4.1 Introduction

  • Jesse E. Bell
    Cooperative Institute for Climate and Satellites - NC
  • Stephanie C. Herring
    National Oceanic and Atmospheric Administration
  • Lesley Jantarasami
    U.S. Environmental Protection Agency
  • Carl Adrianopoli
    U.S. Department of Health and Human Services
  • Kaitlin Benedict
    Centers for Disease Control and Prevention
  • Kathryn Conlon
    Centers for Disease Control and Prevention
  • Jennifer Runkle Davis
    Cooperative Institute for Climate and Satellites - NC
  • Vanessa Escobar
    National Aeronautics and Space Administration
  • Carlos Perez Garcia-Pando
    Columbia University
  • Jeremy Hess
    University of Washington Seattle
  • Jeffrey Luvall
    National Aeronautics and Space Administration
  • Dale Quattrochi
    National Aeronautics and Space Administration
  • Carl J. Schreck, III
    Cooperative Institute for Climate and Satellites - NC

Some regions of the United States have already experienced costly impacts—in terms of both lives lost and economic damages—from observed changes in the frequency, intensity, or duration of certain extreme events (Figure 4.1). Climate change projections show that there will be continuing increases in the occurrence and severity of some extreme events by the end of the century, while for other extremes the links to climate change are more uncertain (Table 4.1). (See also Ch. 1: Introduction)

Four categories of extreme events with important health impacts in the United States are addressed in this chapter: 1) flooding related to extreme precipitation, hurricanes, and coastal storms, 2) droughts, 3) wildfires, and 4) winter storms and severe thunderstorms. The health impacts of extreme heat and extreme cold are discussed in Chapter 2: Temperature-Related Death and Illness. For each event type, the chapter integrates discussion of populations of concern that have greater vulnerability to adverse health outcomes. The air quality impacts of wildfires are discussed below and also in Chapter 3: Air Quality Impacts. Although mental health effects are noted briefly here and in later sections of this chapter, in-depth discussion of the impacts of extreme events on mental health is presented in Chapter 8: Mental Health.

 

Figure 4.1: Estimated Deaths and Billion Dollar Losses from Extreme Events in the United States 2004–2013

Figure 4.1: Estimated Deaths and Billion Dollar Losses from Extreme Events in the United States 2004–2013
This figure provides 10-year estimates of fatalities related to extreme events from 2004 to 2013,2 as well as estimated economic damages from 58 weather and climate disaster events with losses exceeding $1 billion (see Smith and Katz 2013 to understand how total losses were calculated).3 These statistics are indicative of the human and economic costs of extreme weather events over this time period. Climate change will alter the frequency, intensity, and geographic distribution of some of these extremes,4 which has consequences for exposure to health risks from extreme events. Trends and future projections for some extremes, including tornadoes, lightning, and wind storms are still uncertain.

While it is intuitive that extremes can have health impacts such as death or injury during an event (for example, drowning during floods), health impacts can also occur before or after an extreme event as individuals may be involved in activities that put their health at risk, such as disaster preparation and post-event cleanup.1 Health risks may also arise long after the event, or in places outside the area where the event took place, as a result of damage to property, destruction of assets, loss of infrastructure and public services, social and economic impacts, environmental degradation, and other factors. Extreme events also pose unique health risks if multiple events occur simultaneously or in succession in a given location, but these issues of cumulative or compounding impacts are still emerging in the literature (see Front Matter and Ch. 1: Introduction).

Dynamic interactions between extreme events, their physical impacts, and population vulnerability and response can make it difficult to quantitatively measure all the health impacts that may be associated with an extreme event type, particularly those that are distributed over longer periods of time (See “Emerging Issues,” Section 4.8). These complexities make it difficult to integrate human health outcomes into climate impact models, and thus projections of future health burdens due to extreme events under climate change are not available in the literature. Instead, this chapter focuses on explaining the physical processes and pathways that scientists know contribute to human exposure and identifying overarching conclusions regarding the risk of adverse health impacts as a result of changing extreme weather and climate.

Table 4.1: Health Impacts of Extreme Events

Click on a table row for more information.

Event Type Example Health Risks and Impacts (not a comprehensive list) Observed and Projected Impacts of Climate Change on Extreme Events from 2014 NCA 4
Flooding Related to Extreme Precipitation, Hurricanes, Coastal Storms
  • Traumatic injury and death (drowning)
  • Mental health impacts
  • Preterm birth and low birth weight
  • Infrastructure disruptions and post-event disease spread
  • Carbon monoxide poisoning related to power outages

Heavy downpours are increasing nationally, especially over the last three to five decades, with the largest increases in the Midwest and Northeast. Increases in the frequency and intensity of extreme precipitation events are projected for all U.S. regions. [High Confidence]

The intensity, frequency, and duration of North Atlantic hurricanes, as well as the frequency of the strongest hurricanes, have all increased since the 1980s [High Confidence]. Hurricane intensity and rainfall are projected to increase as the climate continues to warm [Medium Confidence].

Increasing severity and frequency of flooding have been observed throughout much of the Mississippi and Missouri River Basins. Increased flood frequency and severity are projected in the Northeast and Midwest regions [Low Confidence]. In the Western United States, increasing snowmelt and rain-on-snow events (increased runoff when rain falls onto existing snowpack ) will increase flooding in some mountain watersheds [Medium Confidence].

In the next several decades, storm surges and high tides could combine with sea level rise and land subsidence to further increase coastal flooding in many regions. The U.S. East and Gulf Coasts, Hawaii, and the U.S.-affiliated Pacific Islands are particularly at risk.

Droughts
  • Reduced water quality and quantity
  • Respiratory impacts related to reduced air quality
  • Mental health impacts
Over the last several decades, drought patterns and trends have been changing, but patterns vary regionally across the United States. Droughts in the Southwest are projected to become more intense [High Confidence].
Wildfires
  • Smoke inhalation
  • Burns and other traumatic injury
  • Asthma exacerbations
  • Mental health impacts
Increased warming, drought, and insect outbreaks, all caused by or linked to climate change, have increased wildfires and impacts to people and ecosystems in the Southwest [High Confidence].

Rising temperatures and hotter, drier summers are projected to increase the frequency and intensity of large wildfires, particularly in the western United States and Alaska.

Winter Storms & Severe Thunderstorms
  • Traumatic injury and death
  • Carbon monoxide poisoning related to power outages
  • Hypothermia and frostbite
  • Mental health impacts
Winter storms have increased in frequency and intensity since the 1950s, and their tracks have shifted northward [Medium Confidence]. Future trends in severe storms, including the intensity and frequency of tornadoes, hail, and damaging thunderstorm winds, are uncertain and are being studied intensively [Low Confidence].

4.2 Complex Factors Determine Health Impacts

The severity and extent of health effects associated with extreme events depend on the physical impacts of the extreme events themselves as well as the unique human, societal, and environmental circumstances at the time and place where events occur. This complex set of factors can moderate or exacerbate health outcomes and vulnerability in the affected people and communities (Figure 4.2). Vulnerability is the tendency or predisposition to be adversely affected by climate-related health effects. It encompasses three elements—exposure, sensitivity, and adaptive capacity —that also interact with and are influenced by the social determinants of health (See Ch. 1: Introduction and Ch. 9: Populations of Concern for additional discussion and definitions of these terms.)

 

Figure 4.2: Climate Change and Health–Flooding

Figure 4.2: Climate Change and Health–Flooding
This conceptual diagram for a flooding event illustrates the key pathways by which humans are exposed to health threats from climate drivers, and potential resulting health outcomes (center boxes). These exposure pathways exist within the context of other factors that positively or negatively influence health outcomes (gray side boxes). Key factors that influence health outcomes and vulnerability for individuals are shown in the right box, and include social determinants of health and behavioral choices. Key factors that influence health outcomes and vulnerability at larger community or societal scales, such as natural and built environments, governance and management, and institutions, are shown in the left box. All of these influencing factors may also be affected by climate change. See Chapter 1: Introduction for more information.

Exposure is contact between a person and one or more biological, psychosocial, chemical, or physical stressors, including stressors affected by climate change. Contact may occur in a single instance or repeatedly over time, and may occur in one location or over a wider geographic area. Demographic shifts and population migration may change exposure to public health impacts. For example, since 1970, coastal population growth (39%) has substantially increased compared to population growth for the United States as a whole (about 13%).5 In the future, this coastal migration in conjunction with rising sea levels has the potential to result in increased vulnerability to storm surge events for a greater proportion of the U.S. population concentrated in these coastal areas. Choices by individuals and governments can reduce or increase some exposure risk to extreme events.6 As shown in Figure 4.2, such choices can include whether to build or allow development in floodplains and coastal areas subject to extreme high tides and sea level rise. Individuals’ responses to evacuation orders and other emergency warnings also affect their exposure to health threats. Factors such as income have been linked to how people perceive the risks to which they are exposed and choose to respond, as well as their ability to evacuate or relocate to a less risk-prone location.7 The condition of the built environment also affects exposure to extreme events, and those living in low-quality, poorly maintained, or high-density housing may have greater risks of health impacts.8

Sensitivity is the degree to which people or communities are affected, either adversely or beneficially, by climate variability and change. It is determined, at least in part, by biologically based traits such as age. For example, older adults (generally defined as age 65 and older) are physiologically more sensitive to health impacts from extreme events because of normal aging processes; they are generally more frail, more likely to have chronic medical conditions that make them more dependent on medications, and require more assistance in activities of daily living.9,10 In addition, social determinants of health affect disparities in the prevalence of medical conditions that contribute to biological sensitivity.11,12 Health disparities are more prevalent in low-income populations, as well as in some communities of color, and are frequently exacerbated during extreme events.13 For example, Black or African American populations have higher rates of chronic conditions such as asthma, decreased lung function, and cardiovascular issues, all of which are known to increase sensitivity to health effects of smoke from wildfires (Ch. 3: Air Quality Impacts).14

Red Cross shelter after Superstorm Sandy

Family affected by Hurricane Sandy prepares to take shelter at the Mennen Sports Arena in Morristown, New Jersey, October 31, 2012.

Adaptive capacity is the ability of communities, institutions, or people to adjust to potential hazards, to take advantage of opportunities, or to respond to consequences. Having strong adaptive capacity contributes to resilience—the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events.15 In the context of extreme events, people with low adaptive capacity have difficulty responding, evacuating, or relocating when necessary, and recovering from event-related health impacts.

For individuals, health outcomes are strongly influenced by the social determinants of health that affect a person’s adaptive capacity. Poverty is a key risk factor, and the poor are disproportionately affected by extreme events.6,11,16 Low-income individuals may have fewer financial resources and social capital (such as human networks and relationships) to help them prepare for, respond to, and recover from an extreme event.17,18 In many urban, low-income neighborhoods, adaptive capacity is reduced where physical and social constructs, such as community infrastructure, neighborhood cohesion, and social patterns, promote social isolation.19,20,21 Those with higher income possess a much higher level of resilience and availability of resources to increase their adaptive capacity.22,23 Other attributes of individuals that contribute to lower adaptive capacity include their age (very young or very old) and associated dependency on caregivers, disabilities such as mobility or cognitive impairments, having specific access and functional needs, medical or chemical dependence, limited English proficiency, social or cultural isolation, homelessness, and institutionalization (prisons, psychiatric facilities, nursing homes).1,10,24

At a larger community or societal level, adaptive capacity is heavily influenced by governance, management, and institutions.25 Governments and non-governmental organizations provide essential extreme-event preparedness, coordination, emergency response, and recovery functions that increase adaptive capacity at the local, state, tribal, and federal levels—for example, in providing early warning systems where possible, evacuation assistance, and disaster relief.15,26 Risk sharing, management, and recovery schemes such as insurance can also play a significant role in building resilience in the context of extreme events and climate change.27,28 For instance, lack of health insurance has been associated with greater risk of hospital admission after exposure to certain weather events.29 Public health actions or interventions that maintain or strengthen the adaptive capacity of communities, institutions, or people could help mediate certain health impacts due to extreme events.30 On the other hand, climate change—particularly its effect on extreme events—has the potential to create unanticipated public health stressors that could overwhelm the U.S. public health system’s adaptive capacity and could require new approaches.30


4.3 Disruption of Essential Infrastructure

When essential infrastructure and related services are disrupted during and after an extreme event, a population’s exposure to health hazards can increase, and losses related to the event can reduce adaptive capacity.6 Disruptions can include reduced functionality, such as poor road conditions that limit travel, or complete loss of infrastructure, such as roads and bridges being washed away. Serious health risks can arise from infrastructure and housing damage and disruption or loss of access to electricity, sanitation, safe food and water supplies, health care, communication, and transportation.1,31,32,33,34 Identifying vulnerable infrastructure and investing in strategies to reduce vulnerability, including redundancy (having additional or alternate systems in place as backup) and ensuring a certain standard of condition and performance can reduce the likelihood of significant adverse impacts to infrastructure from extreme weather events.35

Health Risks Related to Infrastructure

Existing infrastructure is generally designed to perform at its engineered capacity assuming historical weather patterns, and these systems could be more vulnerable to failure in response to weather-related stressors under future climate scenarios.6,36,37 Shifts in the frequency or intensity of extreme events outside their historical range pose infrastructure risks, which may be compounded by the fact that much of the existing critical infrastructure in the United States, like water and sewage systems, roads, bridges, and power plants, are aging and in need of repair or replacement.6,38 For example, the 2013 American Society of Civil Engineer’s Report Card assigned a letter grade of D+ to the condition and performance of the Nation’s infrastructure.39

In addition, recurrent weather-related stressors, such as “nuisance flooding” (frequent coastal flooding that is increasing in frequency due to sea level rise), contribute to overall deterioration of infrastructure like stormwater drainage systems and roads (see Ch. 6: Water-Related Illness).40 These systems are important in the context of health because drainage helps to avoid sewage overflows and maintain water quality,41 and roads are vital for evacuations and emergency response during and after extreme events.42

Energy infrastructure that relies on environmental inputs, such as water for cooling in power generation or for hydroelectric dams, is also vulnerable to changes in extreme events due to climate change.36,43 Power generation accounts for one of the largest withdrawals of freshwater in the United States.44 Longer or more intense droughts that are projected for some regions of the United States (see Table 4.

1
) will contribute to reduced energy production in those regions, which may lead to supply interruptions of varying lengths and magnitudes and adverse impacts to other infrastructure that depends on energy supply.36

Power Outages

Damaged power lines

Power lines damaged by Hurricane Isaac’s wind and surge in Plaquemines Parish, Louisiana, September 3, 2012.

Electricity is fundamental to much modern infrastructure, and power outages are commonly associated with the types of extreme events highlighted in this chapter.45 During power outages, observed health impacts include increased deaths from accidental and natural causes,46 increased cases of foodborne diarrheal illness from consuming food spoiled by lack of refrigeration (see Ch. 7: Food Safety),1 and increased rates of hospitalization.47 In addition, extreme-event-related power outages are associated with increased injuries and deaths from carbon monoxide poisoning after floods, hurricanes, severe winter storms, and ice storms.1,33,48,49,50,51 This is due to increased use of gasoline-powered generators, charcoal grills, and kerosene and propane heaters or stoves inside the home or other areas without proper ventilation (see also Ch. 3: Air Quality Impacts). Populations considered especially vulnerable to the health impacts of power outages include older adults, young children, those reliant on electrically powered medical equipment like ventilators and oxygen, those with preexisting health conditions, and those with disabilities (see Ch. 9: Populations of Concern).1,45,46 In rural communities, power and communications can take longer to restore after damage from an extreme event.52

Transportation, Communication, and Access

Damage to transportation infrastructure or difficult road conditions may delay first responders, potentially delaying treatment of acute injuries and requiring more serious intervention or hospitalization.42 Extreme events can disrupt access to health care services via damage to or loss of transportation infrastructure, evacuation, and population displacement.34 For chronically ill people, treatment interruptions and lack of access to medication can exacerbate health conditions both during and after the extreme event.1,53 Surveys of patients after Hurricane Katrina showed that those with cancer, hypertension, kidney disease requiring dialysis, cardiovascular disease, and respiratory illnesses were particularly affected.53,54,55 Evacuations also pose health risks to older adults—especially those who are frail, medically incapacitated, or residing in nursing or assisted living facilities—and may be complicated by the need for concurrent transfer of medical records, medications, and medical equipment.1,56 Some individuals with disabilities may also be disproportionally affected during evacuations if they are unable to access evacuation routes, have difficulty in understanding or receiving warnings of impending danger, or have limited ability to communicate their needs.57 In addition, persons with limited English proficiency are less likely to understand or have timely access to emergency information, which may lead to delayed evacuation.58,59 Health risks increase if evacuation is delayed until after a storm hits; loss of power and damage to communications and transportation infrastructure can hinder health system operations.1

Water Infrastructure

Extreme precipitation events and storms can overwhelm or damage stormwater and wastewater treatment infrastructure, increasing the risk of exposure to contaminated water (see Ch. 6: Water-Related Illness). Risk of post-flood gastrointestinal illness outbreaks are considered to be low in the United States, but risk increases for displaced populations—especially young children and infants with immature immune systems—where shelter conditions are crowded or have poor sanitation.1,31 There is potential for post-flood mold and fungi growth inside houses to worsen allergic and asthmatic symptoms, but these types of health impacts have not been documented following floods or storms.1,31,60,61 In general, however, adverse health effects from dampness and mold in homes are well known and studied.62,63,64

Cascading Failures

Many infrastructure systems are reliant on one another, and disruption or failure of one system or at any place in the system can lead to the disruption of interconnected systems—a phenomenon referred to as a cascading failure. For example, electricity is essential to multiple systems, and a failure in the electrical grid can have cascading effects on water and sewage treatment, transportation, and health care systems.38,45 Extreme events can simultaneously strain single or multiple components of interconnected infrastructure and related facilities and equipment, which increases the risk of cascading infrastructure failure.65,66 This risk to interconnected systems has been particularly notable in the context of urban areas (especially cities for which the design or maintenance of critical infrastructure needs improvement) and industrial sites containing chemicals or hazardous materials that rely on specific equipment—such as holding tanks, pipelines, and electricity-dependent safety mechanisms like automatic shut-off valves—to prevent releases.6,67,68 Dramatic infrastructure system failures are rare, but such cascading failures can lead to public health consequences when they do occur, including shifts in disease incidence.69

The 2003 blackout in the northeastern United States, caused indirectly by surging electrical demand during a heat wave, is an illustrative example of how climate change could introduce or exacerbate health threats from cascading infrastructure failures related to extreme weather. During this 31-hour event, lack of electricity compromised traffic control, health care and emergency services, wastewater treatment, solid waste collection, and a host of other critical infrastructure operations.70,71,72,73 New York City health officials responded to failure of hospital emergency generators and interruptions in electrically powered medical equipment, contamination of recreational water and beaches with untreated sewage, pest control issues, and loss of refrigeration leading to potential impacts on food and vaccine spoilage.74 Increased incidence of gastrointestinal illness from contaminated food or water, and a large increase in accidental and non-accidental deaths and hospitalizations in New York City were attributed to the blackout.46,47,74 See Chapter 6: Water-Related Illness for other examples of health impacts when interconnected wastewater, stormwater, and drinking water infrastructure fails, such as during the 1993 Milwaukee Cryptosporidium outbreak.


4.4 Flooding Related to Extreme Precipitation, Hurricanes, and Coastal Storms

Floods are the primary health hazard associated with extreme precipitation events, hurricanes, and coastal storms. Risk of exposure to floods varies by region in the United States and by type of flooding that occurs in that location (see Table 4.1 and “Flood Terminology”). People in flood-prone regions are expected to be at greater risk of exposure to flood hazards due to climate change (Table 4.1),11,75,76 which may result in various types of health impacts described below.

Truck stuck in  flood waters

A truck gets stuck in the storm surge covering Highway 90 in Gulfport, Mississippi, during Hurricane Isaac, August 29, 2012.

Most flood deaths in the United States are due to drowning associated with flash flooding.1,31,60 The majority of these deaths are associated with becoming stranded or swept away when driving or walking near or through floodwaters.60,77,78,79 Flash floods in the United States occurred more frequently from 2006 to 2012 and were associated with more deaths and injuries in rural areas compared to urban areas.79 Contributing factors include the following: 1) small, rural basins develop flash flood conditions much more quickly, providing less time to notify rural residents with emergency procedures like warnings, road closures, and evacuations; 2) more rural roads intersect low-water crossings without bridge infrastructure and rural areas have fewer alternative transportation options when roads are closed; and 3) rural areas have fewer emergency response units and slower response times.79 Although flash floods are less frequent in urban areas, a single urban event is likely to result in more deaths and injuries than a rural event.79

Drowning in floodwaters was the leading cause of death (estimated 2,544 persons) among people directly exposed to hazards associated with hurricanes and coastal storms from 1963 to 2012.80 Hurricanes are typically associated with coastal flooding, but they can also cause substantial inland flooding before, during, and after landfall, even when far from the storm’s center (Figure 4.3).81,82,83

 

Figure 4.3: Hurricane-Induced Flood Effects in Eastern and Central United States

Figure 4.3: Hurricane-Induced Flood Effects in Eastern and Central United States

VIEW
Composite map of floods associated with landfalling hurricanes over the past 31 years, based on stream gauge data. The Flood Ratio (Q) refers to maximum hurricane-related flood peaks compared to 10-year flood peaks (expected to occur, on average, once every 10 years and corresponds to the 90th percentile of the flood peak distribution) calculated for the same area. See Villarini et al. 2014 for a detailed description of how Q values are calculated.81 Q values between 0.6 and 1 (light blue and yellow) generally indicate minor to moderate flooding, while values above 1 (orange and red) generally indicate major flooding larger than the 10-year flood peak. The dark gray areas of the map represent the extent of the 500-km buffer around the center of circulation of the hurricanes included during the study period (the light gray areas of the map fall outside of the study area). Figure 4.3 shows that hurricanes are important contributors to flooding in the eastern United States, as well as large areas of the central United States. Land use / land cover properties and soil moisture conditions are also important factors for flooding. (Figure source: adapted from Villarini et al. 2014)81

The deadliest U.S. storms of this century to date were Hurricane Katrina and Superstorm Sandy. Katrina was a very large and powerful Category 3 storm that hit the Gulf Coast region in 2005. Hurricane Katrina was responsible for almost half of the hurricane-related deaths over the past 50 years,80 with the majority of deaths directly related to the storm in Louisiana (an estimated 971 to 1,300 deaths) due to drowning or flood-related physical trauma due to the failure of the levees in New Orleans.84,85 Sandy was a historically rare storm that affected a large portion of the country in October 2012, with particularly significant human health and infrastructure impacts in New Jersey and the greater New York City area. Superstorm Sandy is estimated to have caused between 117 and 147 direct deaths across the Atlantic basin, also with drowning and flood-related physical trauma as the leading cause of death.86,87

Both fatal and non-fatal flood-related injuries can occur in any phase of the event: before (preparation or evacuation), during, and after (cleanup and recovery). Common flood-related injuries include blunt trauma from falling debris or objects moving quickly in floodwater, electrocution, falls, and motor vehicle accidents from wet, damaged, or obstructed roads.1,31,60 Other common, generally non-fatal injuries include cuts, puncture wounds, sprains/strains, burns, hypothermia, and animal bites.1,31,60 Exposure to floodwaters or to contaminated drinking water can cause gastrointestinal illness; wound infections; skin irritations and infections; and eye, ear, nose, and throat infections.1,31 Many of these injuries have been observed in occupational settings 33 and in rural areas.79

In the United States, populations with greater vulnerability to flood-related injuries and illnesses include older adults, the immunocompromised and others with existing illness (especially if dependent on routine medical treatments or drug prescriptions), certain racial/ethnic groups (Black and Hispanic or Latino), people with limited English proficiency, and people with lower socioeconomic status (especially if uninsured, unemployed, or living in poor-quality housing).1,75 Differences in exposure, sensitivity, and adaptive capacity lead to a disproportionate number of flood-related fatalities among older adults, males, and some low-income communities of color.31 For example, almost half of deaths from Hurricane Katrina were people over age 75, while for Superstorm Sandy almost half were over age 65.1,31 The Black adult mortality rate from Hurricane Katrina was 1.7 to 4 times higher than that of whites.31,85 Floods and storms also create numerous occupational health risks, with most storm-related fatalities associated with cleanup activities (44%), construction (26%), public utilities restoration (8%), and security/policing (6%).1 First responders and other emergency workers face greater health and safety risks when working in conditions with infrastructure disruptions, communication interruptions, and social unrest or violence following floods and storms.75,88,89

Pregnant women and newborns are uniquely vulnerable to flood health hazards. Flood exposure was associated with adverse birth outcomes (preterm birth, low birth weight) after Hurricane Katrina and the 1997 floods in North Dakota.90,91 Floods and storms can also create conditions in which children can become separated from their parents or caregivers, which—particularly for children with disabilities or special health care needs—increases their vulnerability to a range of health threats, including death, injury, disease, psychological trauma, and abuse.92,93,94 Flood-related mental health impacts are associated with direct and longer-term losses, social impacts, stress, and economic hardship.1,31,60 Women, children, older adults, low-income populations, and those in poor health, with prior mental health issues, or with weak social networks may be especially vulnerable to the mental health impacts of floods (Ch. 8: Mental Health).


4.5 Droughts

Farmer in drought-stressed peanut  field

Farmer in drought-stressed peanut field in Georgia. Health implications of drought include contamination and depletion of water sources.

Drought may be linked to a broad set of health hazards, including wildfires, dust storms, extreme heat events, flash flooding, degraded air and water quality, and reduced water quantity.76 Exposure risk to potential drought health hazards is expected to vary widely across the nation, depending on several localized variables, such as characteristics of the built environment, loss of livelihoods, local demand for water, and changes in ecosystems.96,97 Researching the health effects of drought poses unique challenges given multiple definitions of the beginning and end of a drought, and because health effects tend to accumulate over time. In addition, health impacts do not occur in isolation. For example, droughts intensify heat waves by reducing evaporative cooling,4 further complicating efforts to attribute specific health outcomes to specific drought conditions.

A primary health implication of drought arises from the contamination and depletion of water sources,97 but there are few studies documenting specific health consequences in the United States.98 Drought in coastal areas can increase saltwater intrusion (the movement of ocean water into fresh groundwater), reducing the supply and quality of potable water.99,100,101 In addition to reducing water quantity, drought can decrease water quality when low flow or stagnant conditions increase concentrations of pollutants or contaminants (such as chemicals and heavy metals) and when higher temperatures encourage pathogen growth.97,98,102,103,104,105 Heavy rain following drought can flush accumulated pathogens or contaminants into water bodies.106,107 Reduced surface and groundwater quality can increase risk of water-related illness as well as foodborne illness if pathogens or contaminants enter the food chain (see Ch. 6: Water-Related Illness and Ch. 7: Food Safety).

In some regions of the United States, drought has been associated with increased incidence of West Nile virus disease.108,109,110,111,112 Human exposure risk to West Nile virus may increase during drought conditions due to a higher prevalence of the virus in mosquito and bird populations as a result of closer contact between birds (virus hosts) and mosquitoes (vectors) as they congregate around remaining water sources (see Ch. 5: Vector-Borne Diseases) .113 Primarily in the Southwest, droughts followed by periods of heavy rainfall have been associated with an increase in rodent populations.114,115,116 This could lead to increased exposures to rodent allergens and rodent-borne diseases, such as hantavirus.117,118,119 

Drought conditions also tend to reduce air quality and exacerbate respiratory illness by way of several mechanisms associated with soil drying, loss of vegetation, airborne particulate matter, and the creation of conditions conducive for dust storms and wildfires.120,121 In addition, air pollutants such as soluble trace gases and particles remain suspended in the air when there is a lack of precipitation (see Ch. 3: Air Quality Impacts).122 Inhalation of particles can irritate bronchial passages and lungs, resulting in exacerbated chronic respiratory illnesses.97 The size of particles is directly linked to their potential health effects. Exposure to fine particles is associated with cardiovascular illness (for example, heart attacks and strokes) and premature death, and is likely associated with adverse respiratory effects.123 There is greater uncertainty regarding the health effects of inhaling coarse particles (often found in soil dust), but some evidence indicates an association with premature death and cardiovascular and respiratory effects.123,124,125

Mental health issues have also been observed during drought periods through research primarily conducted in Australia (see also Ch. 8: Mental Health).96 Rural areas, in particular, can experience a rise in mental health issues related to economic insecurity from drought.96,126,127,128,129


4.6 Wildfires

Climate change is projected to increase the frequency and intensity of large wildfires (Figure 4.4), with associated health risks projected to increase in many regions.76,146 Wildfire can have health impacts well beyond the perimeter of the fire. Populations near the fire or even thousands of miles downwind may be exposed to a complex smoke mixture containing various substances including carbon monoxide, ozone, toxic chemicals, and both fine and coarse particles,147,148 presenting a serious health risk for the exposed populations (see Ch. 3: Air Quality Impacts).149,150 For example, the 2002 forest fires in Quebec resulted in up to a 30-fold increase in airborne fine particulate concentrations in Baltimore, Maryland, a city nearly 1,000 miles downwind.76 Exposure times can range from a few days to several weeks.147,151,152

 

Figure 4.4: Projected Increases in Very Large Fires

Figure 4.4:  Projected Increases in Very Large Fires
Based on 17 climate model simulations for the continental United States using a higher emissions pathway (RCP8.5), the map shows projected percentage increases in weeks with risk of very large fires by mid-century (2041-2070) compared to the recent past (1971-2000). The darkest shades of red indicated that up to a 6-fold increase in risk is projected for parts of the West. This area includes the Great Basin, Northern Rockies, and parts of Northern California. Gray represents areas within the continental United States where there is either no data or insufficient historical observations on very large fires to build robust models. The potential for very large fire events is also expected to increase along the southern coastline and in areas around the Great Lakes. (Figure source: adapted from Barbero et al. 2015 by NOAA )191

Exposure to smoke-related air pollutants from wildfires has been associated with a wide range of human health effects, including early deaths and low infant birth weight, with the strongest evidence for acute respiratory illness.147,148,153,154,155,156,157 Inhalation of smoke from wildfire has been linked to exacerbated respiratory problems, such as shortness of breath, asthma, and chronic obstructive pulmonary disease ( COPD ).156,158,159,160 While the association between smoke exposure and cardiovascular outcomes is uncertain,156 exposure to fine particles contributes to risk of cardiovascular disease and premature death.161,162,163,164

Firefighters battling fire

Exposure to smoke-related air pollutants from wildfires has been associated with a wide range of human health effects.

Wildfires can also affect indoor air quality for those living near affected areas by increasing particulate matter concentrations within homes, leading to many of the adverse health impacts already discussed.151,165 For example, during the 2007 San Diego wildfires, health monitoring showed excess emergency room visits for asthma, respiratory problems, chest pain, and COPD. During times of peak fire particulate matter concentrations, the odds of a person seeking emergency care increased by 50% when compared to non-fire conditions.166 Smoke from wildfires can also impair driving visibility, increasing risks of motor vehicle deaths and injuries.136,167,168,169

Pregnant women, children, and the elderly are more sensitive to the harmful health effects of wildfire smoke exposure (see also Ch. 9: Populations of Concern).14,158,170,171 Firefighters are exposed to significantly higher levels and longer periods of exposure to combustion products from fires, leading to health risks that include decreased lung function, inflammation, and respiratory system problems, as well as injuries from burns and falling trees.147,170,172,173,174,175

Wildfires can also create an increased burden on the health care system and public health infrastructure. For example, wildfires near populated areas often necessitate large evacuations, requiring extensive public health resources, including shelter, and treatment of individuals for injuries, smoke inhalation, and mental health impacts.69,168,176,177 Housing development in or near the wildland–urban interface has expanded over the last several decades and is expected to continue to expand.178 These changing development patterns in combination with a changing climate are increasing the vulnerability of these areas to wildfires.179,180,181

Following wildfire, increased soil erosion rates and changes to runoff generation may contaminate water-supply reservoirs and disrupt downstream drinking water supplies.182,183 Post-wildfire erosion and runoff has been linked to increased flooding and debris flow hazards, depending on the severity of the fire, seasonal rainfall patterns, watershed characteristics, and the size of the burn area.184,185,186,187 Wildfires have a range of short- and long-term effects on watersheds that have the potential to change water quality, quantity, availability, and treatability downstream from the burned area.188,189,190


4.7 Winter Storms and Severe Thunderstorms

The primary health hazards of severe thunderstorms are from lightning and high winds, while the principal winter storm hazards include extreme cold temperatures (see Ch. 2: Temperature-related Deaths and Illness), frozen precipitation, and associated dangerous road and other conditions. Future health impacts associated with these types of storms are uncertain and will depend on how climate change affects storm trends.

During the period 1956 to 2006, lightning caused an estimated 101.2 deaths per year,192 while thunderstorm winds are estimated to have caused approximately 26 deaths per year from 1977 to 2007.193 Thunderstorm precipitation and winds can damage structures, fell trees, and create hazardous road conditions and impair driving visibility, increasing risks of motor vehicle deaths and injuries.136,194,195 Thunderstorm winds can cause blunt trauma or injuries, such as from being struck by falling trees and other flying debris,48 and were responsible for an estimated 4,366 injuries during the period 1993 to 2003.195

Gridlocked traffic

Freezing rain, snow, and ice have been linked to increased injuries associated with treacherous road conditions and impaired driving visibility.

Winter storms can be accompanied by freezing winds and frigid temperatures that can cause frostbite and hypothermia (see also Ch. 2: Temperature-Related Deaths and Illness).196,197 Individuals that lack proper clothing and shelter (for example, the homeless) are more at risk of injuries from direct exposure to weather conditions associated with winter storms and severe thunderstorms.198 Low-income populations have increased exposure risk to severe winter weather conditions because they are more likely to live in low-quality, poorly insulated housing; be unable to afford sufficient domestic heating; or need to make tradeoffs between food and heating expenditures.199,200 Freezing rain, snow, and ice have been linked to increased injuries associated with falling201 as well as motor vehicle deaths and injuries due to treacherous road conditions and impaired driving visibility.136,202

After severe thunderstorms, individuals can suffer injuries during debris removal and cleanup activities195,203 as well as exposure to hazards if flooding occurs (see Section 4.4 of this chapter). Mental health issues and stress are also possible after storms (see Ch. 8: Mental Health). This is especially true of thunderstorms associated with tornadoes, as the aftermath of the storm can involve dealing with the loss of property, displacement, or loss of life.204 After winter storms, snow removal can be strenuous work and can increase the likelihood of illness and death for individuals with preexisting cardiovascular or pulmonary conditions.205


4.8 Emerging Issues

Climate change and changing patterns of extreme weather have the potential to strain the capacity of public health systems. However, few comprehensive or systematic studies have examined the human health impacts of such health-system strain.206 Particularly in the context of floods and hurricanes, the impacts on health systems from short- and long-term population displacement are not fully understood or well quantified.69 In addition, the role of future population migration and demographic changes is just beginning to be elucidated in assessments of local adaptive capacity or resilience to the effects of future extreme events. Methodological challenges remain for accurately quantifying and attributing delayed mortality associated with, but not caused directly by, extreme event exposure—for example, elevated mortality associated with heart disease, cancer, diabetes, and infections and other complications from injuries in populations exposed to hurricanes.32,33


4.9 Research Needs

In addition the emerging issues identified above, the authors highlight the following potential areas for additional scientific and research activity on extreme events based on their review of the literature. Current understanding is limited by a lack of systematic surveillance for the range of health impacts, both short and long term, associated with a wider range of extreme events, including prolonged events like droughts and other extremes that do not currently trigger post-event health surveillance. 

Future assessments can benefit from multidisciplinary research activities that:

  • better define the health implications associated with particular extreme events where longer-term impacts, as well as regional differences in health outcomes, are currently not well understood, such as droughts and floods;
  • enhance understanding of how specific attributes that contribute to individual and community level vulnerability to health impacts after extreme events, including social and behavioral characteristics, interact and contribute to or mitigate risks of adverse health outcomes; and
  • examine how health outcomes can be impacted by other cumulative, compounding, or secondary effects of extreme events, such as access to or disruption of healthcare services and damages to and cascading failures of infrastructure.

References

  1. Adams, Z. W., and others, 2014: Prevalence and predictors of PTSD and depression among adolescent victims of the Spring 2011 tornado outbreak. Journal of Child Psychology and Psychiatry, 55, 1047-1055. doi:10.1111/jcpp.12220 | Detail
  2. Alderman, K., L. R. Turner, and S. Tong, 2012: Floods and human health: A systematic review. Environment International, 47, 37-47. doi:10.1016/j.envint.2012.06.003 | Detail
  3. Aldrich, N., and W. F. Benson, 2008: Disaster preparedness and the chronic disease needs of vulnerable older adults. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 5, A27. PMID: 18082016 | Detail
  4. Anderson, A. H., A. J. Cohen, N. G. Kutner, J. B. Kopp, P. L. Kimmel, and P. Muntner, 2009: Missed dialysis sessions and hospitalization in hemodialysis patients after Hurricane Katrina. Kidney International, 75, 1202-1208. doi:10.1038/ki.2009.5 | Detail
  5. Anderson, G. B., and M. L. Bell, 2012: Lights out: Impact of the August 2003 power outage on mortality in New York, NY. Epidemiology, 23, 189-193. doi:10.1097/EDE.0b013e318245c61c | Detail
  6. Andrulis, D. P., N. J. Siddiqui, and J. L. Gantner, 2007: Preparing racially and ethnically diverse communities for public health emergencies. Health Affairs, 26, 1269-1279. doi:10.1377/hlthaff.26.5.1269 | Detail
  7. Arrieta, M. I., R. D. Foreman, E. D. Crook, and M. L. Icenogle, 2009: Providing continuity of care for chronic diseases in the aftermath of Katrina: From field experience to policy recommendations. Disaster Medicine and Public Health Preparedness, 3, 174-182. doi:10.1097/DMP.0b013e3181b66ae4 | Detail
  8. ASCE, cited 2013: Report Card for America's Infrastructure. American Society of Civil Engineers. URL | Detail
  9. Ashley, W. S., and A. W. Black, 2008: Fatalities associated with nonconvective high-wind events in the United States. Journal of Applied Meteorology and Climatology, 47, 717-725. doi:10.1175/2007jamc1689.1 | Detail
  10. Ashley, W. S., and C. W. Gilson, 2009: A reassessment of U.S. lightning mortality. Bulletin of the American Meteorological Society, 90, 1501-1518. doi:10.1175/2009bams2765.1 | Detail
  11. Ashley, W. S., and T. L. Mote, 2005: Derecho hazards in the United States. Bulletin of the American Meteorological Society, 86, 1577-1592. doi:10.1175/BAMS-86-11-1577 | Detail
  12. Ashley, W. S., S. Strader, D. C. Dziubla, and A. Haberlie, 2015: Driving blind: Weather-related vision hazards and fatal motor vehicle crashes. Bulletin of the American Meteorological Society, 96, 755-778. doi:10.1175/BAMS-D-14-00026.1 | Detail
  13. Špitalar, M., J. J. Gourley, C. Lutoff, P. -E. Kirstetter, M. Brilly, and N. Carr, 2014: Analysis of flash flood parameters and human impacts in the US from 2006 to 2012. Journal of Hydrology, 519, 863-870. doi:10.1016/j.jhydrol.2014.07.004 | Detail
  14. Barbero, R., J. T. Abatzoglou, N. K. Larkin, C. A. Kolden, and B. Stocks, 2015: Climate change presents increased potential for very large fires in the contiguous United States. International Journal of Wildland Fire. doi:10.1071/WF15083 | Detail
  15. Barlow, P. M., 2003: Ground Water in Freshwater-Saltwater Environments of the Atlantic Coast. 113 pp., Reston, VA. URL | Detail
  16. Bashir, S. A., 2002: Home is where the harm is: Inadequate housing as a public health crisis. American Journal of Public Health, 92, 733-738. doi:10.2105/ajph.92.5.733 | Detail
  17. Battle, D. E., 2015: Persons with communication disabilities in natural disasters, war, and/or conflict. Communication Disorders Quarterly, 36, 231-240. doi:10.1177/1525740114545980 | Detail
  18. Beatty, M. E., S. Phelps, C. Rohner, and I. Weisfuse, 2006: Blackout of 2003: Health effects and emergency responses. Public Health Reports, 121, 36-44. doi:10.1177/003335490612100109 | Detail
  19. Beggs, P. J., 2004: Impacts of climate change on aeroallergens: Past and future. Clinical & Experimental Allergy, 34, 1507-1513. doi:10.1111/j.1365-2222.2004.02061.x | Detail
  20. Belnap, J., B. J. Walker, S. M. Munson, and R. A. Gill, 2014: Controls on sediment production in two U.S. deserts. Aeolian Research, 14, 15-24. doi:10.1016/j.aeolia.2014.03.007 | Detail
  21. Beven, J. L., and others, 2008: Atlantic hurricane season of 2005. Monthly Weather Review, 136, 1109-1173. doi:10.1175/2007MWR2074.1 | Detail
  22. Bhattacharya, J., T. DeLeire, S. Haider, and J. Currie, 2003: Heat or eat? Cold-weather shocks and nutrition in poor american families. American Journal of Public Health, 93, 1149-1154. doi:10.2105/AJPH.93.7.1149 | Detail
  23. Black, A. W., and W. S. Ashley, 2010: Nontornadic convective wind fatalities in the United States. Natural Hazards, 54, 355-366. doi:10.1007/s11069-009-9472-2 | Detail
  24. Booze, T. F., T. E. Reinhardt, S. J. Quiring, and R. D. Ottmar, 2004: A screening-level assessment of the health risks of chronic smoke exposure for wildland firefighters. Journal of Occupational and Environmental Hygiene, 1, 296-305. doi:10.1080/15459620490442500 | Detail
  25. Bowles, D. C., C. D. Butler, and S. Friel, 2014: Climate change and health in Earth's future. Earth's Future, 2, 60-67. doi:10.1002/2013ef000177 | Detail
  26. Brahney, J., A. P. Ballantyne, C. Sievers, and J. C. Neff, 2013: Increasing Ca2+ deposition in the western US: The role of mineral aerosols. Aeolian Research, 10, 77-87. doi:10.1016/j.aeolia.2013.04.003 | Detail
  27. Brandenburg, M. A., S. M. Watkins, K. L. Brandenburg, and C. Schieche, 2007: Operation Child-ID: Reunifying children with their legal guardians after Hurricane Katrina. Disasters, 31, 277-287. doi:10.1111/j.0361-3666.2007.01009.x | Detail
  28. Brouwer, R., S. Akter, L. Brander, and E. Haque, 2007: Socioeconomic vulnerability and adaptation to environmental risk: A case study of climate change and flooding in Bangladesh. Risk Analysis, 27, 313-326. doi:10.1111/j.1539-6924.2007.00884.x | Detail
  29. Brunkard, J., G. Namulanda, and R. Ratard, 2008: Hurricane Katrina deaths, Louisiana, 2005. Disaster Medicine and Public Health Preparedness, 2, 215-223. doi:10.1097/DMP.0b013e31818aaf55 | Detail
  30. Caamano-Isorna, F., A. Figueiras, I. Sastre, A. Montes-Martinez, M. Taracido, and M. Pineiro-Lamas, 2011: Respiratory and mental health effects of wildfires: An ecological study in Galician municipalities (north-west Spain). Environmental Health, 10, Article 48. doi:10.1186/1476-069X-10-48 | Detail
  31. Cann, K. F., D. R. Thomas, R. L. Salmon, A. P. Wyn-Jones, and D. Kay, 2013: Extreme water-related weather events and waterborne disease. Epidemiology & Infection, 141, 671-686. doi:10.1017/s0950268812001653 | Detail
  32. Cannon, S. H., and J. DeGraff, 2009: The increasing wildfire and post-fire debris-flow threat in western USA, and implications for consequences of climate change. Landslides – Disaster Risk Reduction, K. Sassa and Canuti, P., Eds., Springer, 177-190. doi:10.1007/978-3-540-69970-5_9 | Detail
  33. Cannon, S. H., J. E. Gartner, R. C. Wilson, J. C. Bowers, and J. L. Laber, 2008: Storm rainfall conditions for floods and debris flows from recently burned areas in southwestern Colorado and southern California. Geomorphology, 96, 250-269. doi:10.1016/j.geomorph.2007.03.019 | Detail
  34. Carnie, T. -L., H. L. Berry, S. A. Blinkhorn, and C. R. Hart, 2011: In their own words: Young people's mental health in drought-affected rural and remote NSW. Australian Journal of Rural Health, 19, 244-248. doi:10.1111/j.1440-1584.2011.01224.x | Detail
  35. Casey-Lockyer, M., R. J. Heick, C. E. Mertzlufft, E. E. Yard, A. F. Wolkin, R. S. Noe, and M. Murti, 2013: Deaths associated with Hurricane Sandy - October-November 2012. Morbidity and Mortality Weekly Report, 62, 393-397. PMID: 23698603 | Detail
  36. Cattell, V., 2001: Poor people, poor places, and poor health: The mediating role of social networks and social capital. Social Science & Medicine, 52, 1501-1516. doi:10.1016/S0277-9536(00)00259-8 | Detail
  37. CDC, EPA, NOAA, and AWWA, 2010: When Every Drop Counts: Protecting Public Health During Drought Conditions—A Guide for Public Health Professionals. 56 pp., Centers for Disease Control and Prevention, U.S. Environmental Protection Agency, National Oceanic and Atmospheric Agency, and American Water Works Association, Atlanta, GA. URL | Detail
  38. Charron, D. F., M. K. Thomas, D. Waltner-Toews, J. J. Aramini, T. Edge, R. A. Kent, A. R. Maarouf, and J. Wilson, 2004: Vulnerability of waterborne diseases to climate change in Canada: A review. Journal of Toxicology and Environmental Health, Part A: Current Issues, 67, 1667-1677. doi:10.1080/15287390490492313 | Detail
  39. Clement, J., J. Vercauteren, W. W. Verstraeten, G. Ducoffre, J. M. Barrios, A. -M. Vandamme, P. Maes, and M. Van Ranst, 2009: Relating increasing hantavirus incidences to the changing climate: The mast connection. International Journal of Health Geographics, 8, 1. doi:10.1186/1476-072x-8-1 | Detail
  40. Collins, T. W., A. M. Jimenez, and S. E. Grineski, 2013: Hispanic health disparities after a flood disaster: Results of a population-based survey of individuals experiencing home site damage in El Paso (Texas, USA). Journal of Immigrant and Minority Health, 15, 415-426. doi:10.1007/s10903-012-9626-2 | Detail
  41. Conlon, K. C., N. B. Rajkovich, J. L. White-Newsome, L. Larsen, and M. S. O’Neill, 2011: Preventing cold-related morbidity and mortality in a changing climate. Maturitas, 69, 197-202. doi:10.1016/j.maturitas.2011.04.004 | Detail
  42. Cutter, S. L., L. Barnes, M. Berry, C. Burton, E. Evans, E. Tate, and J. Webb, 2008: A place-based model for understanding community resilience to natural disasters. Global Environmental Change, 18, 598-606. doi:10.1016/j.gloenvcha.2008.07.013 | Detail
  43. Cutter, S. L., W. Solecki, N. Bragado, J. A. Carmin, M. Fragkias, M. Ruth, and T. Wilbanks, 2014: Ch. 11: Urban Systems, Infrastructure, and Vulnerability. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 282-296. doi:10.7930/J0F769GR | Detail
  44. Daley, W. R., A. Smith, E. Paz-Argandona, J. Malilay, and M. McGeehin, 2000: An outbreak of carbon monoxide poisoning after a major ice storm in Maine. The Journal of Emergency Medicine, 18, 87-93. doi:10.1016/S0736-4679(99)00184-5 | Detail
  45. Dausman, A., and C. D. Langevin, 2005: Movement of the Saltwater Interface in the Surficial Aquifer System in Response to Hydrologic Stresses and Water-Management Practices, Broward County, Florida. 73 pp., Reston, VA. URL | Detail
  46. Delfino, R. J., and others, 2009: The relationship of respiratory and cardiovascular hospital admissions to the southern California wildfires of 2003. Occupational and Environmental Medicine, 66, 189-197. doi:10.1136/oem.2008.041376 | Detail
  47. Dell, J., S. Tierney, G. Franco, R. G. Newell, R. Richels, J. Weyant, and T. J. Wilbanks, 2014: Ch. 4: Energy supply and use. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 113-129. doi:10.7930/J0BG2KWD | Detail
  48. Delpla, I., A. -V. Jung, E. Baures, M. Clement, and O. Thomas, 2009: Impacts of climate change on surface water quality in relation to drinking water production. Environment International, 35, 1225-1233. doi:10.1016/j.envint.2009.07.001 | Detail
  49. Deshmukh, A., E. Ho Oh, and M. Hastak, 2011: Impact of flood damaged critical infrastructure on communities and industries. Built Environment Project and Asset Management, 1, 156-175. doi:10.1108/20441241111180415 | Detail
  50. Dey, A. N., P. Hicks, S. Benoit, and J. I. Tokars, 2010: Automated monitoring of clusters of falls associated with severe winter weather using the BioSense system. Injury Prevention, 16, 403-407. doi:10.1136/ip.2009.025841 | Detail
  51. Du, W., G. J. FitzGerald, M. Clark, and X. -Y. Hou, 2010: Health impacts of floods. Prehospital and Disaster Medicine, 25, 265-272. doi:10.1017/S1049023X00008141 | Detail
  52. Eisenberg, D., and K. E. Warner, 2005: Effects of snowfalls on motor vehicle collisions, injuries, and fatalities. American Journal of Public Health, 95, 120-124. doi:10.2105/AJPH.2004.048926 | Detail
  53. Elliott, C., S. Henderson, and V. Wan, 2013: Time series analysis of fine particulate matter and asthma reliever dispensations in populations affected by forest fires. Environmental Health, 12, 11. doi:10.1186/1476-069X-12-11 | Detail
  54. Emelko, M. B., U. Silins, K. D. Bladon, and M. Stone, 2011: Implications of land disturbance on drinking water treatability in a changing climate: Demonstrating the need for "source water supply and protection" strategies. Water Research, 45, 461-472. doi:10.1016/j.watres.2010.08.051 | Detail
  55. Engle, N. L., 2011: Adaptive capacity and its assessment. Global Environmental Change, 21, 647-656. doi:10.1016/j.gloenvcha.2011.01.019 | Detail
  56. EPA, 2009: Integrated Science Assessment for Particulate Matter. Array, National Center for Environmental Assessment, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC. URL | Detail
  57. Epstein, P. R., and C. Defilippo, 2001: West Nile virus and drought. Global Change and Human Health, 2, 105-107. doi:10.1023/a:1015089901425 | Detail
  58. Fayard, G. M., 2009: Fatal work injuries involving natural disasters, 1992–2006. Disaster Medicine and Public Health Preparedness, 3, 201-209. doi:10.1097/DMP.0b013e3181b65895 | Detail
  59. Fisk, W. J., E. A. Eliseeva, and M. J. Mendell, 2010: Association of residential dampness and mold with respiratory tract infections and bronchitis: A meta-analysis. Environmental Health, 9, Article 72. doi:10.1186/1476-069x-9-72 | Detail
  60. Fisk, W. J., Q. Lei-Gomez, and M. J. Mendell, 2007: Meta-analyses of the associations of respiratory health effects with dampness and mold in homes. Indoor Air, 17, 284-296. doi:10.1111/j.1600-0668.2007.00475.x | Detail
  61. Fothergill, A., and L. A. Peek, 2004: Poverty and disasters in the United States: A review of recent sociological findings. Natural Hazards, 32, 89-110. doi:10.1023/B:NHAZ.0000026792.76181.d9 | Detail
  62. Freese, J., N. J. Richmand, R. A. Silverman, J. Braun, B. J. Kaufman, and J. Clair, 2006: Impact of Citywide Blackout on an Urban Emergency Medical Services System. Prehospital and Disaster Medicine, 21, 372-378. doi:10.1017/S1049023X00004064 | Detail
  63. Fritze, J. G., G. A. Blashki, S. Burke, and J. Wiseman, 2008: Hope, despair and transformation: Climate change and the promotion of mental health and wellbeing. International Journal of Mental Health Systems, 2, 1-10. doi:10.1186/1752-4458-2-13 | Detail
  64. Frumkin, H., J. Hess, G. Luber, J. Malilay, and M. McGeehin, 2008: Climate change: The public health response. American Journal of Public Health, 98, 435-445. doi:10.2105/AJPH.2007.119362 | Detail
  65. GAO, 2015: Army Corps of Engineers Efforts to Assess the Impact of Extreme Weather Events. United States Government Accountability Office. URL | Detail
  66. Garcia, C. A., P. -S. Yap, H. -Y. Park, and B. L. Weller, 2015: Association of long-term PM2.5 exposure with mortality using different air pollution exposure models: Impacts in rural and urban California. International Journal of Environmental Health Research, 26, 145-157. doi:10.1080/09603123.2015.1061113 | Detail
  67. Garcia-Solache, M. A., and A. Casadevall, 2010: Global warming will bring new fungal diseases for mammals. mBio, 1, e00061-10. doi:10.1128/mBio.00061-10 | Detail
  68. Garfin, G., G. Franco, H. Blanco, A. Comrie, P. Gonzalez, T. Piechota, R. Smyth, and R. Waskom, 2014: Ch. 20: Southwest. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 462-486. doi:10.7930/J08G8HMN | Detail
  69. Georgakakos, A., P. Fleming, M. Dettinger, C. Peters-Lidard, Terese (T.C.) Richmond, K. Reckhow, K. White, and D. Yates, 2014: Ch. 3: Water Resources. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 69-112. doi:10.7930/J0G44N6T | Detail
  70. Ghilarducci, D. P., and R. S. Tjeerdema, 1995: Fate and effects of acrolein. Reviews of Environmental Contamination and Toxicology, 144, 95-146. doi:10.1007/978-1-4612-2550-8_2 | Detail
  71. Ginoux, P., J. M. Prospero, T. E. Gill, N. C. Hsu, and M. Zhao, 2012: Global-scale attribution of anthropogenic and natural dust sources and their emission rates based on MODIS Deep Blue aerosol products. Reviews of Geophysics, 50, RG3005. doi:10.1029/2012rg000388 | Detail
  72. Gold, D. R., and others, 2000: Ambient pollution and heart rate variability. Circulation, 101, 1267-1273. doi:10.1161/01.CIR.101.11.1267 | Detail
  73. Goldman, A., B. Eggen, B. Golding, and V. Murray, 2014: The health impacts of windstorms: A systematic literature review. Public Health, 128, 3-28. doi:10.1016/j.puhe.2013.09.022 | Detail
  74. Grineski, S. E., J. G. Staniswalis, P. Bulathsinhala, Y. Peng, and T. E. Gill, 2011: Hospital admissions for asthma and acute bronchitis in El Paso, Texas: Do age, sex, and insurance status modify the effects of dust and low wind events? Environmental Research, 111, 1148-1155. doi:10.1016/j.envres.2011.06.007 | Detail
  75. Guenther, R., and J. Balbus, 2014: Primary Protection: Enhancing Health Care Resilience for a Changing Climate. U.S. Department of Health and Human Services. URL | Detail
  76. Hales, D., and others, 2014: Ch. 14: Rural Communities. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 333-349. doi:10.7930/J01Z429C | Detail
  77. Hanigan, I. C., C. D. Butler, P. N. Kokic, and M. F. Hutchinson, 2012: Suicide and drought in New South Wales, Australia, 1970–2007. Proceedings of the National Academy of Sciences of the United States of America, 109, 13950-13955. doi:10.1073/pnas.1112965109 | Detail
  78. Hefflin, B. J., B. Jalaludin, E. McClure, N. Cobb, C. A. Johnson, L. Jecha, and R. A. Etzel, 1994: Surveillance for dust storms and respiratory diseases in Washington State, 1991. Archives of Environmental Health: An International Journal, 49, 170-174. doi:10.1080/00039896.1994.9940378 | Detail
  79. Henderson, S. B., and F. H. Johnston, 2012: Measures of forest fire smoke exposure and their associations with respiratory health outcomes. Current Opinion in Allergy and Clinical Immunology, 12, 221-227. doi:10.1097/ACI.0b013e328353351f | Detail
  80. Henderson, S. B., M. Brauer, Y. C. Macnab, and S. M. Kennedy, 2011: Three measures of forest fire smoke exposure and their associations with respiratory and cardiovascular health outcomes in a population-based cohort. Environmental Health Perspectives, 119, 1266-1271. doi:10.1289/ehp.1002288 | Detail
  81. Hess, J. J., J. Z. McDowell, and G. Luber, 2012: Integrating climate change adaptation into public health practice: Using adaptive management to increase adaptive capacity and build resilience. Environmental Health Perspectives, 120, 171-179. doi:10.1289/ehp.1103515 | Detail
  82. Hjelle, B., and F. Torres-Pérez, 2010: Hantaviruses in the Americas and their role as emerging pathogens. Viruses, 2, 2559-2586. doi:10.3390/v2122559 | Detail
  83. Holstius, D. M., C. E. Reid, B. M. Jesdale, and R. Morello-Frosch, 2012: Birth weight following pregnancy during the 2003 southern California wildfires. Environmental Health Perspectives, 120, 1340-1345. doi:10.1289/ehp.1104515 | Detail
  84. IPCC, 2012: Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation. A Special Report of Working Groups I and II of the Intergovernmental Panel on Climate Change. C.B. Field et al., Eds., Cambridge University Press, 582 pp. URL | Detail
  85. Iqbal, S., J. H. Clower, S. A. Hernandez, S. A. Damon, and F. Y. Yip, 2012: A review of disaster-related carbon monoxide poisoning: Surveillance, epidemiology, and opportunities for prevention. American Journal of Public Health, 102, 1957-1963. doi:10.2105/ajph.2012.300674 | Detail
  86. Jahromi, A. H., R. Wigle, and A. M. Youssef, 2011: Are we prepared yet for the extremes of weather changes? Emergence of several severe frostbite cases in Louisiana. The American Surgeon, 77, 1712-1713. | Detail
  87. Johnson, B. J., and M. V. K. Sukhdeo, 2013: Drought-induced amplification of local and regional West Nile virus infection rates in New Jersey. Journal of Medical Entomology, 50, 195-204. doi:10.1603/me12035 | Detail
  88. Johnston, F., I. Hanigan, S. Henderson, G. Morgan, and D. Bowman, 2011: Extreme air pollution events from bushfires and dust storms and their association with mortality in Sydney, Australia 1994–2007. Environmental Research, 111, 811-816. doi:10.1016/j.envres.2011.05.007 | Detail
  89. Jones, R. T., D. P. Ribbe, P. B. Cunningham, J. D. Weddle, and A. K. Langley, 2002: Psychological impact of fire disaster on children and their parents. Behavior Modification, 26, 163-186. doi:10.1177/0145445502026002003 | Detail
  90. Jordan, P., K. Turner, D. Nicol, and D. Boyer, 2006: Developing a risk analysis procedure for post-wildfire mass movement and flooding in British Columbia. 1st Specialty Conference on Disaster Medicine, Calgary, Alberta, Canada. URL | Detail
  91. Künzli, N., and others, 2006: Health effects of the 2003 southern California wildfires on children. American Journal of Respiratory and Critical Care Medicine, 174, 1221-1228. doi:10.1164/rccm.200604-519OC | Detail
  92. Keim, M. E., 2008: Building human resilience: The role of public health preparedness and response as an adaptation to climate change. American Journal of Preventive Medicine, 35, 508-516. doi:10.1016/j.amepre.2008.08.022 | Detail
  93. Kellar, D. M. M., and T. W. Schmidlin, 2012: Vehicle-related flood deaths in the United States, 1995-2005. Journal of Flood Risk Management, 5, 153-163. doi:10.1111/j.1753-318X.2012.01136.x | Detail
  94. Kenny, J. F., N. L. Barber, S. S. Hutson, K. S. Linsey, J. K. Lovelace, and M. A. Maupin, 2009: Estimated Use of Water in the United States in 2005. U.S. Geological Survey Circular 1344. 52 pp., U.S. Geological Survey, Reston, VA. URL | Detail
  95. Keppel, K. G., 2007: Ten largest racial and ethnic health disparities in the United States based on Healthy People 2010 objectives. American Journal of Epidemiology, 166, 97-103. doi:10.1093/aje/kwm044 | Detail
  96. Kile, J. C., and others, 2005: Impact of 2003 power outages on public health and emergency response. Prehospital and Disaster Medicine, 20, 93-97. doi:10.1017/s1049023x00002259 | Detail
  97. Kirshen, P., M. Ruth, and W. Anderson, 2008: Interdependencies of urban climate change impacts and adaptation strategies: A case study of Metropolitan Boston USA. Climatic Change, 86, 105-122. doi:10.1007/s10584-007-9252-5 | Detail
  98. Klein, K. R., P. Herzog, S. Smolinske, and S. R. White, 2007: Demand for poison control center services “surged” during the 2003 blackout. Clinical Toxicology, 45, 248-254. doi:10.1080/15563650601031676 | Detail
  99. Kleinpeter, M. A., 2011: Disaster preparedness for dialysis patients. Clinical Journal of the American Society of Nephrology, 6, 2337-2339. doi:10.2215/cjn.08690811 | Detail
  100. Klein, S. L., and C. H. Calisher, 2007: Emergence and persistence of hantaviruses. Wildlife and Emerging Zoonotic Diseases: The Biology, Circumstances and Consequences of Cross-Species Transmission, J.E. Childs, Mackenzie, J.S., and Richt, J.A., Eds., Springer-Verlag, 217-252. doi:10.1007/978-3-540-70962-6_10 | Detail
  101. Klinger, C., O. Landeg, and V. Murray, 2014: Power outages, extreme events and health: A systematic review of the literature from 2011-2012. PLOS Currents: Disasters, 6. doi:10.1371/currents.dis.04eb1dc5e73dd1377e05a10e9edde673 | Detail
  102. Knowlton, K., M. Rotkin-Ellman, L. Geballe, W. Max, and G. M. Solomon, 2011: Six climate change-related events in the United States accounted for about $14 billion in lost lives and health costs. Health Affairs, 30, 2167-2176. doi:10.1377/hlthaff.2011.0229 | Detail
  103. Kovats, R. S., and S. Hajat, 2008: Heat stress and public health: A critical review. Annual Review of Public Health, 29, 41-55. doi:10.1146/annurev.publhealth.29.020907.090843 | Detail
  104. Kuenzi, A. J., M. L. Morrison, N. K. Madhav, and J. N. Mills, 2007: Brush mouse (Peromyscus boylii) population dynamics and hantavirus infection during a warm, drought period in southern Arizona. Journal of Wildlife Diseases, 43, 675-683. doi:10.7589/0090-3558-43.4.675 | Detail
  105. Laditka, S. B., J. N. Laditka, S. Xirasagar, C. B. Cornman, C. B. Davis, and J. V. E. Richter, 2008: Providing shelter to nursing home evacuees in disasters: Lessons from Hurricane Katrina. American Journal of Public Health, 98, 1288-1293. doi:10.2105/ajph.2006.107748 | Detail
  106. Lal, A., M. G. Baker, S. Hales, and N. P. French, 2013: Potential effects of global environmental changes on cryptosporidiosis and giardiasis transmission. Trends in Parasitology, 29, 83-90. doi:10.1016/j.pt.2012.10.005 | Detail
  107. Landesman, W. J., B. F. Allan, R. B. Langerhans, T. M. Knight, and J. M. Chase, 2007: Inter-annual associations between precipitation and human incidence of West Nile Virus in the United States. Vector-Borne and Zoonotic Diseases, 7, 337-343. doi:10.1089/vbz.2006.0590 | Detail
  108. Lane, K., K. Charles-Guzman, K. Wheeler, Z. Abid, N. Graber, and T. Matte, 2013: Health effects of coastal storms and flooding in urban areas: A review and vulnerability assessment. Journal of Environmental and Public Health, 2013, 1-13. doi:10.1155/2013/913064 | Detail
  109. Leavitt, W. M., and J. J. Kiefer, 2006: Infrastructure interdependency and the creation of a normal disaster: The case of Hurricane Katrina and the City of New Orleans. Public Works Management & Policy, 10, 306-314. doi:10.1177/1087724X06289055 | Detail
  110. Leonard, S. S., V. Castranova, B. T. Chen, D. Schwegler-Berry, M. Hoover, C. Piacitelli, and D. M. Gaughan, 2007: Particle size-dependent radical generation from wildland fire smoke. Toxicology, 236, 103-113. doi:10.1016/j.tox.2007.04.008 | Detail
  111. Liddell, C., and C. Morris, 2010: Fuel poverty and human health: A review of recent evidence. Energy Policy, 38, 2987-2997. doi:10.1016/j.enpol.2010.01.037 | Detail
  112. Lim, C., and J. Duflou, 2008: Hypothermia fatalities in a temperate climate: Sydney, Australia. Pathology, 40, 46-51. doi:10.1080/00313020701716466 | Detail
  113. Linnenluecke, M. K., A. Griffiths, and M. Winn, 2012: Extreme weather events and the critical importance of anticipatory adaptation and organizational resilience in responding to impacts. Business Strategy and the Environment, 21, 17-32. doi:10.1002/bse.708 | Detail
  114. Lin, S., B. A. Fletcher, M. Luo, R. Chinery, and S. -. A. Hwang, 2011: Health impact in New York City during the Northeastern blackout of 2003. Public Health Reports, 126, 384-93. doi:10.1177/003335491112600312 | Detail
  115. Lippmann, A. L., 2011: Disaster preparedness in vulnerable communities. International Law and Policy Review, 1, 69-96. | Detail
  116. Litvintseva, A. P., and others, 2015: Valley fever: Finding new places for an old disease: Coccidioides immitis found in Washington State soil associated with recent human infection. Clinical Infectious Diseases, 60, e1-e3. doi:10.1093/cid/ciu681 | Detail
  117. Lowe, D., K. Ebi, and B. Forsberg, 2013: Factors increasing vulnerability to health effects before, during and after floods. International Journal of Environmental Research and Public Health, 10, 7015-7067. doi:10.3390/ijerph10127015 | Detail
  118. Luber, G., and others, 2014: Ch. 9: Human Health. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 220-256. doi:10.7930/J0PN93H5 | Detail
  119. Lutterloh, E. C., and others, 2011: Carbon monoxide poisoning after an ice storm in Kentucky, 2009. Public Health Reports, 126 (Suppl 1), 108-115. URL | Detail
  120. Mann, M. L., P. Berck, M. A. Moritz, E. Batllori, J. G. Baldwin, C. K. Gately, and D. R. Cameron, 2014: Modeling residential development in California from 2000 to 2050: Integrating wildfire risk, wildland and agricultural encroachment. Land Use Policy, 41, 438-452. doi:10.1016/j.landusepol.2014.06.020 | Detail
  121. Marsden-Haug, N., and others, 2014: Coccidioides immitis identified in soil outside of its known range - Washington, 2013. Morbidity and Mortality Weekly Report, 63, 450. PMID: 24848217 | Detail
  122. Masozera, M., M. Bailey, and C. Kerchner, 2007: Distribution of impacts of natural disasters across income groups: A case study of New Orleans. Ecological Economics, 63, 299-306. doi:10.1016/j.ecolecon.2006.06.013 | Detail
  123. McKinney, N., C. Houser, and K. Meyer-Arendt, 2011: Direct and indirect mortality in Florida during the 2004 hurricane season. International Journal of Biometeorology, 55, 533-546. doi:10.1007/s00484-010-0370-9 | Detail
  124. McMeeking, G. R., and others, 2006: Smoke-impacted regional haze in California during the summer of 2002. Agricultural and Forest Meteorology, 137, 25-42. doi:10.1016/j.agrformet.2006.01.011 | Detail
  125. Melillo, J. M., T. (T. C. ) Richmond, and G. W. Yohe, eds., 2014: Climate Change Impacts in the United States: The Third National Climate Assessment. U.S. Global Change Research Program, 841 pp. doi:10.7930/J0Z31WJ2 | Detail
  126. Mendell, M. J., A. G. Mirer, K. Cheung, M. Tong, and J. Douwes, 2011: Respiratory and allergic health effects of dampness, mold, and dampness-related agents: A review of the epidemiologic evidence. Environmental Health Perspectives, 119, 748-756. doi:10.1289/ehp.1002410 | Detail
  127. Moody, J. A., R. A. Shakesby, P. R. Robichaud, S. H. Cannon, and D. A. Martin, 2013: Current research issues related to post-wildfire runoff and erosion processes. Earth-Science Reviews, 122, 10-37. doi:10.1016/j.earscirev.2013.03.004 | Detail
  128. Mooney, H., and others, 2009: Biodiversity, climate change, and ecosystem services. Current Opinion in Environmental Sustainability, 1, 46-54. doi:10.1016/j.cosust.2009.07.006 | Detail
  129. Morman, S. A., and G. S. Plumlee, 2013: The role of airborne mineral dusts in human disease. Aeolian Research, 9, 203-212. doi:10.1016/j.aeolia.2012.12.001 | Detail
  130. Moser, S. C., M. A. Davidson, P. Kirshen, P. Mulvaney, J. F. Murley, J. E. Neumann, L. Petes, and D. Reed, 2014: Ch. 25: Coastal Zone Development and Ecosystems. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 579-618. doi:10.7930/J0MS3QNW | Detail
  131. Munson, S. M., J. Belnap, and G. S. Okin, 2011: Responses of wind erosion to climate-induced vegetation changes on the Colorado Plateau. Proceedings of the National Academy of Sciences of the United States of America, 108, 3854-3859. doi:10.1073/pnas.1014947108 | Detail
  132. Naeher, L. P., M. Brauer, M. Lipsett, J. T. Zelikoff, C. D. Simpson, J. Q. Koenig, and K. R. Smith, 2007: Woodsmoke health effects: A review. Inhalation Toxicology, 19, 67-106. doi:10.1080/08958370600985875 | Detail
  133. Neu, J. L., and M. J. Prather, 2012: Toward a more physical representation of precipitation scavenging in global chemistry models: Cloud overlap and ice physics and their impact on tropospheric ozone. Atmospheric Chemistry and Physics, 12, 3289-3310. doi:10.5194/acp-12-3289-2012 | Detail
  134. NOAA, cited 2010: Weather Fatalities. National Oceanic and Atmospheric Administration. URL | Detail
  135. NOAA, 2013: Service Assessment: Hurricane/Post-Tropical Cyclone Sandy, October 22–29, 2012. 66 pp., U.S. Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service, Silver Spring, MD. URL | Detail
  136. NRC, 2012: Disaster Resilience: A National Imperative. National Academies Press, 244 pp. | Detail
  137. Obrien, L. V., H. L. Berry, C. Coleman, and I. C. Hanigan, 2014: Drought as a mental health exposure. Environmental Research, 131, 181-187. doi:10.1016/j.envres.2014.03.014 | Detail
  138. Olds, B. P., B. C. Peterson, K. D. Koupal, K. M. Farnsworth-Hoback, C. W. Schoenebeck, and W. W. Hoback, 2011: Water quality parameters of a Nebraska reservoir differ between drought and normal conditions. Lake and Reservoir Management, 27, 229-234. doi:10.1080/07438141.2011.601401 | Detail
  139. Olsen, C. S., D. K. Mazzotta, E. Toman, and A. P. Fischer, 2014: Communicating about smoke from wildland fire: Challenges and opportunities for managers. Environmental Management, 54, 571-582. doi:10.1007/s00267-014-0312-0 | Detail
  140. Osofsky, H. J., J. D. Osofsky, J. Arey, M. E. Kronenberg, T. Hansel, and M. Many, 2011: Hurricane Katrina's first responders: The struggle to protect and serve in the aftermath of the disaster. Disaster Medicine and Public Health Preparedness, 5, S214-S219. doi:10.1001/dmp.2011.53 | Detail
  141. Panikkath, R., C. A. Jumper, and Z. Mulkey, 2013: Multilobar lung infiltrates after exposure to dust storm: The haboob lung syndrome. The American Journal of Medicine, 126, e5-e7. doi:10.1016/j.amjmed.2012.08.012 | Detail
  142. Park, B. J., and others, 2005: An epidemic of Coccidioidomycosis in Arizona associated with climatic changes, 1998–2001. The Journal of Infectious Diseases, 191, 1981-1987. doi:10.1086/430092 | Detail
  143. Peek, L., and L. M. Stough, 2010: Children with disabilities in the context of disaster: A social vulnerability perspective. Child Development, 81, 1260-1270. doi:10.1111/j.1467-8624.2010.01466 | Detail
  144. Penner, S. J., and C. Wachsmuth, 2008: Disaster management and populations with special needs. Disaster Management Handbook, J. Pinkowski, Ed., CRC Press, 427-444. | Detail
  145. Peters, M. P., L. R. Iverson, S. N. Matthews, and A. M. Prasad, 2013: Wildfire hazard mapping: Exploring site conditions in eastern US wildland–urban interfaces. International Journal of Wildland Fire, 22, 567-578. doi:10.1071/WF12177 | Detail
  146. Peterson, T. C., T. R. Karl, J. P. Kossin, K. E. Kunkel, J. H. Lawrimore, J. R. McMahon, R. S. Vose, and X. Yin, 2014: Changes in weather and climate extremes: State of knowledge relevant to air and water quality in the United States. Journal of the Air & Waste Management Association, 64, 184-197. doi:10.1080/10962247.2013.851044 | Detail
  147. Pfaller, M. A., P. G. Pappas, and J. R. Wingard, 2006: Invasive fungal pathogens: Current epidemiological trends. Clinical Infectious Diseases, 43 Supp 1, S3-S14. doi:10.1086/504490 | Detail
  148. Phuleria, H. C., P. M. Fine, Y. Zhu, and C. Sioutas, 2005: Air quality impacts of the October 2003 southern California wildfires. Journal of Geophysical Research, 110, D07S20. doi:10.1029/2004jd004626 | Detail
  149. Pope, C. A., M. C. Turner, R. T. Burnett, M. Jerrett, S. M. Gapstur, W. R. Diver, D. Krewski, and R. D. Brook, 2015: Relationships Between Fine Particulate Air Pollution, Cardiometabolic Disorders, and Cardiovascular Mortality. Circulation Research, 116, 108-115. doi:10.1161/CIRCRESAHA.116.305060 | Detail
  150. Pope, C. A., R. T. Burnett, G. D. Thurston, M. J. Thun, E. E. Calle, D. Krewski, and J. J. Godleski, 2004: Cardiovascular Mortality and Long-Term Exposure to Particulate Air Pollution: Epidemiological Evidence of General Pathophysiological Pathways of Disease. Circulation, 109, 71-77. doi:10.1161/01.CIR.0000108927.80044.7F | Detail
  151. Prezant, D. J., and others, 2005: Effects of the August 2003 blackout on the New York City healthcare delivery system: A lesson for disaster preparedness. Critical Care Medicine, 33, S96-S101. doi:10.1097/01.ccm.0000150956.90030.23 | Detail
  152. Puett, R. C., and others, 2008: Chronic particulate exposure, mortality, and coronary heart disease in the Nurses' Health Study. American Journal of Epidemiology, 168, 1161-1168. doi:10.1093/aje/kwn232 | Detail
  153. Radeloff, V. C., R. B. Hammer, S. I. Stewart, J. S. Fried, S. S. Holcomb, and J. F. McKeefry, 2005: The wildland-urban interface in the United States. Ecological Applications, 15, 799-805. doi:10.1890/04-1413 | Detail
  154. Ramin, B., and T. Svoboda, 2009: Health of the homeless and climate change. Journal of Urban Health, 86, 654-664. doi:10.1007/s11524-009-9354-7 | Detail
  155. Rappaport, E. N., 2014: Fatalities in the United States from Atlantic tropical cyclones: New data and interpretation. Bulletin of the American Meteorological Society, 95, 341-346. doi:10.1175/bams-d-12-00074.1 | Detail
  156. Rappold, A. G., and others, 2011: Peat bog wildfire smoke exposure in rural North Carolina is associated with cardiopulmonary emergency department visits assessed through syndromic surveillance. Environmental Health Perspectives, 119, 1415-1420. doi:10.1289/ehp.1003206 | Detail
  157. Reheis, M. C., and F. E. Urban, 2011: Regional and climatic controls on seasonal dust deposition in the southwestern U.S. Aeolian Research, 3, 3-21. doi:10.1016/j.aeolia.2011.03.008 | Detail
  158. Renken, R. A., and others, 2005: Impact of Anthropogenic Development on Coastal Ground-Water Hydrology in Southeastern Florida, 1900-2000. 77 pp., U.S. Geological Survey, Reston, VA. URL | Detail
  159. Reusken, C., and P. Heyman, 2013: Factors driving hantavirus emergence in Europe. Current Opinion in Virology, 3, 92-99. doi:10.1016/j.coviro.2013.01.002 | Detail
  160. Rhoades, C. C., D. Entwistle, and D. Butler, 2012: Water quality effects following a severe fire. Fire Management Today, 72, (2):35-39. URL | Detail
  161. Richardson, L. A., P. A. Champ, and J. B. Loomis, 2012: The hidden cost of wildfires: Economic valuation of health effects of wildfire smoke exposure in Southern California. Journal of Forest Economics, 18, 14-35. doi:10.1016/j.jfe.2011.05.002 | Detail
  162. Rowe, S. T., and G. Villarini, 2013: Flooding associated with predecessor rain events over the Midwest United States. Environmental Research Letters, 8, 024007. doi:10.1088/1748-9326/8/2/024007 | Detail
  163. Sapkota, A., and others, 2005: Impact of the 2002 Canadian forest fires on particulate matter air quality in Baltimore City. Environmental Science & Technology, 39, 24-32. doi:10.1021/es035311z | Detail
  164. Schmidlin, T. W., 2009: Human fatalities from wind-related tree failures in the United States, 1995–2007. Natural Hazards, 50, 13-25. doi:10.1007/s11069-008-9314-7 | Detail
  165. Schulte, P. A., and H. K. Chun, 2009: Climate change and occupational safety and health: Establishing a preliminary framework. Journal of Occupational and Environmental Hygiene, 6, 542-554. doi:10.1080/15459620903066008 | Detail
  166. Schumacher, R. S., and T. J. Galarneau, 2012: Moisture transport into midlatitudes ahead of recurving tropical cyclones and its relevance in two predecessor rain events. Monthly Weather Review, 140, 1810-1827. doi:10.1175/mwr-d-11-00307.1 | Detail
  167. Senkbeil, J. C., D. M. Brommer, and I. J. Comstock, 2011: Tropical cyclone hazards in the USA. Geography Compass, 5, 544-563. doi:10.1111/j.1749-8198.2011.00439.x | Detail
  168. Shaman, J., J. F. Day, and M. Stieglitz, 2005: Drought-induced amplification and epidemic transmission of West Nile virus in southern Florida. Journal of Medical Entomology, 42, 134-141. doi:10.1093/jmedent/42.2.134 | Detail
  169. Shaman, J., J. F. Day, and N. Komar, 2010: Hydrologic conditions describe West Nile virus risk in Colorado. International Journal of Environmental Research and Public Health, 7, 494-508. doi:10.3390/ijerph7020494 | Detail
  170. Sham, C. H., M. E. Tuccillo, and J. Rooke, 2013: Effects of Wildfire on Drinking Water Utilities and Best Practices for Wildfire Risk Reduction and Mitigation. 119 pp., Water Research Foundation, Denver, CO. URL | Detail
  171. Sharif, H. O., T. L. Jackson, M. M. Hossain, and D. Zane, 2014: Analysis of flood fatalities in Texas. Natural Hazards Review, 16, 04014016. doi:10.1061/(asce)nh.1527-6996.0000145 | Detail
  172. Skinner, M. W., N. M. Yantzi, and M. W. Rosenberg, 2009: Neither rain nor hail nor sleet nor snow: Provider perspectives on the challenges of weather for home and community care. Social Science & Medicine, 68, 682-688. doi:10.1016/j.socscimed.2008.11.022 | Detail
  173. Smith, A. B., and R. W. Katz, 2013: US billion-dollar weather and climate disasters: Data sources, trends, accuracy and biases. Natural Hazards, 67, 387-410. doi:10.1007/s11069-013-0566-5 | Detail
  174. Smith, C. E., 1946: Effect of season and dust control on Coccidioidomycosis. Journal of the American Medical Association, 132, 833-838. doi:10.1001/jama.1946.02870490011003 | Detail
  175. Smith, H. G., G. J. Sheridan, P. N. J. Lane, P. Nyman, and S. Haydon, 2011: Wildfire effects on water quality in forest catchments: A review with implications for water supply. Journal of Hydrology, 396, 170-192. doi:10.1016/j.jhydrol.2010.10.043 | Detail
  176. Solomon, G. M., M. Hjelmroos-Koski, M. Rotkin-Ellman, and S. K. Hammond, 2006: Ariborne mold and endotoxin concentrations in New Orleans, Louisiana, after flooding, October through November 2005. Environmental Health Perspectives, 114, 1381-1386. doi:10.1289/ehp.9198 | Detail
  177. Squire, B., C. Chidester, and S. Raby, 2011: Medical events during the 2009 Los Angeles County Station fire: Lessons for wildfire EMS planning. Prehospital Emergency Care, 15, 464-472. doi:10.3109/10903127.2011.598607 | Detail
  178. Srinivasan, S., L. R. O’Fallon, and A. Dearry, 2003: Creating healthy communities, healthy homes, healthy people: Initiating a research agenda on the built environment and public health. American Journal of Public Health, 93, 1446-1450. doi:10.2105/ajph.93.9.1446 | Detail
  179. Stanke, C., M. Kerac, C. Prudhomme, J. Medlock, and V. Murray, 2013: Health effects of drought: A systematic review of the evidence. PLOS Currents: Disasters. doi:10.1371/currents.dis.7a2cee9e980f91ad7697b570bcc4b004 | Detail
  180. Stefanidou, M., S. Athanaselis, and C. Spiliopoulou, 2008: Health impacts of fire smoke inhalation. Inhalation Toxicology, 20, 761-766. doi:10.1080/08958370801975311 | Detail
  181. Steinberg, L. J., H. Sengul, and A. M. Cruz, 2008: Natech risk and management: An assessment of the state of the art. Natural Hazards, 46, 143-152. doi:10.1007/s11069-007-9205-3 | Detail
  182. Sutherland, E. R., B. J. Make, S. Vedal, L. Zhang, S. J. Dutton, J. R. Murphy, and P. E. Silkoff, 2005: Wildfire smoke and respiratory symptoms in patients with chronic obstructive pulmonary disease. Journal of Allergy and Clinical Immunology, 115, 420-422. doi:10.1016/j.jaci.2004.11.030 | Detail
  183. Tapsell, S. M., E. C. Penning-Rowsell, S. M. Tunstall, and T. L. Wilson, 2002: Vulnerability to flooding: Health and social dimensions. Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences, 360, 1511-1525. doi:10.1098/rsta.2002.1013 | Detail
  184. Thelen, B., and others, 2013: Modeling acute respiratory illness during the 2007 San Diego wildland fires using a coupled emissions-transport system and generalized additive modeling. Environmental Health, 12, 94. doi:10.1186/1476-069x-12-94 | Detail
  185. Thomalla, F., T. Downing, E. Spanger-Siegfried, G. Han, and J. Rockström, 2006: Reducing hazard vulnerability: Towards a common approach between disaster risk reduction and climate adaptation. Disasters, 30, 39-48. doi:10.1111/j.1467-9523.2006.00305.x | Detail
  186. Thomas, D. S., and D. T. Butry, 2014: Areas of the U.S. wildland–urban interface threatened by wildfire during the 2001–2010 decade. Natural Hazards, 71, 1561-1585. doi:10.1007/s11069-013-0965-7 | Detail
  187. Thomas, D. S. K., B. D. Phillips, W. E. Lovekamp, and A. Fothergill, 2013: Social Vulnerability to Disasters. CRC Press, 514 pp. | Detail
  188. Tong, V. T., M. E. Zotti, and J. Hsia, 2011: Impact of the Red River catastrophic flood on women giving birth in North Dakota, 1994–2000. Maternal and Child Health Journal, 15, 281-288. doi:10.1007/s10995-010-0576-9 | Detail
  189. USGS, 2012: Wildfire Effects on Source-Water Quality: Lessons from Fourmile Canyon Fire, Colorado, and Implications for Drinking-Water Treatment. 4 pp. URL | Detail
  190. van Vliet, M. T. H., and J. J. G. Zwolsman, 2008: Impact of summer droughts on the water quality of the Meuse river. Journal of Hydrology, 353, 1-17. doi:10.1016/j.jhydrol.2008.01.001 | Detail
  191. Villarini, G., R. Goska, J. A. Smith, and G. A. Vecchi, 2014: North Atlantic tropical cyclones and U.S. flooding. Bulletin of the American Meteorological Society, 95, 1381-1388. doi:10.1175/bams-d-13-00060.1 | Detail
  192. Viswanathan, S., L. Eria, N. Diunugala, J. Johnson, and C. McClean, 2006: An analysis of effects of San Diego wildfire on ambient air quality. Journal of the Air & Waste Management Association, 56, 56-67. doi:10.1080/10473289.2006.10464439 | Detail
  193. Wang, G., R. B. Minnis, J. L. Belant, and C. L. Wax, 2010: Dry weather induces outbreaks of human West Nile virus infections. BMC Infectious Diseases, 10, 38. doi:10.1186/1471-2334-10-38 | Detail
  194. Warner, K., N. Ranger, S. Surminski, M. Arnold, J. Linnerooth-Bayer, E. Michel-Kerjan, P. Kovacs, and C. Herweijer, 2009: Adaptation to Climate Change: Linking Disaster Risk Reduction and Insurance. 30 pp., United Nations International Strategy for Disaster Reduction Secretariat, Geneva. URL | Detail
  195. Watson, D. C., M. Sargianou, A. Papa, P. Chra, I. Starakis, and G. Panos, 2014: Epidemiology of Hantavirus infections in humans: A comprehensive, global overview. Critical Reviews in Microbiology, 40, 261-272. doi:10.3109/1040841x.2013.783555 | Detail
  196. Wegesser, T. C., K. E. Pinkerton, and J. A. Last, 2009: California wildfires of 2008: Coarse and fine particulate matter toxicity. Environmental Health Perspectives, 117, 893-897. doi:10.1289/ehp.0800166 | Detail
  197. Weinhold, B., 2011: Fields and forests in flames: Vegetation smoke and human health. Environmental Health Perspectives, 119, a386-a393. doi:10.1289/ehp.119-a386 | Detail
  198. Whitehead, P. G., R. L. Wilby, R. W. Battarbee, M. Kernan, and A. J. Wade, 2009: A review of the potential impacts of climate change on surface water quality. Hydrological Sciences Journal, 54, 101-123. doi:10.1623/hysj.54.1.101 | Detail
  199. Wilbanks, T. J., and S. J. Fernandez, eds., 2014: Climate Change and Infrastructure, Urban Systems, and Vulnerabilities. Technical Report for the U.S. Department of Energy in Support of the National Climate Assessment. Island Press, 88 pp. URL | Detail
  200. William Sweet, Joseph Park, John Marra, Chris Zervas, and Stephen Gill, 2014: Sea Level Rise and Nuisance Flood Frequency Changes Around the United States. 58 pp., U.S. Department of Commerce, National Oceanic and Atmospheric Administration, National Ocean Service, Silver Spring, MD. URL | Detail
  201. Xiong, X., E. W. Harville, P. Buekens, D. R. Mattison, K. Elkind-Hirsch, and G. Pridjian, 2008: Exposure to Hurricane Katrina, post-traumatic stress disorder and birth outcomes. The American Journal of the Medical Sciences, 336, 111-115. doi:10.1097/MAJ.0b013e318180f21c | Detail
  202. Youssouf, H., C. Liousse, L. Roblou, E. -M. Assamoi, R. O. Salonen, C. Maesano, S. Banerjee, and I. Annesi-Maesano, 2014: Non-accidental health impacts of wildfire smoke. International Journal of Environmental Research and Public Health, 11, 11772-11804. doi:10.3390/ijerph111111772 | Detail
  203. Youssouf, H., C. Liousse, L. Roblou, E. M. Assamoi, R. O. Salonen, C. Maesano, S. Banerjee, and I. Annesi-Maesano, 2014: Quantifying wildfires exposure for investigating health-related effects. Atmospheric Environment, 97, 239-251. doi:10.1016/j.atmosenv.2014.07.041 | Detail
  204. Zender, C. S., and J. Talamantes, 2006: Climate controls on valley fever incidence in Kern County, California. International Journal of Biometeorology, 50, 174-182. doi:10.1007/s00484-005-0007-6 | Detail
  205. Zoraster, R. M., 2010: Vulnerable populations: Hurricane Katrina as a case study. Prehospital and Disaster Medicine, 25, 74-78. doi:10.1017/s1049023x00007718 | Detail
  206. Zwolsman, J. J. G., and A. J. van Bokhoven, 2007: Impact of summer droughts on water quality of the Rhine River - a preview of climate change? Water Science & Technology, 56, 45-55. doi:10.2166/wst.2007.535 | Detail

Likelihood

Very Likely
≥9 in 10
Likely
≥2 in 3
As Likely as Not
≈ 1 in 2
Unlikely
≤ 1 in 3
Very Unikely
≤1 in 10

Confidence Level

Very High Strong evidence (established theory, multiple sources, consistent results, well documented and accepted methods, etc.), high consensus
High Moderate evidence (several sources, some consistency, methods vary and/or documentation limited, etc.), medium consensus
Medium Suggestive evidence (a few sources, limited consistency, models incomplete, methods emerging, etc.), competing schools of thought
Low Inconclusive evidence (limited sources, extrapolations, inconsistent findings, poor documentation and/or methods not tested, etc.), disagreement or lack of opinions among experts
 

Documenting Uncertainty: This assessment relies on two metrics to communicate the degree of certainty in Key Findings. See Appendix 4: Documenting Uncertainty for more on assessments of likelihood and confidence.

Key Finding 1: Increased Exposure to Extreme Events

Health impacts associated with climate-related changes in exposure to extreme events include death, injury, or illness; exacerbation of underlying medical conditions; and adverse effects on mental health [High Confidence]. Climate change will increase exposure risk in some regions of the United States due to projected increases in the frequency and/or intensity of drought, wildfires, and flooding related to extreme precipitation and hurricanes [Medium Confidence].

Key Finding 2: Disruption of Essential Infrastructure

Many types of extreme events related to climate change cause disruption of infrastructure, including power, water, transportation, and communication systems, that are essential to maintaining access to health care and emergency response services and safeguarding human health [High Confidence].

Key Finding 3: Vulnerability to Coastal Flooding

Coastal populations with greater vulnerability to health impacts from coastal flooding include persons with disabilities or other access and functional needs, certain populations of color, older adults, pregnant women and children, low-income populations, and some occupational groups [High Confidence]. Climate change will increase exposure risk to coastal flooding due to increases in extreme precipitation and in hurricane intensity and rainfall rates, as well as sea level rise and the resulting increases in storm surge [High Confidence].