AWareness Against Health ThReats of Climate ChangE (AWARE)

Climate variability and change is adversely impacting the burden of food- and water-borne illnesses including diarrheal diseases. Despite overall decrease in global prevalence, diarrheal disease remains a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Currently, LMIC countries lack a coordinated assessment of the climate change related diarrheal disease burden, and there is a pressing need to enhance community resilience against this threat given ongoing climate change. With the support from Belmont Forum’s first round of Climate, Environment and Health (CEH-I) funding, we established a multinational consortium (AWARD-APR) to conduct a regional assessment of climate change related diarrheal disease burden in the Asia Pacific Region (APR). To date, our multinational team has successfully: 1) compiled diarrheal disease databases for Nepal, Vietnam, Taiwan, and Indonesia; 2) developed uniform extreme weather event (EWE) exposure metrics; 3) generated scientific evidence regarding how climate change related EWEs have exacerbated the burden of diarrheal disease in APR; and 4) built a prototype early warning system (EWS) for Nepal, Taiwan, and Vietnam using classical statistical methods. We have learned that accuracy of the prototype EWS improves considerably when most recent surveillance disease data with finer temporal resolution is available, as was the case in Taiwan. Unfortunately, such data is not available in most LMIC settings that bear the disproportionate burden of diarrheal disease. In AWareness Against Health ThReats of Climate ChangE (AWARE), we will collectively work to enhance community resilience to climate change related increases in the burden of diarrheal disease through integrated research, community engagement, and partnerships. We will build on and expand our partnership to include South Africa and the UK as well as further develop our analyses to quantify the impact of climate change on waterborne disease to inform national adaptation planning. To address limitations related to availability of health data, we will utilize unique datasets consisting of over-the-counter (OTC) medication (loperamide) sales data along with diarrheal disease hospitalization records collected by our South African partners, to explore if such OTC medication data can be used as a novel proxy for underlying disease dynamic in a community. We will also expand our early warning prototype by incorporating modern machine learning (ML) to improve our predictive capacity in high-risk countries (India, Indonesia, Nepal, South Africa, Taiwan, Vietnam). We will carry out a prospective evaluation of our EWS to predict disease burden ahead of time. We will also conduct evaluation studies to assess the benefit of the climate information delivered through mobile app. To ensure that the EWS is effective and feasible, we will work with local communities, non-governmental organizations (NGOs), and local health departments on how to use this mobile app tool to enhance community resilience against health threats of climate change. In Nepal, we will work with female community health volunteers (FCHVs) and staff nurses at Dhulikhel Hospital's 18 rural health centers on the use of the EWS mobile app to prepare for potential diarrheal disease surges in their communities. Our academic partners in other countries will carry out similar activities in partnership with local NGOs (Alliance for Collaboration on Climate & Earth Systems (ACCESS) in South Africa; Gugah Nurani Indonesia (GNI); International Climate Development Institute (ICDI) in Taiwan, and Aarogyam Knowledge to Action Society (AKAS) in India). Since climate change-driven EWEs are projected to continue increasing in the foreseeable future despite mitigation efforts, there is a pressing need to enhance public health adaption measures including preparedness, capability for rapid mobilization of public health resources, healthcare infrastructure resilience, and awareness training. We contend that now is the time to develop, implement, and evaluate climate/weather-informed EWSs to enhance community resilience against the health threats of climate change. Leveraging novel datasets and recent advances in ML, we will enhance the predictive power and geographic resolution of our prototype EWS to forecast diarrheal disease burden at seasonal to sub-seasonal (S2S) scales. AWARE is guided by its’ central theme of leveraging artificial intelligence to synthesize high dimensional data and develop EWSs in partnership with local stakeholders to enhance resilience against health threats posed by climate change. We will achieve our objectives through execution of following four work packages (WPs): Work Package 1: Quantify the impact of climatic factors, including phases of ENSO, monsoon anomaly, and extreme events (extreme heat, extreme precipitation, flooding) on diarrheal disease transmission and identify modifiers of risk, such as sociodemographic and geographic factors. Hypothesis 1: Diarrheal disease incidence will be associated with these climatic factors, and the associations will vary by sociodemographic factors, access to water and sanitation, elevation and latitude. Work Package 2: Measure the extent to which over-the-counter (OTC) medication data can be used as a novel proxy for the most recent diarrheal disease incidence. Hypothesis 2: OTC medication data will predict underlying pediatric diarrheal disease incidence in South Africa. Work Package 3: Incorporate modern machine learning (ML) based methods to enhance predictive capability of our classical statistics-based prototype EWS, and carry out a prospective evaluation of our EWS to predict disease burden weeks to months ahead of time. Hypothesis 3: Deep state space models for time-series forecasting enables S2S forecasting for diarrheal disease. Work Package 4: Co-develop a diarrheal disease EWS mobile app with community partners to provide alerts and advice, and thereby enhance resilience against health threats posed by ongoing climate change. Successful completion of our work will lay a foundation for climate resilient society where communities will be able to anticipate these threats ahead of time, prepare for them, and respond to them when it is time, rather than simply reacting to them after the fact. In doing so, this proposal addresses the recent United Nations’ initiative, Early Warnings for All. With the multi-national group of stakeholders involved as equal partners throughout our work, we will be able to successfully translate our research into actionable climate and health knowledge within our partner communities.