CHAPTER TWO

CONCEPTUAL ISSUES, THEORETICAL FRAMEWORK AND LITERATURE

REVIEW

2.1 Conceptual Issues

2.1.1 Cholera (Causes, types, signs and symptoms)

Cholera is an infection of the small intestine by some strains of the bacterium Vibrio
cholerae (Todar, 2020). Symptoms may range from none, to mild, to severe (Harris,
2015). The classic symptom is large amounts of watery diarrhea lasting a few days
(LaRocque, 2012). Vomiting and muscle cramps may also occur. Diarrhea can be so severe
that it leads within hours to severe dehydration and electrolyte imbalance. This may result
in sunken eyes, cold skin, decreased skin elasticity, and wrinkling of the hands and
feet. Dehydration can cause the skin to turn bluish (Bailey, 2011). Symptoms start two hours
to five days after exposure (Qadri, 2012).

Cholera is caused by a number of types of Vibrio cholerae, with some types producing more
severe disease than others. It is spread mostly by unsafe water and unsafe food that has been
contaminated with faeces containing the bacteria (Todar, 2020). Undercooked shellfish is a
common source (Centre for Disease control and prevention, 2015). Humans are the only
known host for the bacteria. Risk factors for the disease include poor sanitation, insufficient
clean drinking water, and poverty. Cholera can be diagnosed by a stool test,[2] or a
rapid dipstick test, although the dipstick test is less accurate (Centre for Disease control and
prevention, 2015).

Prevention methods against cholera include improved sanitation and access to clean water
(Harris, 2012). Cholera vaccines that are given by mouth provide reasonable protection for
about six months, and confer the added benefit of protecting against another type of diarrhea
caused by E. coli. In 2017 the US Food and Drug Administration (FDA) approved a single-
dose, live, oral cholera vaccine called Vaxchora for adults aged 18–64 who are travelling to
an area of active cholera transmission (Cholera fact sheet, 2018). It offers limited protection
to young children. People who survive an episode of cholera have long-lasting immunity for
at least three years (the period tested) (Harris, 2018).

The primary treatment for affected individuals is oral rehydration salts (ORS), the
replacement of fluids and electrolytes by using slightly sweet and salty solutions. Rice-based
solutions are preferred. In children, zinc supplementation has also been found to improve
outcomes. In severe cases, intravenous fluids, such as Ringer's lactate, may be required,
and antibiotics may be beneficial (Todar, 2012). The choice of antibiotic is aided
by antibiotic sensitivity testing.[3]

Cholera continues to affect an estimated 3–5 million people worldwide and causes 28,800–
130,000 deaths a year (Harris, 2018). To date, seven cholera pandemics have occurred in the
developing world, with the most recent beginning in 1961, and continuing today (Cholera
fact sheet, 2017). The illness is rare in high-income countries, and affects children most
severely. Cholera occurs as both outbreaks and chronically in certain areas. Areas with an
ongoing risk of disease include Africa and Southeast Asia. The risk of death among those
affected is usually less than 5%, given improved treatment, but may be as high as 50%
without such access to treatment. Descriptions of cholera are found as early as the 5th century
BC in Sanskrit (Harris, 2012). In Europe, cholera was a term initially used to describe any
kind of gastroenteritis, and was not used for this disease until the early 19th century (Charles,
2009). The study of cholera in England by John Snow between 1849 and 1854 led to
significant advances in the field of epidemiology because of his insights about transmission
via contaminated water, and a map of the same was the first recorded incidence of
epidemiological tracking (Timmreck, 2012).

The primary symptoms of cholera are profuse diarrhea and vomiting of clear fluid (Nair,
2004). These symptoms usually start suddenly, half a day to five days after ingestion of the
bacteria (Azman, 2013). The diarrhea is frequently described as "rice water" in nature and
may have a fishy odour (King, 2008). An untreated person with cholera may produce 10 to 20
litres (3 to 5 US gal) of diarrhea a day. Severe cholera, without treatment, kills about half of
affected individuals. If the severe diarrhea is not treated, it can result in life-
threatening dehydration and electrolyte imbalances (Sack, 2004). Estimates of the ratio
of asymptomatic to symptomatic infections have ranged from 3 to 100 (King, 2008). Cholera
has been nicknamed the "blue death" because a person's skin may turn bluish-gray from
extreme loss of fluids (Greenough, 2008).

Fever is rare and should raise suspicion for secondary infection. Patients can be lethargic and
might have sunken eyes, dry mouth, cold clammy skin, or wrinkled hands and feet. Kussmaul
breathing, a deep and labored breathing pattern, can occur because
of acidosis from stool bicarbonate losses and lactic acidosis associated with
poor perfusion. Blood pressure drops due to dehydration, peripheral pulse is rapid and
thready, and urine output decreases with time. Muscle cramping and weakness, altered
consciousness, seizures, or even coma due to electrolyte imbalances are common, especially
in children (Sack, 2004).

Transmission is usually through the fecal-oral route of contaminated food or water caused by
poor sanitation. Most cholera cases in developed countries are a result of transmission by
food, while in developing countries it is more often water (Sack, 2004). Food transmission
can occur when people harvest seafood such as oysters in waters infected with sewage,
as Vibrio cholerae accumulates in planktonic crustaceans and the oysters eat the zooplankton
(McElroy, 2009).

People infected with cholera often have diarrhea, and disease transmission may occur if this
highly liquid stool, colloquially referred to as "rice-water", contaminates water used by others
(Ryan, 2004). A single diarrheal event can cause a one-million fold increase in numbers of V.
cholerae in the environment (NIH, 2011). The source of the contamination is typically other
people with cholera when their untreated diarrheal discharge is allowed to get into
waterways, groundwater or drinking water supplies. Drinking any contaminated water and
eating any foods washed in the water, as well as shellfish living in the affected waterway, can
cause a person to contract an infection. Cholera is rarely spread directly from person to
person (Nelson, 2009).

V. cholerae also exists outside the human body in natural water sources, either by itself or
through interacting with phytoplankton, zooplankton, or biotic and abiotic detritus (Nelson,
2009). Drinking such water can also result in the disease, even without prior contamination
through fecal matter. Selective pressures exist however in the aquatic environment that may
reduce the virulence of V. cholera (Morris, 2009). Specifically, animal models indicate that
the transcriptional profile of the pathogen changes as it prepares to enter an aquatic
environment (Calderwood, 2009). This transcriptional change results in a loss of ability of V.
cholerae to be cultured on standard media, a phenotype referred to as 'viable but non-
culturable' (VBNC) or more conservatively 'active but non-culturable' (ABNC) (Camilli,
2009). One study indicates that the culturability of V. cholerae drops 90% within 24 hours of
entering the water, and furthermore that this loss in culturability is associated with a loss in
virulence (Chowdhury, 2018).

Both toxic and non-toxic strains exist. Non-toxic strains can acquire toxicity through
a temperate bacteriophage (Shao, 2018).
About 100 million bacteria must typically be ingested to cause cholera in a normal healthy
adult (Sack, 2004). This dose, however, is less in those with lowered gastric acidity (for
instance those using proton pump inhibitors). Children are also more susceptible, with two- to
four-year-olds having the highest rates of infection (Sack, 2004). Individuals' susceptibility to
cholera is also affected by their blood type, with those with type O blood being the most
susceptible (Sack, 2004). Persons with lowered immunity, such as persons
with AIDS or malnourished children, are more likely to develop a severe case if they become
infected (WHO, 2011). Any individual, even a healthy adult in middle age, can undergo a
severe case, and each person's case should be measured by the loss of fluids, preferably in
consultation with a professional health care provider.

The cystic fibrosis genetic mutation known as delta-F508 in humans has been said to
maintain a selective heterozygous advantage: heterozygous carriers of the mutation (who are
not affected by cystic fibrosis) are more resistant to V. cholerae infections (Bertranpetit,
2017). In this model, the genetic deficiency in the cystic fibrosis transmembrane conductance
regulator channel proteins interferes with bacteria binding to the intestinal epithelium, thus
reducing the effects of an infection.

On 7 June 2017, World Health Organization (WHO) was notified of a cholera outbreak in
Kwara State, Nigeria, where the event currently remains localized. The first cases of acute
watery diarrhoea were reported during the last week of April 2017 and a sharp increase in the
number of cases and deaths has been observed since 1 May 2017. However, the number of
new cases reported has shown a decline over the last four reporting weeks.

As of 30 June 2017, a total of 1558 suspected cases of cholera have been reported including
11 deaths (case fatality rate: 0.7%). Thirteen of these cases were confirmed by culture in
laboratory. 50% of the suspected cases reported are male and 49% are female (information
for gender is missing for 1% of the suspected cases). The disease is affecting all age groups.
Between 1 May and 30 June 2017, suspected cholera cases in Kwara State were reported
from five local government areas; Asa (18), Ilorin East (450), Ilorin South (215), Ilorin West
(780), and Moro (50) (information for local government areas is missing for 45 of the
suspected cases). Poor sanitation conditions observed in the affected communities is one of
the predisposing factors for this cholera outbreak. An important risk factor is the lack of
access to clean drinking water and poor hygiene conditions.
Although cholera may be life-threatening, prevention of the disease is normally
straightforward if proper sanitation practices are followed. In developed countries, due to
their nearly universal advanced water treatment and sanitation practices, cholera is rare. For
example, the last major outbreak of cholera in the United States occurred in 1910–1911
(Rose, 2009). Cholera is mainly a risk in developing countries in those areas where access
to WASH (water, sanitation and hygiene) infrastructure is still inadequate.

Effective sanitation practices, if instituted and adhered to in time, are usually sufficient to
stop an epidemic. There are several points along the cholera transmission path at which its
spread may be halted (Rose, 2009):

 Sterilization: Proper disposal and treatment of all materials that may have come into
contact with the feces of other people with cholera (e.g., clothing, bedding, etc.) are
essential. These should be sanitized by washing in hot water, using chlorine bleach if
possible. Hands that touch cholera patients or their clothing, bedding, etc., should be
thoroughly cleaned and disinfected with chlorinated water or other effective antimicrobial
agents.
 Sewage and fecal sludge management: In cholera-affected areas, sewage and fecal sludge
need to be treated and managed carefully in order to stop the spread of this disease
via human excreta. Provision of sanitation and hygiene is an important preventative
measure (Cholera fact sheet, 2013). Open defecation, release of untreated sewage, or
dumping of fecal sludge from pit latrines or septic tanks into the environment need to be
prevented. In many cholera affected zones, there is a low degree of sewage treatment
(Singer, 2016). Therefore, the implementation of dry toilets that do not contribute
to water pollution, as they do not flush with water, may be an interesting alternative
to flush toilets (Gili, 2019).
 Sources: Warnings about possible cholera contamination should be posted around
contaminated water sources with directions on how to decontaminate the water (boiling,
chlorination etc.) for possible use.
 Water purification: All water used for drinking, washing, or cooking should be sterilized
by either boiling, chlorination, ozone water treatment, ultraviolet light sterilization (e.g.,
by solar water disinfection), or antimicrobial filtration in any area where cholera may be
present. Chlorination and boiling are often the least expensive and most effective means
of halting transmission. Cloth filters or sari filtration, though very basic, have
 significantly reduced the occurrence of cholera when used in poor villages
in Bangladesh that rely on untreated surface water. Better antimicrobial filters, like those
present in advanced individual water treatment hiking kits, are most effective. Public
health education and adherence to appropriate sanitation practices are of primary
importance to help prevent and control transmission of cholera and other diseases.
2.1.2 Climate
Climate is the long-term pattern of weather in an area, typically averaged over a period of 30
years (Serge, 2013). More rigorously, it is the mean and variability of meteorological
variables over a time spanning from months to millions of years (Shepherd, 2005). The
climate of a location is affected by its latitude/longitude, terrain, and altitude, as well as
nearby water bodies and their currents.

Climates can be classified according to the average and the typical ranges of different
variables, most commonly temperature and precipitation. The most commonly used
classification scheme was the Köppen climate classification. The Thornthwaite system in use
since 1948, incorporates evapotranspiration along with temperature and precipitation
information and is used in studying biological diversity and how climate change affects it
(Thorntwaite, 1948). The Bergeron and Spatial Synoptic Classification systems focus on the
origin of air masses that define the climate of a region.

Paleoclimatology is the study of ancient climates. Since very few direct observations of
climate are available before the 19th century, paleoclimates are inferred from proxy
variables that include non-biotic evidence such as sediments found in lake beds and ice cores,
and biotic evidence such as tree rings and coral (Shindell, 2005). Climate models are
mathematical models of past, present and future climates. Climate change may occur over
long and short timescales from a variety of factors; recent warming is discussed in global
warming. Global warming results in redistributions. For example, "a 3°C change in mean
annual temperature corresponds to a shift in isotherms of approximately 300–400 km in
latitude (in the temperate zone) or 500 m in elevation. Therefore, species are expected to
move upwards in elevation or towards the poles in latitude in response to shifting climate
zones" (Hughes, 2000).
2.1.3 Climate Change and Cholera

Climate change is having a profound impact on coastal systems, leading to changes in

biodiversity that have significant consequences for human health. Rising sea temperatures
and ocean acidification are altering the distribution and abundance of marine species,
including those that play a critical role in the transmission of cholera (Flynn et al., 2017).
Cholera is a diarrheal disease caused by the bacterium Vibrio cholerae, which is naturally
found in marine environments. As coastal ecosystems change, the dynamics of cholera
transmission are also shifting. Warmer waters and changes in ocean chemistry are increasing
the growth and survival of V. cholerae, leading to a higher risk of cholera outbreaks (Koelle
et al., 2005). Additionally, changes in coastal biodiversity are altering the composition of
marine food webs, potentially leading to an increase in the abundance of cholera-carrying
species such as zooplankton and shellfish (Lipp et al., 2002).

The consequences of these changes are far-reaching, with cholera infections on the rise in
many coastal regions. In Bangladesh, for example, cholera cases have increased significantly
in recent years, coinciding with changes in ocean temperatures and acidity (Rahman et al.,
2017). Similarly, in Haiti, cholera outbreaks have been linked to changes in coastal water
quality and the presence of V. cholerae in marine environments (Tauxe et al., 2017). The link
between climate change, coastal biodiversity, and cholera transmission is complex and
multifaceted. However, it is clear that changes in coastal ecosystems are having a significant
impact on human health. As the global climate continues to change, it is essential that we take
a holistic approach to understanding and addressing the consequences of these changes.

This includes not only mitigating the effects of climate change but also addressing the social
and economic determinants of health that make communities more vulnerable to cholera
outbreaks. By taking a comprehensive approach to this issue, we can reduce the risk of
cholera infections and protect the health of coastal communities around the world.
 Figure 2.1. Climate change on oceans and Vibrio cholerae: Schematic representation
of the major drivers for cholera infection or cholera outbreaks.
Climate change includes both global warming driven by human-induced emissions of
greenhouse gases and the resulting large-scale shifts in weather patterns. Though there have
been previous periods of climatic change, since the mid-20th century humans have had an
unprecedented impact on Earth's climate system and caused change on a global scale (Von
Schuckman, 2020).

The largest driver of warming is the emission of gases that create a greenhouse effect,
of which more than 90% are carbon dioxide (CO and methane. Fossil fuel burning (coal, oil,
and natural gas) for energy consumption is the main source of these emissions, with
additional contributions from agriculture, deforestation, and the chemical reactions in certain
manufacturing processes. The human cause of climate change is not disputed by any
scientific body of national or international standing. Temperature rise is accelerated or
tempered by climate feedbacks, such as loss of sunlight-reflecting snow and ice cover,
increased water vapor (a greenhouse gas itself), and changes to land and ocean carbon sinks
(Edhenhofer, 2014).
 Temperature rise on land is about twice the global average increase, leading to desert
expansion and more common heat waves and wildfires (Allen, 2018). Temperature rise is
also amplified in the Arctic, where it has contributed to melting permafrost, glacial retreat
and sea ice loss. Warmer temperatures are increasing rates of evaporation, causing more
intense storms and weather extremes. Impacts on ecosystems include the relocation or
extinction of many species as their environment changes, most immediately in coral reefs,
mountains, and the Arctic. Climate change threatens people with food insecurity, water
scarcity, flooding, infectious diseases, extreme heat, economic losses, and displacement
according to public health action support (PHAST, 2017). These human impacts have led the
World Health Organization to call climate change the greatest threat to global health in the
21st century. Even if efforts to minimise future warming are successful, some effects will
continue for centuries, including rising sea levels, rising ocean temperatures, and ocean
acidification (Roy, 2018).

2.2 Theoretical Framework

2.2.1 Climate Change and Health Framework

This report gives an overview of the health risks from climate change and the necessary
response by the global health community to this threat. It describes the specific contributions
currently being made by WHO in the field, and which it is proposed to further enhance in the
transition to the Fourteenth General Programme of Work. It situates the health response to
climate change within the overall response to environmental risks to health, as described in
the WHO global strategy on health, environment and climate change,1 which was noted by
the Health Assembly in decision WHA72(9) (2019), and provides an update on the previous
Health Assembly resolution on climate change and health. The world is warming at a faster
rate than at any time in human history, mainly as a result of the burning of fossil fuels. Unless
urgent action is taken to cut carbon emissions, global warming will soon exceed the 1.5˚C
limit set in the Paris Climate Agreement, and current trends are likely to result in over 3˚C of
warming by the end of the century (Masson-Delmotte, 2021). The Sixth Assessment Report
of the Intergovernmental Panel on Climate Change concludes that climate change is already
having observable adverse impacts on human health and well-being through heat,
malnutrition, infectious diseases, mental health and displacement, both at the global level and
in the majority of the specific regions assessed. More fundamentally, climate shocks and
growing stresses, such as drought and rising sea levels, are undermining the environmental
and social determinants of physical and mental health, from clean air and water to sustainable
food systems and livelihoods – and threatening the existence of some nations (Roberts,
2022). The health impacts of climate change are highly inequitable. The Sixth Assessment
Report estimates that up to 3.6 billion people live in contexts that are highly vulnerable to the
impacts of climate change. Low- and lower-middle-income countries and small island
developing States face the greatest health consequences of climate change, despite
contributing the least to historical global emissions. It is estimated that over the past decade,
mortality from floods, droughts and storms was 15 times higher in highly vulnerable regions
compared to regions with very low vulnerability. Within countries there can also be large
disparities in levels of vulnerability to the impacts of climate change. Populations living in
poverty, the elderly, women, children, indigenous peoples, outdoor workers, the socially
isolated, and individuals with pre-existing medical conditions are typically at highest risk.
There is a large overlap between the development pathways and economic choices that are
driving the climate crisis, and the direct causes of large health impacts. These include
polluting energy systems, which are the main cause of almost seven million premature deaths
from air pollution each year; environmentally destructive and unhealthy food systems that are
contributing to the global increase in noncommunicable diseases; and urban planning and
transport systems that result in car-dependency – contributing to the burdens of physical
inactivity and road traffic injuries. The health care sector itself is now also a significant
contributor to climate change, responsible for approximately 5% of global carbon emissions.
The world is not yet responding adequately to the scale of this challenge. Although the “right
to health” is at the core of the United Nations Framework Convention on Climate Change and
the Paris Agreement, it is largely absent from its operational mechanisms. Less than 0.5% of
international climate finance is currently allocated to health projects, and only 10% of
nationally determined contributions to the Paris Agreement quantify the large health gains
expected from climate change mitigation (Potner, 2022). Similarly, while health is routinely
identified as a top priority for climate action, 70% of countries lack adequate finance to
implement a national adaptation plan for health, and few national or international health
actors allocate significant resources to climate action.

This fundamental threat to human health requires a strong response from the global health
community to protect health from increasing climate hazards, ensure access to high quality,
climate resilient, environmentally sustainable health services, and improve health, while
limiting global warming to the agreed 1.5˚C limit. This will require action on both adaptation
(protecting health from the impacts of climate change) and mitigation (limiting emissions of
greenhouse gases and other climate pollutants into the atmosphere). Achieve climate-resilient
health systems to address health risks and impacts of climate change. There is a need for
national health and environment agencies to systematically assess climate-related risks to
health systems and health outcomes, and to develop national health adaptation plans to ensure
that the health of the population is resilient to climate shocks and stresses. Implementation of
these plans should embed climate resilience as a central component of health systems1 within
the provision of universal health coverage, primary health care and health workforce
capacity, while also implementing specific public health interventions, such as climate
informed surveillance and response systems for key risks, including extreme heat and
infectious diseases. It will also require health actors to work across sectors to jointly
safeguard key environmental determinants, such as promoting climate resilient water and
sanitation, and sustainable food systems, while also closing the financing gap for health
adaptation and resilience.

Increase the provision of low-carbon health systems and the creation of healthy, low-carbon
societies. Given the significant and growing impact of health care on the global climate, it is
necessary for countries to develop and implement plans to stabilize and then reduce carbon
emissions from the health sector. It is important that such actions reinforce rather than
undermine the achievement of universal health coverage, the scaling up of primary health
care, and climate resilience. Particularly in low-income settings, this should focus on
identifying opportunities to bypass polluting, ineffective and expensive technologies and
instead implement cheaper, more reliable and cleaner solutions, such as the rapid roll-out of
renewable energy access for health care facilities. There is also an important role for the
health community in providing evidence and building partnerships towards the achievement
of health “co-benefits” (e.g. lives saved through improved air quality) through health
promoting climate change mitigation in other sectors, notably, energy, food, transport and
urban systems.

2.2.2 Environmental Health Theory

In the environmental health theory, there is a view on how environmental health, human ecology
and health affect the public. The three concepts help in addressing problems in relation to the
environment, health and development. Environmental health, therefore, contributes to explaining
and controlling the environmental factors, which can affect the health of human beings. The theory
has therefore helped in controlling some of the diseases like malaria and cholera, which are
directly linked to environmental exposures. The main contribution of environmental health is the
provision of resources like water, food and air, which are not contaminated and safe work as well
as living environments (Aron & Patz, 2001).

Initially, environmental health was illustrated using the cause-effect approach where

environmental factors were linked directly to the health outcomes. For instance, the epidemic of

cholera in London was linked to the removal of the handle that was in the Broad Street pump.

However, later due to a lot of research on the disease, the concern shifted to the source of water

and this disapproved the approach of cause-effect relationship (Follér, 2001).

Linking environmental exposures to disease outcomes have proved to lack an epidemiologic basis

of argument since there is no sufficient information to explain the link between the environmental

hazard and the health outcome. Due to such challenges, researchers have therefore come up with

more developed formulae of collecting data and devised methodologies of using the already

collected data for different purposes that were not intended initially. The data is therefore used to

express the link by clearing up the gaps in the methodology. Appropriate rules for linking data sets

have been defined which calls for a better understanding of the data sets and clear articulation of

their uses and limits to avoid cases of invalid conclusions (Waltner, 2001).

When linking different types of data to be used, there are basic factors to consider such as the basic

scientific connection of the data and the appropriateness and adequacy of the information in

addressing the issue in question. To handle the information accurately, a framework is provided

for one to adhere to when examining the basic factors to be considered. The framework gives the

steps that an agent takes through the environment to enter the person, which finally results to the

production of the health outcome (Adams & Greeley, 1996).

This entails the surveillance of the hazard where there is the tracking of the agent presumed to

have caused the health outcome. It is tracked in the environment to get the origin before using the

set of data presented. Exposure surveillance is another step where the host of the agent is

monitored. In this case, the human tissues are examined to check those that are infected. In
addition, the surveillance of the health outcome is another step where one examines the sign and

symptoms of the attack. To come up with a strong tool in measuring the causes someone needs to

combine more than one set of data accurately by following the steps provided (Follér, 2001).

Data inadequacy is also another challenge when linking environmental factors and health
outcomes. During the linking, therefore, there is a need to examine the necessary data sources
before looking at the possible statistical methods for linking. The sources of the information, in
this case, include the exposure, health outcome and the environment. For a successful link, there
must be the use of quality information appropriately taking into account the limitation of the data.
As much as this theory tries to explain the link between the hazard, exposure and health outcomes,
the data in each step may be diverse and therefore their uses and limitations outside their original
purpose may not be clear as expressed below (Waltner, 2001).

Hazard Data

This kind of data gives information in relation to the presence and quantity of the contaminants in
the environment. A hazard is presumed to cause harmful effects in the exposure but in most cases,
it is not the case since on its own it cannot. Some of the environmental data include pesticide
exposures and toxic release. Analysis data is always limited when comparing each set of data with
the environmental guidelines. In most cases, the environmental guidelines do not tally with all the
environmental contaminants because those, which exist, are developed from toxicological studies.
Exceeding environmental guidelines results in failure in predicting health outcomes (Adams &
Greeley, 1996).

Exposure Data

This is used to link the hazard environments and the effects they create in human beings.

Examples of exposure data include the biological samples such as urine, stool, blood and saliva.

After the analysis, the result shows that in most cases, the concentration of the agents in the

biological sample is not proportional to that of the environment. There are several factors therefore

which affect the internal concentration of the agent in human bodies.

Such factors include base line health status of the individual, behavioral factors and exposure level.

Exposure data is one of the factors, which contribute to linking gaps since its source is not steady.
For instance, the level of exposure in children might be different from that of adults or even vary

among adults (Aron & Patz, 2001).

Another factor, which may create the gap in the linking system under exposure data, is the

monitoring of the data in the different environments as well as different individuals. This has been

difficult due to lack of bio-monitoring programs to cover exposure data. Metabolism rate in

individuals may also affect the exposure data to be used since it differs in individuals as it is

affected by many other factors. Due to inadequate measures of exposure data, the parameters are

therefore estimated and this creates risks in assessing the data hence assumptions, which distort the

whole process of linking (Waltner, 2001).

Health outcome data is achieved through the analysis of the chronic effects of the diseases caused

and the mortality rates caused by the hazards in human beings. Some of the health outcomes

include asthma, cancer or malaria. Health outcomes are evaluated individually just like in the

cause-effect approach. At times information is obtained through the aggregation of the population

like those from regional or national surveys. Since the methodology focuses on using the limited

data based on the population aggregate, the theory does not succeed since it differs from the

individual data hence the inability to use the data obtained from each set (Adams & Greeley,

1996).

The theory, therefore, fails to work because apart from the three factors of data to be used to show

the link among hazard, exposure and health outcome it failed to acknowledge other relevant

factors, which contribute to the linking. For example, in the examination of asthma as the health

outcome, there are other factors to consider like the place of residence, age, socioeconomic status

and air pollution.

2.3 Literature Review

2.3.1 Climatic Variables

2.3.1.1 Rainfall

The study of rainfall is significant to the existence of man and to the effective understanding

and management of his environment and for the lives of animals and plants. Rainfall affects

water levels and other characteristics such as current of water bodies like streams, lakes and

rivers (Bailey, 1998; Fernandez-Illescas and Rodriquez-Harbe, 2004; Davis, 2002; Eversion,

2001). The knowledge of precipitation is beneficial to farmers to know when to grow their

crops, most especially crops that need a lot of water at some stage of their lives; it has been

reported that crops witness high growth rate during the first two months of rain in Maiduguri,

Nigeria (Adejuwon, 2004). Also, the knowledge of rainfall is needed to successfully plan and

organize outdoor activities and ceremonies like games and campaigns from time to time.

Occurrence of natural disasters like landslides, floods and droughts are dependent on the

intensity of rainfall (Ratnayake and Herath, 2005). Also, it is speculated that the worldwide

increase in floods, droughts and other water related problems like erosions is as a result of the

consequences of climate change, industrializations, population growth and densely populated

urban areas and perhaps signs of end time. On global scale, rainfall trends have shown spatial

and temporal variability in observations carried out (Ratnayake and Herath, 2005). At times

the variations are periodic and predictions are possible (Oduro-Afriyie and Adukpo, 2006;

Kane and Trivedi, 1982). However, in some cases its variations are so erratic that the study

concluded that there is no specific pattern in the rainy season and earlier predictions failed

(Ati et al, 2008).

No two locations no matter how close they are to each other and having similar geographical

features can have the same climate conditions and using the climatic conditions of one

location to estimate that of another location could be a blunder (Udo and Aro, 1999; Paldor,

2008). Many studies on rainfall do not pick on a particular location at a given time, but rather

across a country or region. (Oyegoke and Oyebande, 2008; Partal and Kahya, 2006; Smadi
and Zghoul, 2006). And even when that is not the case, a lot of years are considered in

examining the trend of rainfall for a given location, thus certain information are 'swallowed

up' in the process. The study of rainfall is significant to the existence of man and to the

effective understanding and management of his environment and for the lives of animals and

plants. Rainfall affects water levels and other characteristics such as current of water bodies

like streams, lakes and rivers (Bailey, 1998; Fernandez-Illescas and Rodriquez-Harbe, 2004;

Davis, 2002; Eversion, 2001). The knowledge of precipitation is beneficial to farmers to know

when to grow their crops, most especially crops that need a lot of water at some stage of their

lives; it has been reported that crops witness high growth rate during the first two months of

rain in Maiduguri, Nigeria (Adejuwon, 2004). Also the knowledge of rainfall is needed to

successfully plan and organise outdoor activities and ceremonies like games and campaigns

from time to time. Occurrence of natural disasters like landslides, floods and droughts are

dependent on the intensity of rainfall (Ratnayake and Herath, 2005).

Also, it is speculated that the worldwide increase in floods, droughts and other water related

problems like erosions is as a result of the consequences of climate change, industrialisations,

population growth and densely populated urban areas and perhaps signs of end time. On

global scale, rainfall trends have shown spatial and temporal variability in observations

carried out (Ratnayake and Herath, 2005). At times the variations are periodic and predictions

are possible (Oduro-Afriyie and Adukpo, 2006; Kane and Trivedi, 1982). However, in some

cases its variations are so erratic that the study concluded that there is no specific pattern in

the rainy season and earlier predictions failed (Ati et al, 2008).

2.3.1.2 Temperature

Temperature is the degree of hotness or coldness of the atmosphere on some chosen

scale. It is commonly measured in Celsius or Fahrenheit. Temperature is a very important

factor in determining the weather, because it influences other elements of the weather.
Three temperature scales are in general use today. The Fahrenheit (°F) temperature scale is

used in the United States and a few other English-speaking countries. The Celsius (°C)

temperature scale is standard in virtually all countries that have adopted the metric system

of measurement, and it is widely used in the sciences. The Kelvin (K) scale, an absolute

temperature scale (obtained by shifting the Celsius scale by −273.15° so that absolute zero

coincides with 0 K), is recognized as the international standard for scientific temperature

measurement (Britannic, 2021). Factors that affect temperature include:

i. Sunshine: The amount of sunshine at a certain place can influence its temperature.

The amount of sunshine can be measured in sunshine hours. That is worked out by

the number of hours of daylight and how many of these are cloud free. Sunshine is

variable due to daylight hours as during the night there is no sunshine as the Earth

is pointing away from the sun at the given spot. Also due to the Earth's tilt

sometimes of the year have more sunshine (summer) and some less (winter).

ii. Latitude: Latitude is the distance of a location from the equator. The hottest

temperatures on Earth are found near the equator. This is because the sun shines

directly on it for more hours during the year than anywhere else. As you move

further away from the equator towards the poles, less sun is received during the

year and the temperature become colder. Due to the earth’s inclination, the mid-day

sun is almost overhead within the tropics but the sun’s rays reach the earth at an

angle outside the tropics. Temperature thus diminishes from equatorial regions to

the poles.

iii. Altitude: Altitude is the height you are above sea level. The higher up you are the

lower the temperature will be. This is because air that is higher up is less dense than

it is at lower altitudes and air temperature depends on its density. Since the

atmosphere is
 mainly heated by conduction from the earth, it can be expected that places nearer to

the earth’s surface are warmer than those higher up. Thus, temperature decreases

with increasing height above sea level. This rate of decrease with altitude (lapse

rate) is never constant, varying from place to place and from season to season. As a

general rule for every 1,000m higher you go the temperature will drop by 6.5 °C.

iv. Sea Proximity and Temperature: Sea temperature changes slower than land

temperature. If the temperature on land drops, then the area next to the sea will be

kept warmer for longer than areas inland. Islands therefore have a less dramatic

climate than continents. Different seas have different temperatures therefore

allowing one side of an island to be a different temperature to the other side.

Prevailing Wind: Winds acquire the properties (temperature and humidity) of the places they

pass over. Prevailing winds that accompany a warm ocean current tend to warm adjacent land.

This is due to the thermal properties of land and water. Water warms and cools more slowly

than does land. Inland, places are generally warmer in summer and cooler in winter than

places on a coast.

2.3.2. Climate Change Issues in Nigeria

Climate change in Nigeria is evident from temperature increase, rainfall variability

(increasing in coastal areas and decline in continental areas). It is also reflected in
drought, desertification, rising sea levels, erosion, floods, thunderstorms, bush
fires, landslides, land degradation, more frequent, extreme weather conditions and loss of
biodiversity (Olaniyi, 2019). All of which continues to negatively affect human and animal
life and also the ecosystems in Nigeria.[2] Although, depending on the location, regions
experience climate change with significant higher temperatures during the dry seasons while
rainfalls during rainy seasons help keep the temperature at milder levels. The effects of
climate change prompted the World Meteorological Organization, in its 40th Executive
Council 1988, to establish a new international scientific assessment panel to be called the
International Panel on Climate Change (IPCC) (IPCC, 2012). The 2007 IPCC's fourth and
final Assessment Report (AR4) revealed that there is a considerable threat of climate change
that requires urgent global attention (Ogele, 2020). The report further attributed the
present global warming to largely anthropogenic practices. The Earth is almost at a point of
no return as it faces environmental threats which include atmospheric and marine pollution,
global warming, ozone depletion, the dangers of pollution by nuclear and other hazardous
substances, and the extinction of various wildlife species (Christopher, 2003).

The escalation of climate variability in Nigeria has led to heightened and irregular rainfall
patterns, exacerbating land degradation and resulting in more severe floods and erosion. As
one of the top ten most vulnerable countries to the effects of climate change, Nigeria has
experienced a worsening of these environmental challenges. By 2009, approximately 6,000
gullies had emerged, causing destruction to infrastructure in both rural and urban areas of the
country (World bank, 2023).

There are few comprehensive reports that provide useful evidence of various impacts of
climate change experienced in Nigeria today (Maddison, 2007). The vast majority of the
literature provides evidence of climate change holistically and this does not help in providing
sustainable solutions to the impacts experienced (Ataro, 2021). However, the agricultural
sector should be given more focus especially the existence in diverse regions where large
farming is not dominantly practiced. More deliberations should concentrate on
other mitigation and adaptation measures in literature which often takes the form of
recommendations, rather than examples of what has already been achieved (Haider, 2021).

This topical discourse is likely due to the need for much greater implementation of mitigation
and adaption measures in ensuring Nigeria produce more food all through the year round to
feed the growing population. In addition, while there is some discussion about necessary
capacity building at the individual, group and community level to engage in climate change
responses, there is also more or less attention given to higher levels of capacity building at
the state and national level (Kenar, 2016).

The associated challenges of climate change are not the same across all geographical areas of
the country. This is because of the two precipitation regimes: high precipitation in parts of
the Southeast and Southwest and low in the Northern Region. These regimes can result
in aridity, desertification and drought in the north; erosion and flooding in the south and other
regions, Neglected climate change actions is the issue of recycling of PET Bottles particularly
in the locally (Akande, 2017). The use of polyethylene terephthalate also known as PET or
PETE (a plastic resin materials used for making packaging materials such as bottles and food
containers) is increasingly becoming paramount among manufacturers, as they used these
PET bottles to package their products because it (PET) is an excellent barrier material with
high strength, thermostability and transparency. Nigeria currently has no standard policy to
regulate plastic waste; several efforts including legislations and contracts awarded for the
installation of plastic waste recycling plants across the country have been marred by
corruption and lack of political will by the government (Nkechi, 2016).

2.3.4 Climate Change Issues in Kwara State

The United Nations Framework Convention on Climate Change (UNFCCC 2013) put it as
direct or indirect human activities that alter the composition of the global atmosphere. The
most acceptable definition of climate change was given by IPCC (2007) Fourth Assessment
Report (AR4) as a change in the state of the climate that can be identified (e g. using
statistical tests) by changes in the mean and/or the variability of its properties, and that
persists for an extended period typically decades or longer. The Fifth Assessment Report
(ARS) is now the most inclusive assessment of scientific knowledge on climate changes since
2007. It emphasized the much greater prominence on assessing the socioeconomic change
and its implications for sustainable development (IPCC 2014). Thus the core focus of this
current IPCC fifth assessment is characterizing knowledge about vulnerability, the
characteristics and interactions that make some events devastating while others pass with
little notice. Tologbonse et al. (2010) reported that the rate of sickness/infection increases as a
result of climate change; this in turn reduces family income. Essop (2009) opined that minor
changes to rainfall pattern, increased severity of droughts and floods threaten food security.
According to the WHO (2003) climate change is caused by internal variability within the
climate system together with natural and anthropogenic factors. Theoretically, climate change
may be due to changes in astronomical, extraterrestrial and terrestrial factors. It is a well
known fact that global warming contributes to environmental, social and economic threats in
the world. Past studies (Buba 2004; DeWeerdt 2007; Odjugo 2007, Anselm and Taofeeq
2010) over decades have revealed that anthropogenic activities like urbanization, population
explosion, deforestation, industrialization and the release of greenhouse gases contribute
highly to the depletion of the ozone layer and its associated global warming, climate
variability and change. Indeed climate change started very long ago when man started
clearing forest for agriculture. This makes green house gases to be trapped within the
atmosphere and this changes the climate and alters weather patterns. Global warming results
in climate change and affect every facet of life. It affects health, agriculture (farming, fishing
and livestock) transportation, settlement and water resources just to mention a few. The
impact of climate change is global but the impact is mainly felt by the developing countries
most especially Africa due to their low level of coping capabilities (Nwafor 2007)

Over the years, reports from rural parts of Kwara on the impact of climate change so much
that one wonders whether rural people do not even have their own ways of understanding the
causes, impact and strategies for coping with climate change. According to Mabogunje
(2018), the best way to mitigate the impact of climate change is through effective
understanding, knowledge and awareness creation. It is anticipated that climate variability
and change in sub-Saharan Africa will have overwhelming impacts on agriculture and land
use, ecosystem and biodiversity, human settlements, diseases and health.

2.3.5 Climate Change Mitigation and Adaptation

Climate Carbon mitigation is an issue for the world's economies as they work to combat
climate change and advance environmental and socioeconomic sustainability (Inah, 2022).
However, for most of African countries, including Nigeria, the carbon footprint is low yet the
effects of the climate crises is in the country is huge. The world's economy cannot abruptly
quit using fossil fuels, since that would mean the end of the current way of life. Without the
fossil fuel economy, materials for computers or smartphones, or the ability for online
communications would end. Fossil fuels are necessary for all aspects of modern living,
including food, clothing, shelter, water, entertainment, and others.

Adapting to the effects of the climate crises falls on the whole population, despite individuals
in domestic settings not being a significant source of greenhouse gas emissions. Consequent
disruptions, especially in areas like agriculture and health, cause ripple effects on human
migration, gender inequality, food security and standards of living (The sun, 2011).

2.3.5 Impact of climate on human health

The relationship between human health and climate is not a new concept, nor is it a new
subject. In fact at least as far back as Hippocrates, many believed that human health was
intricately linked to the seasons, local weather patterns, and other environmental factors
(Taylor, 2014). While preceding the advent of Pasteur's germ theory in the mid-1800s, these
notions described certain patterns of disease, and often therapies were based directly on
changes in the environment. Proponents of miasma, i.e., a poisonous atmosphere arising from
swamps and putrid matters, as a source of disease noted that fevers and intestinal ailments
were common in warm seasons and were often associated with wet, poorly drained, and
humid areas, such as swamps (Taylor, 2014). This association motivated draining of swamps
in rural areas and the installation of the first central sewer systems in urban areas in North
America (Taylor, 2014). Of course, the therapeutic benefits of these practices had little to do
with ridding the environment of miasma, but these practices did reduce the size and number
of habitats breeding mosquitoes (disease vectors) and removed raw waste (hence, waterborne
pathogens) from immediate contact with humans. In spite of the developments in the mid- to
late 1800s demonstrating the role of microorganisms in disease, the theory of weather-borne
diseases held firm in early medicine until the late 1800s (Taylor, 2014).

The health impacts of climate, particularly temperature and humidity, have been of
interest for centuries. One area of growing concern is the health effects of heat waves,
especially given the likely increased frequency and intensity of extreme temperature events
under human-induced climate change (Perkins et al, 2012). The mechanism by which heat
impacts humans is complex, and although it is often treated as a sole product of temperature,
in reality it is a result of the interactions between temperature, radiation, wind, and humidity.
Of these variables, the most debated (with respect to health outcomes) is humidity, as there is
significant inconsistency in how humidity is incorporated and interpreted in human health
studies (Perkins et al, 2012).

Despite its physiological importance, humidity is rarely the explicit focus in health
impact studies. Consequently, our goals are to review and summarize the recent literature on
how humidity impacts human health, to define and compare a suite of commonly used
humidity variables, and to provide guidance to researchers regarding humidity variable
selection and implementation. This paper is organized in the following manner. We begin by
presenting an overview of how humidity is examined in the climate/environment and health
literature. We then present a primer on atmospheric humidity, which is followed by a review
of research that considers humidity either directly or indirectly in health outcomes. Finally, to
demonstrate how humidity variable selection may influence the interpretation of the impacts
of atmospheric moisture on health, we re-evaluate the analysis of a previously published
study on the association between weather and respiratory syncytial virus (RSV) in Singapore.
We conclude with recommendations concerning how to incorporate humidity in
climate/environment and health studies (Peter 2000).
 Conceptually, humidity is linked with anomalous mortality and morbidity levels
through its role in affecting heat stress and hydration state. During excessive heat, the body is
under considerable duress from a range of heat-stress related physiological reactions
(Parsons, 2003). The skin surface loses heat to its surroundings through convection (heat
carried away from warm skin via buoyant air currents), long-wave radiation exchange (heat
loss from the warm skin to colder air), and evaporation of moisture from the skin surface.
These processes are most efficient when strong temperature and humidity gradients are
present between the skin surface and the surrounding air. However, in extreme conditions
when air temperature is greater than skin temperature, the body can no longer cool via direct
heat exchange with the environment in fact, the opposite can occur. Accordingly, the only
mechanism for shedding heat is evaporation, the rate of which depends upon a strong skin–
atmosphere humidity gradient. When cooling processes are insufficient, the body core
temperature will rise and a range of adverse health outcomes may result (Hogan, 2010). In
increasing severity, these are heat rash, heat oedema, heat syncope, heat cramps, heat
exhaustion, and heat stroke, the latter of which can be fatal. Increasing dehydration and body
core temperature can also exert strain on the cardiovascular system, exacerbating existing
heart-related disease.

Renal disease and premature death may also result from dehydration. Although the
environmental epidemiology literature is replete with studies linking heat and health that
recognize the importance of atmospheric humidity, an explicit humidity variable is rarely
incorporated in the research despite its potential direct physiological importance. More often,
humidity is treated as a confounding variable that may be related to both the predictor and
response variables (Barnett and Tong, 2010). This approach is a part of the analysis strategy
in numerous studies (Cao et al, 2009), although this list is certainly not exhaustive. Alternate
approaches incorporate humidity in biometeorological indices or include it as an input
variable in human heat balance models. The extremely common use of RH in most climate
and health studies is particularly troubling given the confounding influence of temperature,
which inherently introduces a number of interpretation problems. This diversity of
approaches is emblematic of the difficulty in using atmospheric humidity as an exposure
variable in environmental epidemiological research.

Clearly, the relationship between climate and health has been a subject of study for a very
long time. However, during the past 2 decades, development of modern tools and
technologies has led to fascinating observations sparking new interest in the role of the
environment, including weather and climate, in infectious disease dynamics. Scientific
interest has been further stimulated by the growing problems of antibiotic resistance among
pathogens, emergence and reemergence of infectious diseases worldwide, the potential threat
of bioterrorism, and the debate concerning climate change. During the past few years,
scientists and several agencies, including the World Health Organization, American Academy
of Microbiology, Intergovernmental Panel on Climate Change (IPCC), and U.S. Global
Change Research Program, among others, have published papers and issued reports
highlighting the topic of climate and health (Rose, 2011). Concerns over the impact of
anthropogenic alterations to both terrestrial and aquatic habitats, coupled with a changing
global climate, have helped to spawn an expanding cross-disciplinary effort to understand
how such changes might affect human health. Progress is under way in using climate factors
in predictive models for certain diseases, notably cholera.

Part of the growing interest in the effects of climate on health is due to concerns about global
climate change and variability. In concurrently appearing papers in Science, Barnett et al.
(Barnet, 2011) and Levitus et al. (Levitus, 2011) independently reported warming in the top
3,000 m of the global ocean since 1950. Furthermore, models incorporating anthropogenic
forces (e.g., gases) match the observed changes in oceanic heat content (Rose, 2011. These
studies provide more evidence of human-induced climate change than those models that rely
on near-surface temperatures, largely because the heat capacity of the oceans gives a more
stable parameter than the surface temperatures (Levitus, 2011). Superimposed on global
trends or long-term changes in climate are periodic signals in the ocean-atmosphere that
result in climate variability at interannual to interdecadal scales. In particular, the El Niño-
southern oscillation (ENSO) has been the focus of much attention in the popular press and
scientific communities. This phenomenon originates in the eastern equatorial Pacific,
offshore from Peru, where every few years near Christmastime (hence, “El Niño,” the Christ
child) the normally cool waters of this region are suppressed by a layer of warm water
arriving from the west. This event triggers changes in weather patterns across the globe and is
considered to be among the most-important factors in global climate variability (Rose, 2011).
Climatologists have also begun to look at global impacts of other modes of atmospheric
variability associated with large ocean basins, e.g., the North Atlantic oscillation (NAO),
where decadal oscillations in the atmospheric pressure difference between Iceland and the
Azores affect wintertime weather in Europe and the Atlantic coast of the United States.
Research is under way to improve prediction of such climate signals, which is poor in
comparison to the better-understood ENSO (J. Marshall, Y. Kushnir, D. Battisti, P. Change,
J. Hurrell, M. McCartney, and M. Visbeck, unpublished data
[http://geoid.mit.edu/accp/avehtml.html]). Although controversy remains over how human
activities might be driving climate variability and change, most scientists in the field agree
that our climate is changing and there is an increasing need to understand the potential
outcomes of such changes on human health.

2.3.6 Cholera As a Model for Climate Related Infectious disease

Cholera, caused by V. cholerae, lends itself to the study of the role of climate in infectious
disease. This disease has a historical context linking it to specific seasons and
biogeographical zones. Although cholera is an ancient disease and had disappeared from
most of the developed world during the second half of the 20th century, it persists in many
parts of the world with serious epidemics, most often centered in tropical areas. The
association between the disease and water has been long held in folk tradition but was first
established epidemiologically in the 1850s when John Snow made the link between the
disease and a shallow well in London, United Kingdom (Rosenberg, 2012). Subsequently,
extensive studies demonstrated that V. cholerae is, in fact, native to coastal ecosystems
(Colwell, 2017). Vibrios, including V. cholerae, can be found in virtually any coastal water
body, especially in the tropics and subtropics, when appropriate techniques are used.
Recently, ecologically based models have been developed which define the role of
environmentally, weather-, and climate-related variables in outbreaks of the disease (Colwell,
2014). Data on the association between plankton and V. cholerae have been gathered over the
last 20 years and strongly support the hypothesis of a commensal or symbiotic relationship
between zooplankton and this bacterium. Because V. cholerae is highly concentrated on
zooplankton carapaces and in their gut, the risk of ingesting an infectious dose increases
when untreated surface waters are used for consumption. In this way, cholera shares some
properties of a vector-borne disease. This hypothesis is currently under study in our
laboratory at the Center of Marine Biotechnology and elsewhere (E. Whitcomb, personal
communication, 2001).

Cholera and V. cholerae offer an excellent example of the effect of climate and weather on
infectious diseases and pathogens. Here we discuss some of the recent research on the
subjects of V. cholerae, climate, and health and describe a framework for future studies using
the cholera model.
2.3.7 Climate and Cholera

Seasonality

Analysis of the frequency of specific disease cases throughout the year is a logical first-order
assessment of the potential role of climate in disease transmission. For many diseases
(vector-, air-, and waterborne) there is a clear seasonal trend in the detection or isolation of a
pathogen and prevalence of disease. For cholera, a distinct seasonal pattern is evident,
particularly in regions of endemicity. In the following sections we discuss environmental and
climatic factors that drive the seasonality and occurrence of V. cholerae and the disease
cholera.

Endemicity.

For most of its known history, V. cholerae was believed by physicians and clinical workers to
be only coincidentally associated with environmental waters and detectable only if there was
contamination by an infected individual. While we now know that V. cholerae is
autochthonous in riverine, estuarine, and coastal waters, as first proposed in 1977 by Colwell
et al. (Colwell, 2017), Cockburn and Cassanos (Cockburn, 2010) reported that as early as the
1800s there was discussion about environmental connections of the disease. By the late
1800s, areas of endemicity had been defined, along with relevant descriptions of the
environment, and an association of cholera with monsoons had been noted (Politzer, 2009).
V. cholerae was shown to withstand high-pH conditions, and the notion that ponds may be a
potential source of infection had been put forward (Cockburn, 2010). In retrospective studies
of cholera in India during the 19th century, there is clearly a series of epidemic years
associated with monsoons and other weather events (Whitcomb, personal communication,
2001).

Today, geographical areas once known to have experienced cholera epidemics can be
characterized into three levels. Cholera-free communities are defined as having no locally
acquired infections. In areas of cholera epidemicity, the disease diminishes after an outbreak.
In regions of cholera endemicity, the disease does not disappear after an epidemic peak and
returns in successive waves (Torres, 2011). Of particular interest and relevance to identifying
environmental or climate factors that may promote epidemics is the understanding of
dynamics of the disease in areas of endemicity. For example, what causes periodic
oscillations in cholera outbreaks, and why are some areas more prone to endemism? Torres
Codeço (Torres, 2011) incorporated seasonality into a model of endemic cholera and showed
that cholera infections occurred 2 to 4 months after the onset of V. cholerae growth in the
environment; however, this predictive model was influenced by population size and rate of
contact. Furthermore, only transient environmental reservoirs of V. cholerae were required to
maintain endemism in poor communities (Torres, 2011).

(i) Ecology and biogeography of V. cholerae. Detection of V. cholerae, both non-O1 and O1
strains, has been reported from almost every part of the world where there are rivers and
coastal regions (Postgate, 2009). In regions no longer with endemic Asiatic cholera in North
America, V. cholerae has been isolated from estuarine and coastal water collected along the
Pacific, Atlantic, and Gulf coasts of the United States (Motes, 2014), and it has also been
isolated in Australia (Dorsch, 2012), Southeast Asia, the island nations of the South Pacific,
Africa, Asia, and throughout Europe. V. cholerae has been similarly isolated in areas of
endemicity (India, Bangladesh, and Central and South America) (Caper, 2015). Despite the
prevalence of the causative organism worldwide, only certain regions of the world, mainly in
the tropics and subtropics, maintain endemicity for the disease. The nature of this
phenomenon is not entirely understood but is most likely related to both environmental and
socioeconomic factors. Following the sixth pandemic (∼1950), areas with endemic cholera
had been reduced to southeastern India and Bangladesh, a significantly narrower geographic
region, historically (Cockburn, 2010). During the current seventh pandemic, the range of
endemicity has expanded and includes areas of Africa and South and Central America
(Kaper, 2019).

Where cholera is endemic, cases tend to demonstrate distinct seasonal trends. These patterns
are strongly related to the ecology of V. cholerae in the environment, where high numbers are
observed during times of warm water temperatures and zooplankton blooms (Lobitz, 2020).
Over the last 25 years, the major cholera epidemics, including the first outbreak of O139
disease, have originated in coastal areas (T. Ramamurthy et al., Letter, Lancet 341:703-704,
1993). Currently, the main regions of cholera endemicity include the coasts surrounding the
Bay of Bengal, both Bangladesh and the Indian subcontinent, and coastal Latin America. In
each of these three geographical regions, patterns of disease frequency follow similar trends
and are most likely explained by the same physical or environmental drivers (see “Hierarchy
in the cholera model” below). In Bangladesh, there is a bimodal distribution in the frequency
of cases over an annual cycle. The first, and smaller, peak occurs in the spring. The larger
peak, however, follows the monsoon season in the fall. The onset of epidemics coincides with
dry weather and the warmest water temperatures of the year (August or September) (Kaper,
2015). The frequency of cases is reduced to background levels of a few cases as the
temperature decreases in winter (22, 25, 104). In Calcutta, India, cholera cases tend to peak in
April, May, and June (90). In South America, where the disease has become endemic since
its reemergence in 1991, cases are concentrated in the austral summer months (January and
February) (Kaper, 2015). The geographic limits of endemicity are also consistent and suggest
a biogeographical pattern of endemic disease that follows the environmental habitat of the
causative organism. Although inland countries report cases of cholera (WHO, 2020) and
freshwater plankton species harbor vibrios, case frequency and location of regions of
endemicity increase near coastlines. Along the Indian subcontinent, there is a distinct
boundary approximately 150 miles inland and to the northern part of the peninsula where the
frequency of cholera cases rapidly diminishes (Politzer, 2009). In South America, outbreaks
start along the coast, and epidemiological studies in Mexico demonstrate that people living in
coastal states are at a high risk of contracting the disease ( M. L. Lizarraga-Partida, I. Wong-
Chang, G. Barrera-Escorcia, A. V. Botello, A. Flisser, L. Gutierrez, A. Huq, and R. R.
Colwell, 2014).

V. cholerae O1 is also endemic in regions where there are now only sporadic cases of
cholera. Such endemic clones are found along the U.S. Gulf Coast and in Australia and are
unique, although closely related, based on phage typing and gene sequence analyses
(Karaolis, 2015). In these regions, sanitation practices are well developed and the waterborne
disease occurs rarely, although V. cholerae is often detected in estuaries and shellfish
(Murphree, 2011). Consumption of raw or improperly cooked shellfish harboring V.
cholerae, and not contaminated drinking water, causes the sporadic cases of diarrhea and
occasional septicemia that do occur (Hlady, 2016). Yet, as in the case of the range of areas of
cholera endemicity, the geographic distribution of these endemic strains tends to be limited to
the subtropical and subtemperate climates. Similarly, along the U.S. Gulf Coast and in
Australia, the frequency of isolation of V. cholerae from both the environment and patients
peaks during the warmer months of the year (Motes, 2014). Non-O1 isolates also follow this
pattern, with sporadic cases occurring mostly in the late summer in the United States and in
the early summer in Bangladesh (prior to the annual fall epidemic) (Morris, 2020). Europe
also reports detection of V. cholerae during the summer and early fall (Garay, 2005).
Seasonality in detection of the presence of V. cholerae in water and sediment in the
Chesapeake Bay of the east coast of the United States, a cholera-free region, has been
abundantly demonstrated (V. Louis et al., 2010).

(ii) Emergence of toxigenic strains from the environment. When cholera reemerged in South
America during the seventh pandemic in 1991, a new focus of endemicity was initiated.
Many investigators have speculated on the reemergence of cholera in South America after its
hundred-year absence, and several hypotheses have been put forth. One theory was that an
isolated event led to the epidemics—that is, an exchange of ballast water by a ship previously
traveling through areas of cholera endemicity. It has also been proposed that given the
similarity between strains isolated in Latin American and Asia (O1 El Tor), cells in the
VBNC state may have been transported from Southeast Asia to Peru with a transfer of water
associated with the 1991 El Niño event (Mourina, 2018). V. cholerae may have also already
been a feature of the nearshore aquatic environment in South America, but some
environmental cue triggered the bacterial population numbers past a threshold point, resulting
in outbreaks of the disease (Seas, 2020). Following this, further contamination with infected
stool and poor sanitary conditions led to outbreaks and epidemics. However, hospital records
from the months prior to the official onset of the epidemic in Peru (January 1991) indicate the
occurrence of cases matching the description of cholera as early as October of the previous
year (Seas, 2020). Furthermore, cases were detected at about the same time in several
geographically distant locales, suggesting that multiple strains contributed to the epidemic
(Seas, 2020). This scenario supports the notion that a population of V. cholerae already
existed along the coast of Peru and South America. Furthermore, data show that both O1 and
non-O1 isolates had been detected in South and Central America prior to the onset of
epidemics, as early as 1978 (Seas, 2020).

Recent molecular analyses also suggest that multiple strains may have been and continue to
be involved in outbreaks or emergence of toxigenic strains. Prior to 1992, the origin of all
cholera epidemics had been strains of V. cholerae O1; however, during that year cholera
outbreaks were associated with a new toxigenic serogroup, V. cholerae O139, in India and for
a short time this group replaced the V. cholerae O1 El Tor (Cholera working group, 2013).
Since the emergence of V. cholerae O139 strains in 1992, there has been much interest in
determining the mechanisms by which this pathogenic serogroup could have arisen.
Various researchers have now demonstrated that O139 strains associated with epidemics
arose via an homologous recombination event. Part of the sequence for O-antigen
biosynthesis in an O1 El Tor strain was lost and replaced with sequences derived from a non-
O1 strain (Seas, 2020). This recombination event also led to the expression of a capsule in
O139, a feature often associated with non-O1 strains (Dumontier, 2018). Furthermore,
ribotyping of both toxigenic and nontoxigenic strains of V. cholerae O139 revealed that
isolates might have arisen from at least two different progenitors, including non-O1
serogroups; half of the nontoxigenic isolates produced distinctly different ribotype patterns
than those produced by V. cholerae O1 El Tor (Faruque, 2020). Moreover, analysis of
housekeeping genes in the sixth (classical) and seventh (El Tor) pandemic and U.S. Gulf
Coast strains suggests that these pathogenic clones were derived independently from
nontoxigenic non-O1 progenitors (Kaper, 2019). Thus, given the likelihood of more
recombination events leading to new toxigenic strains, it becomes increasingly clear that
there is a need to understand the occurrence of and monitor for V. cholerae non-O1 in the
environment.

Interestingly, even in areas of endemicity it is often difficult to isolate V. cholerae O1 or

O139 from the environment, particularly during interepidemic periods, while V. cholerae
non-O1 is more readily detected (Khan, 2004). The first study to demonstrate the presence of
V. cholerae year-round in Bangladesh was conducted in the late 1990s using direct detection
methods (Huq, 2010). In attachment studies using copepods, there was no difference
observed between V. cholerae O1 and non-O1 strains. However, other studies have shown
that non-O1 V. cholerae strains survive better in the environment and are more resistant than
O1 strains to detergents and chelating agents, which may be discharged into the environment
(Montila, 2016). There was early speculation about the possibility of conversion between O1
and non-O1 serogroups, and phage-mediated seroconversion between biovars (Inaba and
Ogawa) has been reported (119). Later, serogroup conversion was demonstrated in laboratory
microcosms (Montilla, 2016). Conversion from non-O1 to O1, and vice versa, was observed
in all microcosms of both artificial seawater and natural water at various temperatures;
however, seroconversion occurred earliest (within 5 days) at a salinity of ∼10‰ and
temperatures near 35°C (Montila, 2016).

Environmental conditions affect both the overall abundance and, potentially, the serogroup of
V. cholerae in the environment. Surprisingly, even in areas of cholera endemicity, O1 strains
are detected infrequently in the environment compared to non-O1 strains using traditional
culture methods. Evidence for spontaneous seroconversion, in part, may explain this
observation (Colwell, 2016). Furthermore, in both endemic and cholera-free areas (e.g.,
Chesapeake Bay), increased environmental water temperatures correspond with increased
detection rates of V. cholerae, which suggests a triggering factor may be responsible for
enhancing the number of organisms in a given environment and condition (V. Louis et al.,
2010).

Contributing to the apparent dichotomy between clinical (toxigenic) and environmental

(nontoxigenic) strains is the issue of acquisition of virulence genes in the environment, as
most environmental isolates harbor neither tcp nor ctxAB (Singh. 2011). Recombination and
acquisition of foreign DNA appear to be common features among vibrios and V. cholerae
(Heidelberg, 2010). Genes for both TCP and CTX can be readily transduced into recipient
strains via temperate phages. While this is a key issue in the emergence of toxigenic strains,
how this occurs in the environment and/or intestine is still under investigation. Recent studies
show that, in general, phage-mediated transduction may occur at higher rates in the marine
and estuarine environment than originally thought. Jiang and Paul (Jiang, 2010) showed
transduction rates of 1013 transformants year−1 in Tampa Bay Estuary, Fla. Furthermore, in
the same subtropical estuary, prophage induction was demonstrated in 52% of surface water
samples, and at least 41% of the bacterial isolates were lysogens (carrying a prophage in the
genome or as a self-replicating element) (Cochran, 2018). Work to date on the CTXΦ reveals
that while there is no induction in the intestine (Faruque, 2018), exposure to sunlight is a key
factor in the induction of CTX prophage from the host and subsequent propagation of the
phage particle (Faruque, 2020). Environmental conditions, such as pH and temperature, also
influence V. cholerae phage infection and lysogenizing of the host or recipient cell (E. K.
Lipp, I. N. G. Rivera, M. Talledo, A. Neale, D. Karaolis, A. Huq, and R. R. Colwell, Abstr.
101st Gen. Meet. Am. Soc. Microbiol., a, 2001). Although continued research is needed, it
appears that seasonal environmental factors may affect phage-host dynamics and acquisition
of virulence genes to a significant degree.

Hierarchy in the cholera model. The spatial and temporal patterns of emerging and
reemerging diseases have been changing throughout history due to a variety of factors. Their
patterns as well as incidence or prevalence of disease are influenced by a complex interaction
of direct and indirect factors. Among physical factors, temperature perhaps has the most
direct and significant effect on the ecology of most bacteria. It is not any different for V.
cholerae, because warmer temperatures in combination with elevated pH and plankton
blooms can influence its attachment, growth, and multiplication in the aquatic environment,
particularly in association with copepods (Huq, 2004).

2.3.8 Impacts of Climate Change on Aquatic Ecosystems Related to Vibrio Infections

—An Overview of Evidence
Oceans have certainly become warmer, especially on the surface, with the upper 75 m
warmed by 0.11 ◦C per decade between 1971 and 2010 (IPCC, 2014). Although ocean
warming is slower, the pace of climate change and seasonal shift in the ocean is as high as on
land (Burrows, 2011). Moreover, around one-third of the emitted anthropogenic CO 2 is stored
in the oceans. Oceanic uptake of increased atmospheric CO 2 has resulted in decreased pH of
ocean surface water by 0.1, which corresponds to a 26% increase in acidity (Hoegh-
Guldberg, 2010). Ocean acidification poses marine ecosystems, and especially coral reefs and
polar ecosystems, significant risk (IPCC, 2014). Moreover, ocean acidification acts in
synergy with other global impacts, such as warming and gradually reduced oxygen levels,
and with local phenomena, such as pollution and eutrophication, resulting in shifts in species’
geographic ranges, seasonal activities, migration patterns, abundances, and interactions with
other species (Hoegh-Guldberg, 2010). Redistribution or even extinction of marine species
and reduced biodiversity can challenge the productivity of fisheries and other services but
also propagate growth and transmission of some pathogens, and may result in serious
outbreaks (e.g., zoo-plankton blooms and Vibrio infections) (Altizer, 2013). Finally, climate
change affects the amount of salt in the oceanic surface. Since the 1950s, seawater of high
surface salinity, where evaporation dominates, has become more saline, while areas of low
saltiness, where precipitation is frequent, have become fresher (IPCC, 2014). The abundance
of some pathogens, like that of cholera, depends on salinity (Dvorak, 2018).

Table 1 summarizes the environmental risk factors and their effect on V. cholerae expansion,
spread, or disease potential. Ocean surface temperature, CO 2 and oxygen concentrations, and
ocean acidification, pollution, and salinity affect bacterial replication, while ocean level,
rainfall, or floods and droughts affect the spread of V. cholerae.

Due to climate change, the amount of sea ice has diminished considerably. Over the period
1992-2011, the Greenland and Antarctic ice sheets have been losing mass, while the yearly
averaged

Arctic sea-ice extent declined from 1979 to 2012, with a decennial rate between 3.5% to
4.1% (IPCC, 2014). Ice melting and ocean thermal expansion due to warming have largely
contributed to sea-level rise (Dvorak, 2014). The global averaged sea level rose by 0.19 m
between 1901 and 2010, demonstrating a rapid increasing rate since the mid-19th century
compared with the mean rate during the previous two millennia (IPCC, 2014). Climate
change and especially the upward shift of the sea surface severely affect coastal locations
over and above the impact of other important factors, including increased population density,
runoff and pollution, and human activities, such as overfishing. According to recent analyses
and despite some spatial and seasonal variation, approximately 71% of the coastlines
analyzed also showed significant increases in sea surface temperature (SST) (Soneja, 2016).
Along with oxygen concentration that has decreased in coastal waters, warming affects the
biodiversity of coastal systems. Moreover, the elevation of sea level is likely to cause an
intrusion of seawater into coastlands, coastal rivers, and freshwater, erosion, serious regular
flooding events, and even covering of low-lying areas. Under these circumstances, the
likelihood of transmission of water-borne (e.g., cholera) and rodent-borne (e.g., leptospirosis)
pathogens increases substantially (Dvorak, 2018). If stagnant water is also trapped following
a flooding event, vulnerability to mosquito-borne diseases (e.g., malaria or dengue fever)
becomes larger.

Table 2.1. Risk factors for cholera infection and effect of climate change on these risk factors
resulting in altering Vibrio cholerae expansion, spread, or disease potential.
Risk Factor Effect of Climate Vibrio cholerae Disease
Change Potential
Ocean surface Increase Bacterial replication
temperature
CO2 concentration Increase Bacterial replication
Oxygen levels Decrease Bacterial replication
Ocean acidification Increase Bacterial replication
Ocean pollution Increase Bacterial replication
Increase or decrease
Salinity depending on decreasing or Bacterial replication
increasing precipitation
Flooding events,
disruption of water
Ocean level Increase
systems/Increased
spread
 Disruption of water
Rainfall/Flood Increase systems/Increased
spread
Drought Increase Increased spread
Inthecontextofclimatechange, rainfallpatternsaredynamic.Heavierand frequentprecipitationin
some areas can overwhelm wastewater treatment plants and septic systems, resulting in
contamination of surface water and wells. On the other hand, lower rainfall in other regions
may cause droughts and water scarcity, leading to increased microbial load in limited water
supplies, use of contaminated rainwater, or competition for scarce water (Mora, 2018).
Altered rainfall patterns, higher temperatures, and intense and more frequent weather
extremes, often resulting in natural disasters in countries with vulnerable infrastructure, are
likely to compromise the supply of clean and safe water, sanitation, and the function of
drainage systems with important consequences to the spread of water-borne diseases
including cholera (Levy, 2018)..

CHAPTER THREE

RESEARCH METHODOLOGY
3.1. Data Required for the Study
The following are the list of data that are required for this study:

i. Cholera cases by year or LGA in Ilorin metropolis between 2003 and 2023

ii. Climatic data (such as rainfall, humidity and temperature, between 2003 and

2023)

iii. information on effect climate on cholera in the area;

iv. Map of the study area

3.2. DATA SOURCES

The data sources for this study are both primary and secondary data.
3.2.1 Secondary Source
The secondary data source is map of the study area, population of the study area, climatic

data (rainfall, temperature and humidity) the data (number of cholera cases by year in Ilorin

LGAs).

The data on cases of cholera and frequency of occurrences will be gotten from the University

of Ilorin teaching hospital (UITH) Ilorin, while the climatic data will be obtained from

Nigerian meteorological agency (NIMET).

3.3 Sampling Procedure

3.3.1 Sample Frame

The sample frame for the study is the total population of Ilorin which is 593,000

(NPC, 2006). Using Taro Yamane population projection formula, the projected population of

Ilorin 2017 using a growth rate of 2.84% is 609,841.

( )
n
r
Formula P1=P0 1+
100

Where P1=projected population

P0=current population

r= growth rate

n= time interval

The projected population for (P1) to 2022 was therefore gotten by substituting the formula

with appropriate figure. This is expressed as

P0 =609,841

r = 2.84%

n = 16 years

Therefore;
 ( )
n
r
P1 = P0 1+
100

( )
16
2.84
P1 = 609,841 1+
100

P1= 954,574

3.3.2 Sample Size

The sample size for the study was derived from Taro Yamane (1973) formula written

below

N
n=
1+ N (e)2

Where n =sample size

N = population size

e = error of sampling

This study allows for error of sampling on 0.08, hence the sample size shows as follow;

N=954,574

e=0.08

3.4 Method of Data Analysis

The data collected will be analysed using both descriptive and inferential statistics.

1. The cases of cholera and frequency in the study will be analysed using Tables,

percentages, Charts and mean weight score.

2. Time series analysis will be used to analyse theclimatic data from 2003 to 2023.

3.4.1. Descriptive statistics include

i. Tables: this will be used to arrange the monthly rainfall data.

ii. Mean: this will be used to summarize the data into arithmetic values of rainfall.

The formula is given as thus:

 ------------------ Equation 1

x mean

f = frequency of the set of

data x = set of data

iii. Standard deviation: It is a method used for calculating dispersion. It tells how far

or near a score is to the mean score. It is calculated as the square root of the

arithmetic means it a given observation. It will be used to quantify the amount of

variation in the set data i.e. the variation in climatic pattern. The formula is given

as thus:

------------------ Equation 2

= standard deviation

I = class interval

= each value of data

set x = the arithmetic

mean of data N= the

total number of data

3.4.2 Inferential statistics

i. Time series: this is the series of observation assumed by a variable over a

successive time period. It analysis to fit an array of time bound data on a line of

best fit. It also helps to show the type of trends existing in the data graphically.

Time series will used to determine the pattern of minimum, maximum temperature
 and rainfall for the study area for predicting for future years. The trend line

equation of a time series data is shown below

Y=A+B(X)…………………….Equation 3

Where, A = Intercept

B = Rate of change per

time X = Coded values

of years.

Correlation: This is a statistical technique that measures the degree of linear

relationship between two variables; there is a number of coefficient of

correlation that measures linear relationship. For any of these correlation, the

range of values of coefficient of correlation is between -l and +l i.e. -1<r<+1s.

Correlation analysis was used to examine the relationship between Climate

change and cholera of the study area using:

r =n ¿ ¿ ------------------ Equation 4

Where,

y = climate change

x = cholera

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