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 Post subject: Environmental Health Indicators for Climate Change
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Discussion Paper for National Climate Assessment
Environmental Health Indicators for Climate Change
As part of the Climate Change Indicators Subcommittee of
The Council of State and Territorial Epidemiologists (CSTE)
(Authors: Paul English, California Department of Public Health; Mandy Green, Oregon Health
Authority; Shelly Shaw, Henry Anderson, Kristen Malecki, Marjory Givens, Megan Christenson,
Jonathan Patz, Wisconsin Department of Health Services and University of Wisconsin; and Shao Lin,
New York State Department of Health)
Acknowledgements: Partial funding for the preparation of this report was provided by Cooperative
Agreement Number 5U38HM000414 between CDC and CSTE. Its contents are the views of the authors
and not their agencies.
Summary
The National Climate Assessment (NCA) anticipates that climate change indicators will be selected as
part of their process to “increase understanding of rates of change, thresholds, etc. in support of decision
making.” Therefore we present a synthesis of the latest research of environmental health indicators of
climate change, and recommendations for future development of these measures.
I Background
Indicators are quantitative summary measures that can be used to track changes in conditions by person,
place, and time. The State Environmental Health Indicator Collaborative (SEHIC), a subcommittee of
the Council of State and Territorial Epidemiologists (CSTE), described environmental health indicators
as elements of environmental sources, hazards, exposures, health effects, and intervention and
prevention activities which can be used to assess positive and negative environmental determinants of
health. Climate Change Environmental Health Indicators can be used to:
 Assess human health vulnerability to climate change
 Identify disease thresholds of weather factors in different geographic regions
 Identify areas for intervention and prevention
 Evaluate the outcomes of specific policies or programs aimed at improving public health.
 Promote development of dose–response models
 Identify populations at risk through tracking risk factors and population susceptibility
 Predict disease burden for public health planning and intervention
 Serve as important communication tools for making environmental health information available
to stakeholders, including environmental health practitioners, partners, policy makers, and the
general public.
The National Climate Assessment (NCA) anticipates that climate change indicators will be selected as
part of their process to “increase understanding of rates of change, thresholds, etc. in support of decision
making.” Therefore we present a synthesis of the latest research of environmental health indicators of
climate change, and recommendations for future development of these measures.
2
II Synthesis of Literature
Measures of environmental health indicators for climate change have been developed, including efforts
by the WHO/Europe, U.S. Environmental Protection Agency (U.S. EPA), the National Research
Council, California EPA, and the climate change indicator subcommittee of the Council of State and
Territorial Epidemiologists (CSTE).
World Health Organization/Europe
In 2009, WHO/European Centre for Environment and Health held a symposium on “Development of
Health-Relevant Climate Change Indicators.” Eight indicators were agreed upon: (1) Excess mortality
to heat waves; (2) Flooding; (3) Population Vulnerability to Flooding; (4) Ozone air quality; (5)
Airborne pollen/allergens; (6) Salmonellosis incidence; (7) Cryptosporidiosis incidence; and (8)
Lyme borreliosis incidence (Dalbokova, et al. 2009)
U.S. EPA
The 2010 Report: “Climate Change Indicators in the United States” had one measure directly relevant to
human health in the “Society and Ecosystems” chapter: Heat-Related Deaths. Heat-related deaths were
defined in this measure as those in which heat was the underlying cause of death on the death certificate.
(U.S. EPA, 2010)
National Research Council (NRC)
In 2010, the National Research Council published “Monitoring Climate Change Impacts,” which
examined metrics of climate change, human vulnerability and earth system on a global level (NRC,
2010). Human health metrics included disease transmission, incidence of respiratory disease,
waterborne disease, and environmental health.
California EPA (Cal/EPA)
The 2009 report: “Indicators of Climate Change in California” has two measures which are directly
relevant to human health: heat-related mortality and morbidity and mosquito-borne diseases (California
EPA, 2009). The report ranked heat-related mortality and morbidity as a Type III indicator (“no ongoing
surveillance”) and mosquito-borne diseases as a Type II indicator (“full or partial data but further
analysis needed”). Cal/EPA also issued a supplemental report in 2010 (California EPA, 2010) focusing
on environmental justice impacts which identified four more measures with direct relevance to human
health: air conditioner ownership and cost; farm worker exposure to extreme heat; exposure to urban
heat; and vulnerability to wildfires.
Council of State and Territorial Epidemiologists (CSTE)
The CSTE climate change indicator subcommittee published a 2009 paper entitled, “Environmental
Health Indicators of Climate Change for the United States” (English, et al. 2009) (Appendix A). This
paper proposed 27 indicators in six categories: Environmental, morbidity and mortality, vulnerability,
mitigation, adaptation, and policy. These formed the basis for the development and pilot testing of 25
climate change indicators (Table 1). The CSTE subcommittee then developed how-to guides to complete
each proposed climate change indicator. CSTE funded three states and one municipality (Illinois,
Montana, North Carolina, and Washington, District of Columbia) to compile data to evaluate the suite of
indicators and an additional seven states participated in the pilot without funding from CSTE. All
jurisdictions compiled data following the guide, and completed an assessment that addressed the time
3
frame required to complete each indicator, perceived usefulness of the proposed indicators, and the
likelihood of these indicators being adopted by the state’s health department. Additional information
about the CSTE pilot is available on request.
CDC /National Environmental Public Health Tracking Program
The CDC’s National Environmental Public Health Tracking Program (NEPHT), which started in 2002,
integrates data on environmentally related health, hazards, and exposures. A variety of health, hazard,
and exposure indicators have been developed by CDC and the states funded by CDC, and these data are
posted on the CDC NEPHT portal. Recently NEPHT added three climate indicators including heat
vulnerability, heat-related mortality, and temperature distribution to its public portal
(http://ephtracking.cdc.gov/showClimateC ... ing.action). NEPHT is also recommending that
excess mortality/morbidity be calculated for heat wave events.
Table 1: CSTE Climate change indicators used in 2011 pilot
Table 2 compares the recommended indicators in each of the reports listed above.
Environmental Indicators
1 Greenhouse Gas Emissions
2 Air Mass Stagnation Events
3 Max/Min and Diurnal Temperature
4 Pollen Indicator
5 Number of fires and percent of total acres impacted by state
6 Positive test results in sentinels and reservoirs
Health Outcome Indicators
7 Rate of heat deaths, hospitalizations, and emergency room visits
during summer months
8 Injuries and deaths due to extreme weather events
9 Human cases of Lyme disease
10 Human cases of West Nile Virus
11 Human cases of valley and dengue fever, Hantavirus
12 Allergic disease related to climate change
Mitigation Indicators
13 Total energy consumption per capita
14 Renewable energy consumption per capita
15 Vehicle miles traveled
Adaptation Indicators
16 Development of a state adaptation plan
17 Access to cooling centers
18 Heat island mitigation plans
19 Health surveillance systems related to climate change
20 Public health workforce trained in climate change research,
surveillance, and adaptation
Policy Indicators
21 Development of a state climate change advisory board
22 Development of a state climate change action plan
23 Completion of a greenhouse gas inventory
24 Number and percent of local governments participating in ICLE
25 Percent of Population living in cities participating in the U.S.
conference of mayors climate protection agreement
4
Table 2: Comparison of Reports with Human-Health Relevant Climate Change Indicators
Report Environmental
Exposures
Human Health
Outcomes
Population
Vulnerability
Other
WHO/EU Ozone; pollen Food, water, and
vector-borne
disease
Flooding None
NRC Heat; drought;
flooding;
ozone; pollen;
wildfire;
harmful algae
blooms
Disease
transmission;
respiratory disease;
waterborne disease
Living in
vulnerable
areas;
migration;
Elderly
living alone;
infant
mortality
Earth systems
U.S. EPA Heat; drought;
extreme
weather
Heat-related deaths None Ecosystems
CSTE Same as NRC Mortality/morbidity
due to heat;
deaths/injuries due
to extreme weather;
Environmental
infectious disease;
Respiratory disease
Heat;
flooding;
sea level rise
Mitigation;
adaptation;
policy
Cal EPA Heat; sealevel
rise
Heat-related
mortality/morbidity;
mosquito-borne
illness
None Ecosystems;
environmental
justice
III Criteria for selecting indicators/frameworks in referenced reports
These reports have chosen different approaches for selecting indicators. The U.S EPA had a set of
screening criteria that considered usefulness, objectivity, data quality, transparency, ability to show a
meaningful trend, and relevance to climate change. The National Research Council selected indicators based
on “[how] it must inform how climate change affects the five domains of human vulnerability: water,
food, energy, health, and shelter.” Cal/EPA selected climate change drivers, measures which indicate
changes in climate, and those which indicate climate change impacts. They classified the indicators
based on availability of data. CSTE selected indicators which measured current vulnerability to climate
variability and change or measures of environmental variables that can directly or indirectly affect
human health. Indicators were also selected to track possible changes in health outcomes to determine if
climate change is actually affecting their geographic range and incidence. Screening criteria included
data temporality, completeness, and availability.
5
Hambling et al. (2011) reviewed various frameworks for establishing environmental health indicators of
climate change and recommended the Driving force-Pressure-State-Exposure-Effect-Action (DPSEEA)
framework as established by the WHO. They conclude that the DPSEEA framework shows the links
“between exposures and health effects as determined by many different factors operating through a
chain of events, and clearly shows the many entry points for interventions”.
IV Current State of Readiness of our Proposed Indicators
Table 3 lists selected proposed indicators from all the sources listed above for overall readiness for
implementation. We have only included those indicators that meet the highest standards considering
data quality/completeness, availability, temporality, and the sensitivity of the measure to public health
effects. Even among these selected indicators, some are at a better state of readiness than others, thus
each indicator is assigned one of three categories of readiness: high, medium, or low. The rationale for
these selections and limitations to these proposed indicators follow.
6
Table 3: Evaluation of Overall Readiness for Climate Change Environmental Health Indicators for the
U.S. (Excluding Adaptation, Policy, and Mitigation Indicators)
Measure Data
quality/Completeness
Availability Temporality Sensitivity* Overall
Readiness
Environmental
Extreme heat High High High High High
Stagnation air mass
events
High High High Medium High
Increases in ozone
due to climate
change
Based on modeling;
downscaling issues
Low High Medium Low
Pollen counts Low Low UK Medium Low
Wildfires High High High High High
Drought High High High Medium High
Harmful algae
blooms
Medium Medium Medium Medium Medium
Extreme weather
events (other than
heat)
Medium Medium High High High
Human Health
Excess
mortality/morbidity
to extreme heat
Medium Low-med High High Medium
Rate of Heat
deaths/illnesses
Medium Med-High High Medium Medium
Injuries/Mortality
from extreme
events
Low Low-med Med High Low
Env. Infectious
Disease (e.g. West
Nile, Lyme, Valley
Fever
High High High Medium Medium
Increased
respiratory disease
due to increased
ozone/pollens
Based on modeling Low High Medium Low
Food-borne disease Under-reporting High High Low-med Medium
Water-borne
disease
Under-reporting High High High Medium
Vulnerability
Flooding Low Low N/A High Low
Wildfires Medium UK N/A High Medium
Heat High High N/A High High
Drought Medium Medium N/A Medium Medium
Sea-level Rise High High N/A Medium High
Note: * sensitivity to public health impacts due to climate change
7
A) Indicators with High Readiness for Implementation for Surveillance
1) Extreme Heat. This measure is at high readiness for surveillance but there is a lack of
consensus on its definition. We are concurring with the definition recommended from the
CDC Environmental Health Tracking Program, which is generally consistent with the
scientific literature. This definition of extreme heat day is a day in May through (and
including) September where the maximum temperature or heat index exceeds the 95th
percentile for that day based on the 1971-2000 climate normal dataset (Anderson and Bell,
2010). The maximum temperature must exceed 85 degrees F and the heat index 90 degrees F.
A heat wave is two or more extreme heat days.
2) Stagnation Air Mass Events. An air mass stagnation day is defined as one with sea-level
geostrophic wind < 8 m/sec, 500 millibars (mb) wind < 13 m/sec, and no precipitation (Wang
and Angell 1999), and although not directly related to pollutant emissions, air stagnation
days can exacerbate the effects of existing air pollution. Air mass stagnation events are one
of the climate impact indicators proposed by the National Climatic Data Center (NCDC) and
are expected to increase O3 production and will increase in frequency as weather conditions
favorable to heat waves increase (CCSP 2008). Air mass stagnation events are available by
request from the NCDC (2009).
3) Wildfires. Data from the National Interagency Fire Center (2009) can be used to monitor
national wildfire trends. Recommended indicators include examining the frequency, severity,
distribution, and duration of wildfires. Suggested measures include the annual area burned
and the average yearly increase in the proportion of acres burned.
4) Drought conditions. Drought indicators should be monitored by public health officials
because drought is associated with degraded water quality and quantity, waterborne disease,
and food safety, among other concerns (Georgia Water Advisory Group 2007). There is no
single indicator for drought. Several indices are available, including percent of normal, the
standardized precipitation index (SPI), the Palmer Drought Severity Index, and the surface
water supply index (SWSI) [National Drought Mitigation Center (NDMC) 2006]. The
NDMC uses the SPI because it can project emerging droughts sooner than other indices. It is
recommended that the SWSI be used in western states, where water quantity and quality are
dependent on snow pack levels. Therefore, we recommend that the SPI and SWSI be used as
climate change drought measures. Several web-based tools exist for monitoring drought and
its effects, such as the NDMC’s Drought Impact Reporter (2009), which monitors drought
effects on agriculture, water/energy, environment, fire, and social factors. To assess the
impact of drought on human populations, Falkenmark et al. (1989) used water scarcity (water
supply < 500 m3/person) and water stress (water supply < 1,000 m3/person) as indicators.
5) Extreme weather events. Extreme weather events are available from the Spatial Hazard
Events and Losses Database for the United States (SHELDUS, 2012). SHELDUS contains
county-level hazard data for the U.S. for 18 different natural hazard events types such
thunderstorms, hurricanes, floods, wildfires, and tornados that resulted in at least $50,000 in
damages. For each event the database includes the beginning date, location (county and
state), property losses, crop losses, injuries, and fatalities that affected each county.
6) Heat Vulnerability. Populations that have been found to have high vulnerability to heat
mortality and morbidity include the socially isolated, children, the poor, and the elderly. Reid
et al. (2008) conducted a principal component analysis to construct an index of community
heat vulnerability at the census tract level, which combined vulnerability factors from the
8
U.S. Census with air conditioning data from the American Housing Survey and comorbidity
data from the Behavioral Risk Factor Surveillance System (BRFSS).
7) Sea-level rise Vulnerability. The USGS has developed an index of coastal vulnerability to
future sea-level rise, which incorporates tidal range, wave height, coastal slope, shoreline
erosion rates, geomorphology, and historical rates of sea-level rise (Thieler 2000). Coastal
vulnerability is ranked from low to very high. The coastal vulnerability index could be used
with U.S. Census population data and boundaries for coastal census block groups for the
contiguous United States to create a measure that provides a general indication of the
population living in close proximity to high-risk areas.
B) Indicators with Medium Readiness for Implementation for Surveillance
1) Rates of Heat Deaths/Illnesses and Excess Mortality/Morbidity from Extreme Heat Events.
The CDC’s National Environmental Public Health Tracking Program (NEPHTP) will be
soon requiring states participating in their program to track heat-related deaths,
hospitalizations, and emergency room visits. Although these events are easy to identify
based on the use of specific diagnostic codes, the full burden of mortality and morbidity from
heat events are better estimated by computing overall excess mortality and morbidity. Data
are available on a national scale from the National Center for Health Statistics to compute
excess mortality from heat events; states would be able to compute excess morbidity from
their data
2) Harmful Algae Blooms. A worldwide increase in cyanobacterial (blue-green algae) sources
has been observed in both coastal and freshwaters (Hallegraeff 1993; Moore et. al. 2008).
These harmful algae blooms (HABs), which produce nerve and liver toxins, are longer in
duration, of greater intensity, and are suspected of being tied both to increased temperatures
due to climate change and nutrient runoff. Human exposure is of concern through both
drinking water contamination and recreational exposure. The National Center for
Environmental Health (NCEH) has developed the Harmful Algal Bloom-related Illness
Surveillance System (HABISS) to collect data on human and animal health and on the
environmental effects of harmful algal blooms, which is currently active in 13 states.
Assurance of continued funding for this program is unknown. The NEPHTP is currently
considering adopting HAB indicators.
3) Environmental Infectious Disease. Climate change may affect the geographic range and
incidence of several environmental infectious diseases, including West Nile encephalitis,
Lyme disease, coccidioidomycosis (“valley fever”), dengue fever, and human hantavirus
cardiopulmonary syndrome (HCPS). Data on many of these conditions are available through
the CDC’s ArboNET surveillance system. Since there are outstanding uncertainties on how
these vectors may respond to changes in climatic conditions, this does not warrant a high
readiness classification at this time.
4) Food-borne disease. That climate change may increase the incidence of food-borne
diseases, especially Salmonellosis, has been of recent concern. However, the fact that cases
of foodborne illness continue to be underreported and that there exists some disagreement on
the impacts of increased temperature on disease risk causes this indicator to rank as medium
readiness.
5) Water-borne disease. During extreme weather events such as heavy precipitation, waste
water systems are often overwhelmed and sewage may contaminate drinking water sources
9
(Patz et al 2008). Waterborne disease such as gastroenteritis has been related to heavy
precipitation events. Waterborne diseases continue to be underreported. We recommend this
indicator at medium readiness.
6) Wildfire Vulnerability. Some states have identified communities at high risk for wildfires,
primarily based on proximity to forested areas which have high potential to burn. However,
due to the complexity of wind patterns and meteorology, population exposure assessment to
wildfire smoke is still in its infancy. We therefore rank this measure as medium readiness.
7) Drought vulnerability. Vulnerable populations affected by drought include dialysis patients,
the elderly, pregnant and nursing women, infants, immunocompromised individuals (e.g.,
chemotherapy and AIDS patients), and persons with preexisting health conditions, such as
hypertension and diabetes. This concept has not been sufficiently developed, and therefore is
ranked as medium readiness.
C) Indicators with Low Readiness for Implementation for Surveillance
1) Increases in ozone due to climate change. Projections of increases in ozone due to climate
change require the application of Global Climate Models and then these estimates need to be
downscaled to local areas and are not currently widely available.
2) Pollen Counts. Pollen count data are available through the National Allergy Bureau. Pollen
counting stations are manned by volunteers and the spatial distribution of stations is sparse.
3) Injuries/mortality from extreme weather events. There is no coordinated system for
reporting. Data is collected by the Red Cross and other disaster organizations and reports
often rely on media.
4) Increased respiratory disease due to changes in air pollution and pollens. Requires modeling,
downscaling, and application of exposure/response formulas; these analytical strategies are
under development.
5) Vulnerability to Flooding. The Federal Emergency Management Agency has not completed
converting all flood plain maps to digital format and has not adjusted flood risk for climate
change projections.
V Recommendations
 Several environmental health indicators for climate change are at a high state of readiness for
surveillance. Many of them, such as heat, extreme weather events, and wildfires are already
being tracked by federal agencies such as NOAA/NASA, but definitions should be standardized
and surveillance data should be available in one location.
 Excess morbidity/mortality from extreme heat and heat and sea-level rise vulnerability be
tracked by the NEPHTP.
 Funding should continue in order to promote the development, pilot testing, and compilation of
state and national data for climate change indicators.
 Maintenance of surveillance systems for the incidence of Harmful Algae Blooms and their
human health effects should be a high priority for NOAA and CDC.
 Continued research should be funded on how environmental infectious diseases and foodborne
diseases will respond to changing climatic conditions.
10
 Further development of food and waterborne disease surveillance systems is recommended to
reduce underreporting.
 More research should be funded for human exposure assessment for wildfires and factors
involved with human vulnerability to drought.
 More modeling and research is necessary to predict increased ozone levels and respiratory
illness due to climate change.
 Funding for a robust nationwide pollen monitoring system should be a priority.
 A coordinated system needs to be developed to provide accurate and timely information on
deaths and injuries due to extreme weather events.
 Electronic flood plain maps which take into account predicted changes due to future climate
variability need to be developed.
 The climate indicators may be more sensitive or more suited to some areas than others. Each
state should identify its appropriate local indicators.
11
VII References
Anderson GB, Bell ML, 2010 Heat Waves in the United States: Mortality Risk during Heat Waves and
Effect Modification by Heat Wave Characteristics in 43 U.S. Communities. Environ Health Perspect
119(2): doi:10.1289/ehp.1002313
California Environmental Protection Agency. Office of Environmental Health Hazard Assessment.
Indicators of Climate Change in California. 2009
http://oehha.ca.gov/multimedia/epic/cli ... ators.html [Accessed 2/17/12]
California Environmental Protection Agency. Office of Environmental Health Hazard Assessment.
2010. Indicators of Climate Change in California: Environmental Justice Impacts.
http://oehha.ca.gov/multimedia/epic/epic123110.html [Accessed 2/17/12]
CCSP 2008. Weather and Climate Extremes in a Changing Climate In: Karl TR, Meehl GA, Miller CD,
Hassol SJ, Waple AM, Murray WL. , editors. Regions of Focus: North America, Hawaii, Caribbean, and
U.S. Pacific Islands. Washington, DC: Climate Change Science Program.
Dalbokova, Dafina; Krzyzanowski, Michal; Menne, Bettina; Matthies, Franziska. Development of
Health-Relevant Indicators of Climate Change for Europe. Epidemiology November 2009 - Volume 20
- Issue 6 - p S57 Abstracts: ISEE 21st Annual Conference, Dublin, Ireland, August 25-29, 2009: Oral
Presentations
English PB, Sinclair AH, Ross Z, Anderson H, Boothe V, Davis C, Ebi K, Kagey B, Malecki K, Shultz
R, Simms E. Environmental health indicators of climate change for the United States: findings from the
State Environmental Health Indicator Collaborative. Environ Health Perspect. 2009 Nov;117(11):1673-
81. Epub 2009 May 18.
Falkenmark M, Lundqvist J, Wilkdstrand C. 1989. Macro-scale water scarcity requires micro-scale
approaches: aspects of vulnerability in semi-arid development Nat Resour Forum 13(4):258–267.
Georgia Water Advisory Group2007 [[accessed 21 September 2009]]. Drought Response Guidance for
Public Health and Food Industry Professionals.
Hambling T, Weinstein P, Slaney D A review of frameworks for developing environmental health
indicators for climate change and health. Int J Environ Res Public Health. 2011 Jul;8(7):2854-75. Epub
2011 Jul 13.
Hallegraeff GM. 1993. A review of harmful algal blooms and their apparent global increase Phycologia
32(2):79–99.
Moore SK, Trainer VL, Mantua N, Parker MS, Laws EA, Backer LC, et al. 2008. Impacts of climate
variability and future climate change on harmful algal blooms and human health Environ Health 7(suppl
2):S4.10.1186/1476-069X-7-S2-S4 [Online 7 November 2008]
12
National Interagency Fire Center2009 [[accessed 20 April 2009]]. National Interagency Fire Center
Homepage.
NDMC (National Drought Mitigation Center)2009 [[accessed 4 November 2008]]. The Drought
Reporter.
NCDC (National Climatic Data Center)2009b [[accessed 30 September 2009]]. Storm Data
Publications.
NDMC (National Drought Mitigation Center)2006 [[accessed 4 November 2008]]. What Is Drought?
National Research Council. 2010. Monitoring Climate Change Impacts: Metrics at the Intersection of
the Human and Earth Systems. http://www.nap.edu/catalog.php?record_id=12965 Accessed [2/17/12]
Patz JA, Vavrus SJ, Uejio CK, McLellan SL. Climate change and waterborne disease risk in the Great
Lakes region of the U.S. Am J Prev Med. 2008 Nov; 35(5):451-8.
Reid CE, O'Neill MS, Gronlund CJ, Brines SJ, Brown DG, Diez-Roux AV, Schwartz JMapping
community determinants of heat vulnerability. Environ Health Perspect. 2009 Nov;117(11):1730-6.
Epub 2009 Jun 10.
Spatial Hazard Events and Losses Database for the United States (SHELDUS). 2012. University of
South Carolina. http://webra.cas.sc.edu/hvri/products/sheldus.aspx [Accessed 2/17/12)
Thieler ER 2000 [[accessed 15 November 2008]]. National Assessment of Coastal Vulnerability to
Future Sea-Level Rise .
U.S. EPA. 2010. Climate Change Indicators in the United States.
http://www.epa.gov/climatechange/indicators.html [Accessed 2/17/12]
Wang JXL, Angel JK 1999. Air Stagnation Climatology for the United States (1948–1998). Silver
Spring, MD: NOAA/Air Resources Laboratory ATLAS, No. 1.
13
VIII Appendix
Environmental Health Indicators of Climate Change for the United States
http://ehp03.niehs.nih.gov/article/info ... hp.0900708
Citation: English PB, Sinclair AH, Ross Z, Anderson H, Boothe V, Davis C, Ebi K, Kagey B, Malecki
K, Shultz R, Simms E. Environmental health indicators of climate change for the United States:
findings from the State Environmental Health Indicator Collaborative. Environ Health Perspect. 2009
Nov;117(11):1673-81. Epub 2009 May 18.


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