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SPECIAL FOCUS
Sea-Level-Rise Disaster in Micronesia: Sentinel Event
for Climate Change?
Mark E. Keim, MD
ABSTRACT
Objectives: To describe the impact of an acute-onset sea-level-rise disaster in 2 coral atoll populations and to
generate hypotheses for further investigation of the association between climate change and public health.
Methods: Households of Lukunoch and Oneop islands, Micronesia, were assessed for demographics, asset dam-
age, food availability, water quantity and quality, hygiene and sanitation, and health status. Every fourth house-
hold on Lukunoch was randomly selected (n=40). All Oneop households were surveyed (n=72). Heads of
each household were interviewed in the local language using a standard survey tool. Prevalence data were
analyzed, and 95% confidence intervals were calculated.
Results: A total of 112 total households were respondents representing 974 inhabitants. On Lukunoch, roughly half
of all households surveyed reported at least a partial loss of their primary dietary staple and source of calories (taro
and breadfruit). Six (15%) of 40 Lukunoch households surveyed (95% CI, 6%-30%) reported a complete loss of
taro and four (10%) of the 40 households (95% CI, 3%-24%) reported a complete loss of breadfruit. On Oneop,
nearly all households reported at least a partial loss of these same food staples. Twenty four (31%) of all 76 Oneop
households reported a complete loss of taro and another 24 (31%) households reported a complete loss of bread-
fruit. One third of all households surveyed reported a complete loss. On Lukunoch 11 (28%) of 40 households, (95%
CI, 15%-43%) reported damage from salination, but none were damaged to the point of a complete loss. Forty-nine
(64%) of 76 Oneop households reported salination and five (6%) reported complete loss of their well.
Conclusion: On March 5, 2007, an acute-onset, sea-level-rise event resulting in coastal erosion, shoreline inun-
dation, and saltwater intrusion occurred in two coral atoll islands of Micronesia. The findings of this study
suggest that highly vulnerable populations of both islands experienced disastrous losses involving crop pro-
ductivity and freshwater sources. These findings reveal the need for effective public health research and sus-
tainable interventions that will monitor and shape the health of small island populations predicted to be at
high risk for adverse health effects due to climate change.
(Disaster Med Public Health Preparedness. 2010;4:81-87)
Key Words: Climate change, natural disasters, sea-level rise, Pacific islands, vulnerable population, Small Island
Developing States
Populations living on several remote coral atolls of
the Lower Mortlock region of the Federated States
of Micronesia (FSM) report that on March 5, 2007,
islands were inexplicably flooded by ocean water twice in
1 day. The inundation of seawater was described as occur-
ring “like a rising tide”—slowly and with minimally de-
structive force. In many places, the sea level covered the
island to a height estimated at 12 to 18 inches deep and
then receded within a few hours. These events were not
associated with tsunamis, storms, or the timing of the tides.
Major agricultural losses were reported due to shore-
line inundation and salinity intrusion. Because food
sources on these remote atolls are largely locally de-
rived, the damage prompted concerns about the poten-
tial for hunger.
BACKGROUND
The most important direct physical effects of a sig-
nificant rise in mean sea level are coastal ero-
sion, shoreline inundation, and salinity intrusion, pri-
marily into estuaries and groundwater aquifers.1
Coastal erosion destroys shorelines, marshlands,
and mangroves, affecting property and island ecologi-
cal systems. Shoreline inundation may damage shel-
ter and contaminate soil with salinity, resulting in
crop failure. Saltwater intrusion can be particularly
damaging to the groundwater aquifers of small
islands.
The aquifer lens of an ocean island is normally composed
of a layer of fresh water derived from rainfall and floating
on a denser layer of salt water (derived from the ocean).
When saline intrusion occurs, salt water from the inunda-
tion mixes with fresh water of the aquifer to create a brack-
ish solution throughout that adversely affects palatability,
vegetation, and agriculture. This report describes the ef-
fects of 1 acute-onset sea-level-rise disaster on 2 coral atoll
populations.
Disaster Medicine and Public Health Preparedness 81
(Reprinted) ©2010 American Medical Association. All rights reserved.
METHODS
Study Design
A cross-sectional survey was performed among the disaster-
affected populations of Lukunoch and Oneop islands. Institu-
tional review board requirements were waived according to a
standard protocol wing to the emergency nature of the re-
quest. Procedures followed were in accordance with US and FSM
institutional and national ethical standards on human experi-
mentation and with the Helsinki Declaration. Informed con-
sent to perform the study was obtained from the traditional lead-
ership of the island and from each individual survey respondent.
All respondents remained anonymous.
A 2-page survey instrument was developed to assess asset dam-
age and needs at the household level. The household survey
evaluated the following indicators: demographics; asset dam-
age; food availability; availability of water, ie, sources, treat-
ment, storage, and use; sanitation; existence of a toilet and soap;
health status; and crude mortality.
Population and Setting
Lukunoch Island and Oneop Islands are crescent-shaped islands
located 7 miles apart within the Lukunor atoll, in the remote Lower
Mortlock region of FSM. Lukunoch is 2.3 miles long and 1800
feet wide at its widest diameter. Oneop is 1 mile long and 1600
feet wide. Each island is composed of 1 very large central com-
munal taro garden surrounded by a tree-lined perimeter of homes.
On Lukunoch, this garden was 0.9 miles long and 1000 feet wide.
On Oneop, the main garden was 0.7 miles long and 600 feet wide.
The government of FSM estimated the census of Lukunoch to
be 1500 persons living among approximately 150 homes and the
census of Oneop to be 600 persons living in approximately 60
homes. Baseline health and demographic data were not avail-
able for either population. There is 1 local primary health care
worker on each island. The dispensary had scant medications in
stock at the time of this assessment. Health records included a
reporting of births and deaths, but not clinical encounters.
Sample Size Calculation
A sample of 61 households was calculated as necessary to achieve
a 95% confidence level and a 5% confidence interval (CI) among
approximately 72 households on Oneop Island. All 72 house-
holds were surveyed. A sample of 113 households was calcu-
lated as necessary to achieve a 95% confidence level and a 5%
CI interval among approximately 160 households on Luku-
noch. Unfortunately, logistical constraints and inclement
weather severely limited the amount of time available on-site,
and only 40 households were surveyed. This resulted in poor
statistical power (95% CI, 13.5) for Lukunoch data.
Data Collection
On Lukunoch, all homes were located along a single path that
encircled the entire island. Starting with the communal house,
every fourth household was selected for an interview by use of a
systematic random sampling method. A total of 40 Lukunoch Is-
land households were assessed. All 72 households on Oneop were
surveyed. Representatives of the government of the FSM inter-
viewed heads of each household in the local language regarding
damages and needs for the entire household after receiving 15 min-
utes of instruction. Respondents consulted with other house-
hold members for consensus regarding their responses. Subject mat-
ter experts from the US Forest Service (USFS) and US Geological
Survey performed a simultaneous on-site inspection of island ag-
riculture and hydrology as another means of evaluating damage
to island crops and groundwater.
Statistical Analysis
Prevalence data were analyzed for Lukunoch and Oneop popu-
lations, and 95% CIs were produced for Lukunoch data by use
of EPI-INFO, version 3.4 (Centers for Disease Control and Pre-
vention, Atlanta, Georgia).
RESULTS
Demographics
All 974 inhabitants of the 112 total households interviewed on
both islands were Micronesian and spoke the Chuukese dialect.
The mean number of persons per household in Lukunoch was 9.5
and was 8.3 in Oneop. All households were supported by farm-
ing and fishing within a subsistence economic system. Table 1 and
Table 2 detail the demographics of the study population.
Structural Losses
No respondents reported a complete loss of their home due to struc-
tural damage from floodwaters. On Lukunoch, eight (20%) of 40
households (95% CI, 9%-36%) reported that flood water caused
partial damage to their home. Nineteen (20%) of all 76 house-
holds on Oneop reported partial damage to their homes.
TABLE 1
Population Demographics for Lukunoch Island
Age, y Males Females Total Percentage of Total
0-5 26 31 57 15.1
6-18 54 58 112 29.6
19-60 100 90 190 50.3
Older than 60 10 9 19 5.0
Total 190 188 378 100.0
Sea-Level-Rise Disaster in Micronesia
82 Disaster Medicine and Public Health Preparedness VOL. 4/NO. 1
(Reprinted) ©2010 American Medical Association. All rights reserved.
On Lukunoch, none of the respondents interviewed reported com-
plete loss of their well due to salination and 11 (28%) of 40 house-
holds (95% CI, 15%-43%) reported damage from salination. Five
(6%) of all households on Oneop reported complete loss of their
well and 49 (64%) of 76 households reported well salination. Rain
catchment systems, in general, were poorly maintained, but not
affected by the floodwaters.
Food Losses
On Lukunoch, half of all households reported at least partial
loss of their primary dietary sources of carbohydrates: taro and
breadfruit. Of the Lukunoch households, 15% (95% CI, 6%-
30%) reported a complete loss of taro and 10% (95% CI, 3%-
24%) reported a complete loss of breadfruit. On Oneop, nearly
all households reported at least a partial loss of taro and bread-
fruit. Of all Oneop households, 31% reported a complete loss
of taro and 31% reported a complete loss of breadfruit. USFS
inspections revealed that the taro crops located in the very large
communal garden in the center of Lukunoch were nearly com-
pletely destroyed, along with most of the breadfruit trees. The
taro garden on Oneop had less damage, mostly confined to one
end of the patch (Figure 1 and Figure 2). Table 3 and Table 4
list the degree of agricultural losses on Lukunoch and Oneop,
according to food source.
Water Quality and Quantity
On Lukunoch, 43% (95% CI, 27%-59%) of households
reported the use of water purification techniques. The aver-
age amount of water reportedly consumed by each person per
day was 1.1 gallons. On Oneop, 97% of all households
reported using water purification. The average amount of
water reportedly consumed by each person per day was 1.8
gallons.
The populations of both islands obtain water through a vari-
ety of means, including covered wells, open wells, and water
catchment systems. All households reported access to a well.
On Lukunoch, 25% (95% CI, 13%-41%) of households were
able to store 500 to 650 gallons of rainwater; 55% (95% CI,
39%-71%) of households had a storage cistern capable of stor-
ing 1000 gallons of rainwater. Of all Oneop households,
64% were able to store 500 to 650 gallons of rainwater; 3% of
Oneop households reported having a cistern capable of stor-
ing 1000 gallons of rainwater. No cisterns were damaged by the
inundation.
Sanitation and Hygiene
On Lukunoch, 13% (95% CI, 4%-27%) of households reported
use of a water-seal flush toilet, 33% (95% CI, 19%-49%) re-
TABLE 2
Population Demographics for Oneop Island
Age, y Males Females Total Percentage of Total
0-5 58 90 148 24.8
6-18 80 90 170 28.5
19-60 124 132 256 43.0
Older than 60 14 8 22 3.7
Total 276 320 596 100.0
FIGURE 1
Lukunoch villager showing taro spoiled by saline
intrusion.
Photograph by John Quidachay, US Forest Service. Used with permission.
FIGURE 2
A portion of the large taro patch on Lukunoch revealing
extensive damage.
Photograph by John Quidachay, US Forest Service. Used with permission.
Sea-Level-Rise Disaster in Micronesia
Disaster Medicine and Public Health Preparedness 83
(Reprinted) ©2010 American Medical Association. All rights reserved.
ported using pit latrines dug into land, and 38% (95% CI, 23%-
54%) reported use of outhouses perched over the water shore-
line. Eighteen percent Of the Lukunoch households, 18% (95%
CI, 7%-33%) reported not having a toilet, routinely engaging in
open bush or reef defecation instead. People on Lukunoch re-
portedly used an average of 1.1 bars of soap per person per month.
On Oneop, 22% of all households reported use of a water-seal flush
toilet. No households reported using pit latrines, and 72% re-
ported use of outhouses perched over the water shoreline. None
of the households on Oneop reported not having a toilet. People
reportedly used an average of 0.6 bars of soap per person per month.
Health Status
Mortality and Natality
Respondentsreported that since March5, 2007, 1 death(a 6-month-
old)had occurred on Lukunoch and 1 (a5-month-old) had occurred
on Oneop. There were 8 live births reported in Lukunoch and 1
live birth reported in Oneop since March 5, 2007.
Morbidity
Respondents were surveyed about the incidence of new-onset
symptoms consistent with infections that have occurred since
the sea-level-rise event. These data were not categorized ac-
cording to age. Many respondents described an increase in the
TABLE 3
Agricultural Losses as Reported by Lukunoch Island Heads of Householda
Food Source No Damage/Loss Partial Damage/Loss Complete Loss
Taro 22/40 (55; 39-71) 12/40 (29; 15-44) 6/40 (16; 6-30)
Breadfruit 18/40 (45; 29-62) 18/40 (45; 29-62) 10/40 (10; 3-24)
Coconut 24/40 (60; 43-75) 13/40 (32; 19-49) 3/40 (8; 2-20)
Garden 25/40 (62; 45-77) 14/40 (35; 21-52) 1/40 (3; 0.1-13)
Livestock 30/40 (75; 59-87) 10/40 (25; 11-39) 0 (0)
aData are given as number (percentage; 95% confidence interval, in percentages).
TABLE 4
Agricultural Losses as Reported by Oneop Island Heads of Householda
Food Source No Damage/Loss Partial Damage/Loss Complete Loss
Taro 9 (13) 43 (56) 24 (31)
Breadfruit 16 (22) 36 (47) 24 (31)
Fish 30 (39) 44 (58) 2 (3)
Coconut 23 (30) 40 (53) 13 (17)
Garden 6 (8) 38 (50) 32 (42)
Livestock 11 (14) 38 (50) 27 (36)
aData are given as number (percentage).
TABLE 5
Percentage of Households Reporting at Least 1 Case of New-Onset Illness Since the Sea-Level-Rise Eventa
Any New Cases 1 New Case 2 New Cases 3 New Cases
Lukunoch
Cough 37/40 (93) 8/40 (20; 9-36) 11/40 (28; 15-44) 8/40 (20; 9-36)
Diarrhea 22/40 (55) 7/40 (18; 7-33) 9/40 (23; 11-39) 4/40 (10; 3-24)
Fever 26/40 (65) 16/40 (40; 25-57) 6/40 (15; 6-30) 3/40 (8; 2-20)
Eye infection 2/40 (5) 2/40 (5; 1-17) 0 (0) 0 (0)
Skin rash 24/40 (60) 15/40 (38; 23-54) 8/40 (20; 9-36) 1/40 (3; 0.1-13)
Oneop
Cough 70/76 (92) 32/76 (42) 11/76 (14) 5/76 (6)
Diarrhea 71/76 (94) 33/76 (44) 14/76 (19) 2/76 (2)
Fever 76/76 (100) 36/76 (47) 5/76 (6) 11/76 (14)
Eye infection 13/76 (17) 11/76 (14) 2/76 (3) 0 (0)
Skin rash 70/76 (92) 43/76 (56) 5/76 (6) 2/76 (3)
aData are given as number (percentage) or number (percentage; 95% confidence interval, in percentages).
Sea-Level-Rise Disaster in Micronesia
84 Disaster Medicine and Public Health Preparedness VOL. 4/NO. 1
(Reprinted) ©2010 American Medical Association. All rights reserved.
incidence of such infections after the sea-level-rise event, al-
though this frequency was not measured. Table 5 lists the per-
centages of households reporting at least 1 case of new-onset
illness since the March 5, 2007, event. Table 6 lists the per-
centages of households reporting a preexisting chronic illness
or vulnerable condition among household members.
DISCUSSION
The impact of the sea-level rise that occurred in the FSM seems
to follow a pattern that has been predicted by experts to be a
result of climate change. Global warming is predicted to result
in an increase in the number and severity of many extreme
weather and sea-level rise events. It is considered likely that a
trend of increased incidence of extremely high sea levels has
already occurred during the late 20th century and will con-
tinue through the 21st century as a result of climate change.2
The following trends are projected with high confidence2:
• Coasts will be exposed to such increasing risks as coastal ero-
sion due to climate change and sea-level rise.
• In low-latitude regions, crop productivity is expected to de-
crease, thus increasing the risk for hunger, particularly in
Africa and Small Island Developing States.
• By 2020, between 75 and 250 million people will be ex-
posed to decreased sources of water as a result of droughts
and sea-level rise.
• The communities predicted to be most vulnerable to cli-
mate change are the poor coastal communities that are de-
pendent on local water and food sources.2,3
Demographics
The population of Lukunor atoll can be generally described as
young and impoverished. Inhabitants working within such a
cash-poor subsistence economies could easily be expected to
place in the lowest World Bank gross domestic product cat-
egory (⬍$976 per year).4
On Lukunoch, 45% of the study population was younger than
18 years. On Oneop, this number was even higher, constitut-
ing 54% of the population. In comparison, the relative propor-
tion of this age group in the population is double that for the
same age group in the United States (21%).5The proportion
of the study population older than 60 years was 5% on Luku-
noch and 4% on Oneop (comparable to the national estimate
of 5%).6This proportion is 3 times smaller than that of the same
age group in the United States.
Structural Losses
Structural damage seems limited and involved mostly simply
constructed open wells and traditional thatch “local houses”
that were hand constructed of traditional materials and pri-
mary residences made of concrete and/or wood. Wells de-
scribed as damaged were contaminated by salination and con-
tained brackish water, but well structures were not physically
disrupted.
Food Losses
The USFS agricultural assessment of the islands of Lukunoch
and Oneop confirmed the loss of nearly all standing taro crops
and many of the breadfruit trees on both islands. Livestock
(mostly chickens and pigs) seemed mildly affected in the short-
term but could be expected to compete with wildlife and hu-
mans for limited food and water sources in the future. Respon-
dents described coping mechanisms that included a diet mostly
composed of fish and coconut, supplemented on occasion with
a few garden vegetables and (less preferably) with foraged greens.
Respondents also reported eating partially rotted taro.
The USFS agricultural experts inspecting food availability on
Lukunoch and Oneop found that no household food stores were
present and expect crop production to be very low for the next
several years before sufficient rainfall adequately dilutes the sa-
linated island soil. The US Geological Survey estimates that
it will likely require 1 year of normal rainfall to replenish the
freshwater aquifer lens of these affected islands. It was deemed
that anthropometric measurement would not add signifi-
cantly to the evidence of major losses to the primary food sup-
ply of these populations.
Water Quantity and Quality
Access to fresh water for cooking, drinking, and hygiene did
not seem to be a substantial public health concern among the
populations of Lukunoch and Oneop. Lukunoch and Oneop
households reported average daily water consumption less than
the internationally accepted daily water ration for humanitar-
ian assistance.7However, these amounts may also represent ad-
equate quantities of water consumed through ingestion and cook-
TABLE 6
Percentage of Households Reporting a Preexisting Chronic Illness or Vulnerable Condition in at Least 1 Household Membera
High-risk Factor Lukunoch Oneop
Chronic obstructive pulmonary disease or asthma 18/40 (45; 29-62) 21/76 (28)
Diabetes 7/40 (18; 7-33) 5/76 (6)
Physical disability 9/40 (23; 11-39) 6/76 (8)
Newborn younger than 3 mo 4/40 (10; 3-24) 2/76 (3)
Nursing mothers 4/40 (10; 3-24) 2/76 (3)
Pregnant females 4/40 (10; 3-24) 13/76 (17)
aData are given as number (percentage) or number (percentage; 95% confidence interval, in percentages).
Sea-Level-Rise Disaster in Micronesia
Disaster Medicine and Public Health Preparedness 85
(Reprinted) ©2010 American Medical Association. All rights reserved.
ing. It is difficult to interpret reports of low consumption when
much of the water requirements for cleaning and hygiene are
also easily met by way of quick access to the ocean and sali-
nated wells as sources of “gray water.” At the present levels of
normal rainfall, even a poorly efficient use of water catchment
systems seemed able to sustain the population’s current needs
for potable water. However, the island is now more vulnerable
to water stress in the future because the contaminated aquifer
is no longer available as a reserve during drought. Drought is
also expected to occur in Micronesia with greater frequency and
severity in the future as a result of climate change.3
Water quality did not seem to pose a significant health hazard
to the disaster-affected populations at the time of this assess-
ment. Nearly half of the households in Lukunoch reported using
water purification techniques. Almost all households on Oneop
reported treatment of their drinking water. The US Geologi-
cal Survey tested the salinity of the water aquifer on Luku-
noch and Oneop islands 10 weeks postinundation and found
both island aquifers to be 7 times higher than accepted US drink-
ing standards.8The palatability of the ground water was poor;
however, it was still being used for drinking. There is limited
expected health impact from drinking the brackish tasting
water.
Hygiene
Households from both islands reportedly used approximately
half the soap than is currently recommended during an acute
health emergency.7This seems to be an indigenous practice,
not impacted by the disaster event. During emergency condi-
tions, however, hand washing is known to prevent the spread
of skin, respiratory, and diarrheal infections.9-11 This practice
may make this population more vulnerable to outbreaks and
future such disasters.
Sanitation
Although less than adequate for effective disease control, sani-
tation measures on Lukunoch and Oneop seemed unaffected
by the sea-level-rise event. More than half of all households
surveyed on both islands had toilet practices that resulted in
the deposition of sewage on the open land or on the nearby beach
or atoll reef. This indigenous practice may place inhabitants
at higher risk for fecal-oral transmission of gastrointestinal in-
fections on a regular basis, not merely after disasters.9
Health Status
Mortality
The death of 2 infants (one 6-month-old and one 5-month-
old) is notable and deserves further surveillance to better es-
tablish the comparability of this statistic with baseline mortal-
ity rates that are not currently available for this population.
Morbidity
As illustrated in Table 5, a majority of households reported a
new onset of multiple cases of illness consistent with skin, res-
piratory, and gastrointestinal infections occurring during the
10 weeks following disaster impact. However, preimpact base-
lines are unknown for the islands.
Many households included members of vulnerable popula-
tions known to be more susceptible to disaster-related morbid-
ity and mortality.9-11 These populations included people with
chronic illness such as emphysema, asthma, and diabetes. The
survey population also included people who require special care
or feeding, such as physically disabled people, pregnant fe-
males, nursing mothers, and newborns. These factors may
contribute to the overall vulnerability of these populations to
future disasters.
Subsequent Reports of Other Sea-level Disasters
in the Region
Since this March 2007 event, the US Federal Emergency Man-
agement Agency has performed 2 more preliminary damage as-
sessments for sea-level-rise events: another in Micronesia in 2008,
and one in the nearby Republic of Marshall Islands in 2009.12
On December 8 through 12, 2008, islands throughout all 4 states
of FSM experienced widespread ocean inundation. The tradi-
tional chief of Kapingamarangi (a coral atoll located 300 miles
south of Lukunoch and Oneop and severely impacted by the
2008 event) estimated that 90% of the taro was lost during the
flooding there, a degree of crop loss similar to the magnitude
that USFS experts observed on Lukunoch and Oneop just 18
months earlier.12
LIMITATIONS
Although this case report is less scientifically rigorous than con-
trolled data involving a larger sample, it may be argued to have
scientific value in that it permits reporting of new health ef-
fects with a high sensitivity for detecting novel situations (like
climate change) in which historical precedence does not ex-
ist. The results of this survey are limited as a result of several
sources of potential bias. First, the relatively small sample of
the population on Lukunoch precludes accurate interpreta-
tion of those data. However, findings using an acceptable sample
size on Oneop were consistent with results from the Lukunoch
survey. Case reports are also commonly associated with recall
bias. However, respondent replies regarding loss of food and wa-
ter resources were verified by direct physical inspection by USFS
and US Geological Survey experts. Finally, it is not possible to
accurately interpret trends among morbidity and mortality data
among such a small population and in the absence of preevent
baseline health information for comparison.
CONCLUSIONS
On March 5, 2007, an acute-onset, sea level rise event result-
ing in coastal erosion, shoreline inundation, and saltwater in-
trusion occurred in two coral atoll islands of Micronesia. The
findings of this study suggest that highly vulnerable popula-
tions of both Lukunoch and Oneop islands experienced disas-
trous losses in crop productivity and freshwater sources. While
it is not possible to extrapolate the results of this study to all
SIDS in general, the findings associated with this event are con-
Sea-Level-Rise Disaster in Micronesia
86 Disaster Medicine and Public Health Preparedness VOL. 4/NO. 1
(Reprinted) ©2010 American Medical Association. All rights reserved.
sistent with events that have been predicted to occur as a re-
sult of climate change.1,2 These findings reveal the need for ef-
fective public health research and sustainable interventions that
will monitor and shape the health of small island populations
predicted to be at high risk for adverse health effects due to cli-
mate change.
RECOMMENDATIONS
Effectively addressing the health risks of climate variability and
change will require wide-ranging responses from federal and state
agencies and departments. Costs would need to be determined
by the individual agencies, but would likely exceed $100 mil-
lion annually.13 A comprehensive surveillance and moni toring
system to address the health risks of climate change is neces-
sary to provide the information needed to implement timely
and appropriate programs and activities to reduce the health
risks of climate change.13 Key public health research catego-
ries that address these essential services include surveillance and
monitoring; field, laboratory, and epidemiologic research; model
development; development of decision support tools; and edu-
cation and capacity building of the public and public health
and health care professionals.14 The findings of this study sug-
gest that the need for this research has become even more ur-
gent.
About the Author
Author Affiliations: National Center for Environmental Health, Agency for
Toxic Substances and Disease Registry, Centers for Disease Control and Pre-
vention, Atlanta, Georgia.
Correspondence: Mark Keim, MD, National Center for Environmental Health,
Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-F29, At-
lanta, GA USA 30341-3724.
Funding/Support: This survey was supported by funds from the Centers for
Disease Control and Prevention, Coordinating Office for Terrorism Prepared-
ness and Emergency Response.
Disclaimer: The material in this article reflects solely the views of the author.
It does not necessarily reflect the policies or recommendations of the Centers
for Disease Control and Prevention or the US Department of Health and Hu-
man Services.
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