

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Extensive work has been carried out in Östersund since 2010/2011, as tens of thousands of people got ill due to a parasite that contaminated the drinking water. Through preventive solutions, such as a new purification-mechanism in the form of a membrane filter, the municipality hopes to prevent similar situations from occuring in the future.

Today the water that provides Östersund with drinking water is taken from Swedens 5th largest lake, Storsjön. The raw water which provides Östersunds biggest water work is taken a few hundred meters from the shore. The water is clear, rich in oxygen and nutrient-poor, but due to climate change the quality of the raw water is expected to change. Increased precipitation and a warmer climate are projected to lead to more particles in the water, such as humus and microbiological substances.

After finding the Cryptosporidium-parasite in the drinking water during the winter of 2010/2011 a water and sewerage plan was put forward by the municipality. In the plan implementation of drinking water measures are prioritized according to three categories: necessary, urgent and desirable. One of the necessary measures described in the plan is to exchange an inactivating barrier with a separating barrier in the greatest water work in Östersund. A separating barrier is a preparation process for drinking water which separates micro-organisms with a physical barrier. An inactivating barrier is a process that deactivates micro-organisms. The National Food Agency recommends both types of barriers in the preparation process.

A test facility with two kinds of membrane filters was discussed. Tests were to be used to decide which kind of membrane filters that should be installed in the purification process, utra-filters (pore size 10-100 nm) or nano-filter (pore size 1-10 nm). Ultra-filters filter bacteria, viruses’ humus-particles and parasites. A nano-filter also filters some ions. Using nano-filter demands more energy than using an ultra-filter since a greater pressure is needed to push the water through the smaller pores.

Investigation of drinking water supply The Swedish government started an investigation of drinking water supply, from raw water to tap water, in 2013. The main purpose of the investigation was to identify existing and potential long and short term challenges and, if necessary, suggest suitable measures. The mission of the investigation was primarily to focus on the effects of climate change and the demands for adaptation that are needed with regards to drinking water. Sweden will be affected by climate change through higher average temperatures, increased precipitation, changing runoff and evaporation patterns, as well as increasing sea levels. The investigation has resulted in a number of proposals aiming to develop a strategic mode of working, increased cooperation as well as necessary requirements on the provision of drinking water. Increased cooperation, information and knowledge sharing is needed at both a municipal and governmental level. The proposals include, amongst others, creating protected areas around all the greater water sources in Sweden, with locally designed protective regulations. This way the water sources can be protected for the long term. The investigation also highlights that the producers of drinking water need to examine the raw water that is being used on a regular basis in order to detect risks and adjust the preparation of the drinking water accordingly. The methods and scope of sampling and analysis need to be developed further. Development of national guidance – Swedish Public Health Agency The Public Health Agency of Sweden is currently working on a project aiming at increasing the ability to handle negative health effects of increasing temperatures. The project is financed by The Swedish Civil Contingencies Agency and includes the production of scientifically substantiated knowledge on measures to counteract the negative health effects caused by heat waves. Step one was to publish the report Health effects of high temperatures – a knowledge compilation (Hälsoeffekter av höga temperaturer – kunskapssammanställning). The project also includes describing a well-functioning alarm-chain as well as the organizational provisions that are required to enable people on different levels in society to act in a suitable manner.

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The Public Health Agency of Sweden is working on a pilot study in cooperation with the municipality of Uppsala. The end result will be a national guidance focusing on the management of heat waves. The ambition is to contribute to decreasing the mortality and diseases caused by high temperatures. The project will be concluded in June 2017. A reference group has been formed consisting of participants from the Swedish Meteorological and Hydrological Institute, The National Board of Health and Welfare, other municipalities and regions as well as the University of Umeå. Strategic work for drinking water supply and climate change adaption – Swedish national food agency Sydvatten AB – Southern Sweden Water Supply is municipally owned company producing drinking water for 900,000 inhabitants in the region of Skåne, the southern part of Sweden. The company is owned by 16 municipalities and this cooperation strengthens the ability for more improved solutions. Working with climate change analysis and raw water strategy for the region are an important issue to secure the municipalities’ water supply. In order secure the redundancy for both raw water and drinking water in the region they had decided to utilize water from the Lake Bolmen also for the Vomb plant. The company builds new double water pipes to ensure the water supply for the Vomb plant and the consumers getting drinking water from the Vomb plant as well as for the region. Regional cooperation and solutions with linked infrastructure are ways to improve

capacity and redundancy also for the other water plants in the region43.

Population Health Vulnerabilities to Vector-Borne Diseases: Increasing Resilience under Climate Change Conditions in Africa – Swedish International Development Cooperation Agency - A Joint TDR-IDRC Research

Initiative (2012-2016)44

Lack of knowledge on the possible impacts of climate change on vector-borne diseases (VBD) in Africa remains a serious obstacle to evidence-based health policy change. Thus, the importance of research in the area of transmission dynamics and the disease burden of VBDs along with an understanding of the complex interaction of a plurality of factors within a socio-ecological system that is under pressure from climate change. The overall goal of the TDR-IDRC Research Initiative is to generate evidence through research projects that will enable the development of innovative strategies to reduce VBD-related human vulnerability and to increase resilience of African populations to such VBD-related health threats. In addition, it will result in knowledge, research capacity, collaboration and policy advice products that can be used throughout Africa and other regions. Capacity will be built to ensure that researchers and communities will have the know-how to generate and use the evidence necessary to reduce population health vulnerabilities in a sustainable manner. The five research projects that are funded by this research initiative are as follows: 1.Social, environmental and climate change impact of vector-borne diseases (malaria and schistosomiasis) in arid areas of Southern Africa (Botswana, Zimbabwe and South Africa) Principal Investigator: Professor Moses J Chimbari, College of Health Sciences, University of Kwazulu-Natal, George Campbell Building, Howard College Campus, Durban, South Africa 2.Early warning systems for improved human health and resilience to climate sensitive vector-borne diseases (malaria and Rift Valley fever) in Kenya Principal Investigator: Professor Benson B A Estambale, Research, Innovation and Outreach, Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya

43

http://sydvatten.se/om-sydvatten/ekonomi/ 44

(Acknowledgements: The International Development Research Centre (IDRC), Ottawa, Canada; International Research Institute on Climate and Society (IRI) at Columbia University, New York, USA; WHO Department of Public Health, Environmental and Social Determinants of Health (PHE), Geneva, Switzerland; Programme for the Protection of the Human Environment (PHE), WHO Regional Office for Africa (AFRO); Ministries of Health and Ministries of Environment in countries where the research is conducted; communities; Special Project Team; research teams, consultants and facilitators)

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3.Predicting vulnerability and improving resilience of the Maasai communities to vector-borne infections (trypanosomiasis): an ecohealth approach in the Maasai Steppe ecosystem (Tanzania) Principal Investigator: Professor Paul S Gwakisa, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania; and the Genome Science Centre and Department of Veterinary Microbiology and Parasitology, Faculty of Veterinary Medicine, Sokoine University of Agriculture, Morogoro, Tanzania 4.Human African trypanosomiasis: alleviating the effects of climate change through understanding human-vector-parasite interactions (Tanzania, Zimbabwe) Principal Investigator: Professor John Hargrove, South African Centre for Epidemiological Modelling and Analysis (SACEMA), Department of Science and Technology and National Research Foundation’s Centre of Excellence in Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa 5.Vulnerability and resilience to malaria and schistosomiasis in northern and southern fringes of the Sahelian belt in the context of climate change (Cote d'Ivoire and Mauritania) Principal Investigator: Dr Brama Kone, Centre Suisse de Recherches Scientifiques en Côte d’Ivoire (CSRS), Abidjan, Côte d'Ivoire Examples of knowledge gaps The National Veterinary Institute is producing its first plan for Climate Adaptation of the authorities work in the field of diseases and health of production animals during 2016. During the last 10 years we have been working with several governmental commissions with aspects on risks for animal health and infections, including zoonoses, due to climate change. To conclude from this work we need more knowledge on how changes in nature and ecosystem influence the epidemiology and geographical distribution of infectious diseases, especially diseases transmitted by arthropod vectors or by water. The surveillance of some climate sensitive diseases as well as the presence and distribution of arthropod vectors should be developed. Also the laboratory diagnostic possibilities need to be developed in some aspects, e.g. diagnostics of large amounts of samples and the search for unknown microbial pathogens. The geographical distribution of diseases and emerging health issues In Sweden, the models used for prioritisation of active surveillance efforts in animal populations have criteria that take into account epidemiological criteria such as changes in the distribution of a hazard, where an increasing trend would highlight the pathogen as a candidate for active surveillance (unless it is already subject to such activities). The outcome of existing surveillance activities are followed continuously and compiled

annually in to a report, which can be downloaded45. Research and development projects are continuously being

performed, for instance a project supported by the Swedish Civil Contingencies Agency, the transmission of zoonotic pathogens such as Salmonella and enterohemorrhagic E. coli via the environment, including water, is modelled to assess the risks for both humans and animals. This model could potentially be used to assess risks under different climate scenarios (Collaborators SVA, Chalmers, SLU and SMHI). Vector-borne diseases There is ongoing development of diagnostic competence both for microbial pathogens and arthropod vectors. Research projects modeling the distribution of potential vector species in Sweden as well as a project to determine vector competence of Swedish mosquito species are conducted. The organization of vector surveillance needs to be developed in Sweden to handle vector monitoring in case of an outbreak of a vector borne infection. The presence in Sweden of mosquito species has been studied and several new species has been detected, some of these are potential disease carriers. Also ticks have been studied in the aspect of which diseases they may carry.

45

http://www.sva.se/globalassets/redesign2011/pdf/om_sva/publikationer/surveillance2014.pdf

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Protecting women’s human rights in the global zika-response, International Planned Parenthood Federation –, Core support from Sida, Swedish International Development Cooperation Agency The connections between climate change and health are well established. A WHO modelling exercise showed that an increase in global temperature by 2-3oC would increase the number of people at risk of malaria by

several hundred million46. In fact, mosquitoes, the vector of many diseases including Zika, are very sensitive to

temperature changes. An increase in temperature impacts the number of times they bite per day, extends their

breeding season, and enables the microbes they carry to develop quicker47. According to WHO there is scientific

consensus that the Zika virus is the cause of the severe birth-defect microcephaly and the Guillain-Barré

syndrome.48Between 2007 and 2015, 65 countries globally have reported Zika transmission.

With the outbreak of the Zika virus, the IPPF has brought attention to the gap in in countries response in putting in place comprehensive responses to the spread of the virus, which include risk-communication with information regarding contraceptive and family planning options, access to modern contraceptives, and access to safe and legal abortions, in addition to vector control strategies.

In response to the ongoing Zika outbreak, the IPPF’s International Medical Advisory Panel issued a statement49,

which includes, among others, the following recommendations:

- Strengthen public education and awareness about contraception and family planning options (including emergency contraception, and male and female condoms), and post‐abortion care.

- Strengthen service delivery points to provide appropriate counselling; effective contraception, including emergency contraception, and male and female condoms; and safe abortion where it is available legally, and post‐abortion care services, to vulnerable women with unintended pregnancy and suspected Zika infection.

- For women who are victims of sexual and gender‐based violence: Strengthen provision of counselling and support services, including pregnancy testing, emergency contraception and post‐exposure prophylaxis for HIV.

- Protect and preserve women’s right to decide on the timing of pregnancy, independent of the status of the Zika epidemic.

- Advocate for abortion and other legal reforms to ensure access to safe abortion services for women who have Zika infection and might want an abortion because of fear of microcephaly.

- Ensure availability of a secure supply of essential sexual and reproductive health commodities and supplies, including a range of long‐acting reversible contraceptives, emergency contraceptives and condoms.

Spain Spain is a country highly vulnerable to climate change’s effects; so, impact assessment and the adoption of measures conductive to adaptation to climate change are a priority objective. The National Climate Change Adaptation Plan, approved in 2006 by the Climate Change Policy Coordination Commission and the National Climate Council is the national reference framework. This National Plan, headed by the Ministry of Agriculture, Food and Environment (MAGRAMA) is developed through Work Programmes. The health sector is being a priority for sectorial evaluation since the second Work Programme (2009-2013) and continues being a priority in the Third Work Programme which is nowadays being developed (2014-2020). The main instrument to implement the actions in the Health sector is the Health and Climate Change

Observatory (OSCC- Observatorio de Salud y Cambio Climático)50, created by the Cabinet of Ministers on 24

46 http://www.who.int/globalchange/environment/en/chapter6.pdf

47 http://www.nejm.org/doi/pdf/10.1056/NEJMp058079

48 http://apps.who.int/iris/bitstream/10665/246180/1/zikasitrep7Jul16-eng.pdf?ua=1

49 http://www.ippf.org/sites/default/files/ippf_imap_zika_web.pdf

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April, 2009 as an instrument to analyze, diagnose, assess and monitor climate change impacts on public health and on the National Health Care System. Its activities are jointly co-ordinated by the General Directorate of Public Health, Quality and Innovation under the Ministry of Health, Social Services and Equality, and by Spanish Climate Change Office. Its functions include:

- The establishment of a system of indicators on health and climate change, related to the health consequences of mitigation policies and adaptation, and vulnerability and effects on morbidity and mortality. This system will be the basis for health orientation of climate change policies, detection of health problems and needs for action and setting priorities in research and development in this area.

- Coordination of a network of scientific experts to provide a basis for collaboration and common knowledge to facilitate communication and collaboration between different administrations and institutions.

- Periodic reporting of evaluation and monitoring of the effects of climate change policies on health. As an example of the work carried out by the Observatory of Health and Climate Change the report "Impacts of

Climate Change on Health"51, was published in 2014. In this report a number of environmental issues with a

recognized direct influence on the health and well-being are described. Aspects such as the effects of extreme temperatures expressed as heat waves and cold, air quality or water and the possible spread of diseases have on morbidity and mortality of the population are addressed. Extreme temperatures and health In Spain, predictions indicate a progressive increase in average temperatures over the course of the century, significantly higher in summer than in winter, lower annual accumulated precipitation, higher amplitude and frequency of monthly thermal anomalies in comparison with the current climate and a higher frequency of days with extreme temperatures, especially in summer. The main adaptive options proposed on a national and international level include preparing in situ alert systems for possible thermal extremes, improvement of urban planning, including bioclimatic constructions, providing relevant and opportune meteorological information, elaborating prevention plans, providing information to the population regarding measures to adopt and training and improvement of health services. Water quality and health Global warming observed over the past decades is associated to variations in certain components of the water cycle. In Spain, climatic scenarios predict a decrease in average annual precipitations and an increase of temperatures, which would give way to a decrease in total run off. Predictions of climatic models point indicate an intensification of dry periods in summer, and a total precipitation in winter similar to the current one, although it would be concentrated over a lesser number of months. On the other hand, the climatic change will also increase the probability of cyanobacteria occurrence due to an increase in water temperatures. Since Spain is a country vulnerable to variations in water resources, water planning processes and specific regulations have been developed, with a high number of approved Water Basin Plans. Within the scope of Public Health, work is being carried out on promotion, protection and surveillance as to the quality of water for human consumption. The adaptive options proposed for handling hydric stress may respond to supply and/or the demand for these resources.

50

http://www.oscc.gob.es/es/general/home_es.htm 51

http://www.oscc.gob.es/docs/documentos/05_Resumen_Ejecutivo_Camb_Climat_ENG_COMPL.pdf