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Climate Change and the Urban Poor Quantifying the health risks of floods in Manila, Philippines
By: Tran Thi Viet Nga 1 , Kensuke Fukushi 2, and Michael Parsons3 Background Paper for Conference on the " The Environments of the Poor”, 24-26 Nov 2010, New Delhi3 SUMMARY
1. Exposure to contaminated flood water in urban areas can pose a significant human

health risk. Climate change may see a rise in more extreme flood events, and consequently, the risk of exposure to polluted water and of contracting flood induced diseases may also increase, particularly for the most vulnerable. To quantify this potential risk, a range of inundation scenarios were developed. Established dose-response relationships (Hass, 1989) for the main flood water contaminant (E. coli) were used to estimate varying rates of gastrointestinal infection for different age groups.
2. At flood levels from less than half a metre to over 2 metres, the probability of

gastrointestinal illness due to E.Coli from incidental ingestion, averaged over a year, ranged from 1% to nearly 20%. The risks for gastrointestinal illness reach the highest level in the 4 to 15 year old age group. The risk analysis suggests that contact with flood water poses significant human health risks for residents in the flood-prone region like Manila, and particularly for poor children and youth.
3. As health risks of the poor may increase with climate change, quantifying such risks

can assist in future health planning and community-based natural disaster risk management. Where such risks threaten life and property, quantification may also


Dr. Tran Thi Viet Nga is Lecturer at Institute for Environmental Science and Engineering, National University of Civil Engineering, 55 Giai Phong, Hanoi, Vietnam 2 Dr. Fukushi Kensuke is Associate Professor at TGIS, IR3S, the University of Tokyo, 73-1 Hongo, Bunkyo-ku, Tokyo 113-8654 Japan. 3 Dr. Micheal Parsons is Senior Advisor at Institute of Strategy and Policy on Natural Resources and Environment, Ministry of Natural Resources and Environment, 1116 Hoang Quoc Viet, Cau Giay, Hanoi, Vietnam.

help encourage the development of financial responses, such micro-insurance. 1. INTRODUCTION Earlier studies have shown that there are measurable health impacts associated with swimming in contaminated surface waters. Cabelli (1982) reported that this swimmingassociated illness was an acute, but relatively benign, gastroenteritis which had a short incubation period and duration. In the flood season, there is a higher risk of infection due to more frequent direct contact with severely polluted water over a longer period. Infectious disease is a major flood-related health concern many flooding-prone areas, especially in settings where infectious disease transmission is an endemic public health problem (Tyndall, 2004). Infectious disease outbreaks have been reported following major flood events in developing countries, and these outbreaks vary in magnitude and rates of mortality. There is some evidence from India and Bangladesh that diarrhoeal disease increases after flooding. This study aims to characterize and quantify the human health risks associated with varying levels of exposure to pathogens present in flood water. In this analysis, exposure scenarios according to inundation levels were developed in which direct and indirect contact with polluted water was assumed to occur. Probabilities of gastrointestinal infection were estimated based on established dose-response relationships for the key pathogen (E. coli) to be present in the flood water. (Hass, 1989. See Note below for dose-relationship details) A key factor in determining health risks involved in exposure of pathogens in surface water is the volume of water that is being swallowed. To date, no studies have estimated volumes of accidental ingestion by those living in the flood zone. Therefore exposure levels during swimming and/or wading for different age groups, as determined by the United States Environmental Protection Authority, were adopted. It was also assumed that residents lack the option of evacuating or relocating when flooding occurs. As these assumptions are untested, the study results may be over- or underestimated. 2. STUDY SITE The selected study area was the City of Manila with a population of just over one millon (May 2000). Metro Manila is the social, economic and political centre of the Philippines. It is also at the heart of the tropical monsoon climatic zone. Frequent

flooding associated with typhoons and other climatic factors is a perennial problem, intensified by the city being located at sea-level. Furthermore, rapid urbanization, inadequate river channel and drainage capacity, poor maintenance, growing number of informal settlers, institutional challenges and financial restraints exacerbate the flood situation (JICA, 2001).

Figure 1: Metro Manila district boundaries and the City of Manila study area

In this study, data provided by JBIC was used to create maps of population density and the inundation status-quo, and to calculate risk assessment. These data include barangay boundaries of Metro Manila as of 2003 with the barangays in the City of Manila grouped together by District, population (National Statistics Office 2000 census), and inundation scenarios. ArcGIS 9.2 was used to match population with boundaries districts. The newly-created shapefile contains the district boundaries of the City of Manila (as of 2000) and matched population in 2000. Based on this shapefile, a population density (people per hectare) map was created. Inundation GRID data was used to create the inundation map using the minimum level (in metres) of status-quo 2003. Levels of risk associated with different exposure scenarios according to inundation levels were then calculated.

These results were then matched with the inundation map to create a new map of potential risks in relevant areas. 3. EXPOSURE SCENARIOS A human health risk assessment was conducted to evaluate the risks associated with exposure to polluted flood water (E.coli) using the following scenarios: (i) inundation depth of less than one metre; (ii) inundation depth of a half to one metre, (iii) inundation depth of one to two metres, and (iv) inundation depth of above two metres. These scenarios were derived from impacts set out in the Flood Fighting Act of Japan, 2001 (see Table 1).
Table 1: Classification of inundation depth4 Level I II III IV Inundation depth 0-50 cm 50-100 cm 100-200 cm > 200 cm Impacts most houses will stay dry and it is still possible to walk through water there will be at least 50 cm of water on the ground floor the ground floor of the houses will be flooded both the 1st floor and often also the roof will be covered by water.

Peoples’ vulnerabilities, experiences, coping behaviour and responses to flooding differ due to various factors, such as gender, age, occupation, lifestyle and living standard. Because of data limitations, this analysis focuses on differences due to age. The population of Manila was divided into four age groups, (i) less than 4 years, (ii) from 5 to 14 years, (iii) from 15 to 59 years and (iv) above 60 years old (National Statistics Office 2000 census). Secondary sources were used to examine daily activities and behaviour of each age group to confirm the amount of time people would spend in water during flood event.


11 % 0-4 year-old 19 % 5-14 year-old 15-59 year-old over 60 year-old

64 %

Figure 2.

Distribution of


Note: Classification based on Flood Fighting Act, Japan, 2001

age in Metro Manila Source: NSO, 2000 Census of Population and Housing

In this analysis, E. coli concentration in flood water was used to evaluate the risk and the exposure route was assumed to be ingestion. Default ingestion intake values were derived from US-EPA Risk Assessment Guidance of Superfund (RAGS). For each exposure scenario, risk was first calculated for a single exposure event. (1) Inundation depth of less than half a metre This scenario presents direct contact with flood water during time spent outdoors. Since the inundation depth is less than half a metre, it is likely that water-contact activities would only occur during moving around in flooded streets. For the purposes of this assessment, it was assumed that in one day the total amount of time spent outdoors for the age group of less than 4 years was two hours, from 5 to 14 and 15 to 59 years four hours and over 60 years old one hour, assuming that half of the total outdoor time was spent in water.. One major potential routes of pathogen exposure is accidental swallowing of flood water. Hand-to-mouth transfer is viewed as most likely for those less than 4 years old who spend time playing with water. In this analysis, it was summed that, on average, children under four years old would accidentally swallow around 50 ml per hour, those aged from five years and over, 10 ml per hour. These values were derived from USEPS risk Assessment Guidance for Individuals Exposed to Surface Water during Wading. (2) Inundation depth of a half to one metre At this inundation depth, it is likely that people would be in water whenever they left their house. Exposure to waterborne pathogens would be through accidental ingestion while moving around or walking in flood water, using flood water for bathing, or for washing personal belongings. (3) Inundation depth of one to two metres In this scenario, the water contact time was assumed to be the same as for scenario (2). However, at this inundation depth, it is likely that people would have to swim or do swimming-like activities during commuting. Because children would have the opportunity to play or swim in the water and to repeat exposure events within the one day, it was assumed that accidental ingestion of flood water could be considerable higher than that experienced by other age groups. Studies have indicated that non-

adults ingest about twice as much water as adults during swimming activities (Dufour, 2006). In this assessment, the incidental ingestion rate was assumed to be 100ml per hour for children, and half that rate for adults. (4) Inundation depth of above two metres At this depth, both the first floor and often also the roof will be covered by water. Given the high frequency of water contact by inhabitants of flooded houses, it was assumed that incidental ingestion of flood water could be considerably higher compared to that occasioned by swimming. For the purpose of this assessment, it was assumed the ingestion rate was 200 ml children for children and half that rate for adults. 4. FLOOD INDENTIFICATION Figure 3 shows that among the fourteen districts of Manila (named from 1 to 14), district 1 in the Northeast has highest population density, more than 500 person per ha. Coastal districts have the lowest population density, of less than 110 person per ha.
Table 2. Population densities on City of Manila District Area (ha) Population density (persons/ha) 682 176 291 253 347 455 184 District Area (ha) Population density (persons/ha) 38 111 298 230 476 80 526

1 2 3 4 5 6 7

865.13 66.11 84.69 163.85 309.01 774.71 91.37

8 9 10 11 12 13 14

158.91 67.26 259.58 278.69 166.00 315.28 337.45

The GRID data of inundation was then used to create the inundation map. We used the minimum level (in meters) of status-quo 2003 to present the map (Figure 4).   The
serious flood area where have high inundation level and high population density are District 1, 6, 12, and 14.

Figure 3. Population densities map of City of Manila 5


The map was created using ArcMap 9.2; data from National Statistics Office 2000 Census of Population and Housing

Figure 4. Inundation map of City of Manila 6


The map was created using ArcMap 9.2; inundation level classification from the Flood Fighting Act, Japan, 2001, inundation data of year 2003.

Table 3: Flooded area by districts, Manila City District 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Area (m2) 8,651,257 661,052 846,864 1,638,521 3,090,140 7,747,139 913,711 1,589,072 672,642 2,595,763 2,786,865 1,660,035 3,152,817 3,374,456 Flooded-area (m2) according to inundation depth of 0-50cm 3,133,920 97,532 221,356 374,456 1,436,061 2,694,595 20,703 666,652 87,122 1,394,040 664,108 354,012 923,386 1,184,077 50-100cm 2,418,052 433,096 331,086 224,576 621,836 1,716,456 204,298 230,610   31,988 1,326,063 304,645 14,442 508,537 100-200cm 97,081 107,356 283,055 40,318 57,987 469,742 535,774 14,628     172,772 723,402 9,459 702,738 >200cm           13,187             4,634  



Figure 5. Estimated daily risk of infection via incidental ingestion of flood water in City of

Manila 7.

Figure 6. Number of infected people due to gastrointestinal illness via incidental

The infected risk was calculated using the mean E.coli exposure level of 30,000 MPN/100 ml from the contaminated surface water data (Nga, 1998) and daily risks of gastrointestinal illness via incidental ingestion were 0.000674, 0.001345, 0.005631 and 0.010328 for the inundation scenarios of 0-50 cm, 50-100 cm, 100200 cm, and above 200 cm, respectively. Map was created in ArcMap 9.2 by overlaying polygons of districts boundaries on the classified risk levels

ingestion of flood water in City of Manila

Table 4. Number of infected people per day due to gastrointestinal illness via incidental ingestion of flood water in Manila (based on inundation data of year 2003) District Population Infected people (person) according to inundation depth of 0-50cm 1 2 3 4 5 6 7 8 9 10 11 12 13 14 590,307 11,619 24,615 41,517 107,154 352,329 16,798 5,969 7,466 77,398 64,184 79,003 25,243 177,480 142 1 4 6 33 83 0 2 1 28 9 11 5 41 50-100cm 223 10 13 7 29 105 5 1 0 1 42 19 0 34 100-200cm 37 10 46 6 12 119 55 0 0 0 22 193 0 208 >200cm 0 0 0 0 0 6 0 0 0 0 0 0 0 0 402 21 63 19 74 313 60 3 1 29 73 223 5 283 Total (person)

Table 5. Single risk and annual risk associated with pathogen exposure during flooding period, for different group of people Group of Age 0-4 5 to 14 15 to 59 >60 Total Risk daily risk total risk daily risk total risk daily risk total risk daily risk total risk daily risk < 50 0.001491 0.029407 0.000598 0.011898 0.000598 0.011898 0.000150 0.002992 0.000674 Inundation depth (cm) 50-100 100-200 0.002968 0.005879 0.057715 0.111231 0.001194 0.005879 0.023615 0.111231 0.001194 0.005879 0.023615 0.111231 0.000299 0.001491 0.005972 0.029407 0.001345 0.005631 >200 0.005879 0.111231 0.011536 0.207095 0.011536 0.207095 0.001491 0.029407 0.010328

total risk





According to Zoleta-Nantes (2000), 18 to 20 floods occur in Metro Manila each year. A survey by JICA in 2000 also reported that the duration of flooding was ranging from ten to twenty hours. In this analysis, one flood will be considered as one exposure to inundation water, and assuming that the time length for one exposure will be one day,

the annual risk based on a single exposure can be calculated. 6. CONCLUSIONS In this analysis, the risk of the poor contracting gastrointestinal illness due to E.Coli from incidental ingestion of flood water in City of Manila over the course of a year varies according to inundation levels and age. The level of risk ranges from 1% to nearly 20%, given flood levels of less than a metre to over two metres. The highest level of risk is to the five to fourteen years old age group. However, if flood heights of more than two metres become the norm due to climate change, and if these foods occur more frequently, and last longer, then the vulnerability baseline for all groups will shift accordingly. As with any risk assessment, there are many sources of uncertainty in this analysis. While the health risks associate with E.coli in this assessment are considerable, the level of risk for gastrointestinal illness, in fact, may be significantly higher, because other potentially pathogenic microorganisms may be present in the flood water that could affect those most vulnerable to frequent exposure. The most vulnerable may also include women. As women are generally more involved than men in supervising outdoor activities of young children, they may also incur a higher risk of accidentally ingesting polluted water. Urban poor women are also more involved in street trading, food preparation and other water-related activities such as washing, which could put them at a higher level of risk than men in contracting waterborne diseases. The data presented here is suggestive, and is hedged in by many assumptions. To verify the results, evidence of group behaviour during floods, inundation water quality and natural, social and economic data pertaining to the study area need to be collected. However the aim of this analysis is to make a contribution to the quantification of climate change-related risks, and to simulate further discussion and reflection of methodologies for undertaking quantitative assessments. In the present case under consideration, such a methodology can be usefully employed to make a rapid assessment of threatened areas where evidential data is lacking, and the time and resources required are unavailable. A useful contribution can thus be made to strategic health planning, and in particular, pre-positioning health resources to manage areas under threat. When field-tested and evidentially validated, predictive quantitative assessments of climate change-related risks may also help promote development of financial instruments such as insurance. Micro-insurance, in particular, may be of great benefit to the poor in hazard-prone areas. During the recovery phase of natural

disasters, they can insulate poor families against negative economic impacts of shocks. They have the potential to widen and hasten full recovery and thus help build livelihood resilience. 7. REFERENCES Donovan E., Unice K., Robert J.D., Harris M., and Finley B. Risk of Gastrointestinal Disease Associates with Exposure to Pathogens in the Water of the Lower Passaic River. Applied and Environmental Microbiology, Feb. 2008, p. 994-1003 Dufour A.P, Evans O., Behymer T. D., and Cantu R. Water ingestion during swimming activities in a pool: a pilot study. J. Water Health 4:425-430 Charles N. Haas, Joan B. Rose, Charles P. Gerba. Quantitative microbiological risk assessment. John Wiley and Sons, NY, 1999 JICA, 2001. Metro Manila Flood Control Project Nga T.T.V. Master thesis. Asian Institute of Technology, 1999. US-EPA. Risk Assessment guidance for Superfund. Vol.1. Human health evaluation manual (Part A). EPA/540/1-89/002. US-EPA, Washington DC. Zoleta-Nantes, D. 2002. Differential Impacts of Flood Hazards among the Street children, the Urban Poor and Residents of Wealthy Neighborhood in Metro Manila, Philippines. Journal of Mitigation and Adaptation Strategies for Global Change. 7(3): 239-266. The Netherlands: Kluwer Publishing. Roger Few, Mike Ahern, Franziska Matthies and Sari Kovats. Floods, health and climate change: a strategic review. Tyndall Centre for Climate Change Research Working, 2004.


Dose-response Relationship The following equation was used to calculate the single-exposure illness rate (Hass, 1989) for E.coli Risk = 1 – [1+ (D/ N50)(21/α-1)]-α With Risk= probability of infection; N50=medium infectious dose α: slope parameter Table 6. Assumption uses in risk calculation

Parameter Concentration E.Coli


MPN/100 ml

Distribution/notes A mean value of 30,000 MPN/100mL (18,000-50000) was taken for E.Coli concentration in flood water (Nga, Master thesis, 1999)
50 ml/h 10 ml/h 10 ml/h 10 ml/h

Water Ingestion Rate during walking Age <4 Age 5-14 Age 15-59 Age >60 Water Ingestion Rate during swimming Age 5-14 Age 15-59 Time spent outdoor Age <4 Age 5-14 Age 15-59 Age >60 Fraction of outdoor time spent in water Dose-response model (Hass equation) N50 α F T


ml/hour 100 ml/h 50 ml/h hours/da y Assumed 1 hour Assumed 4 hours Assumed 4 hours Assumed 1 hours % Assumed, varies according to inundation levels 8.6x10^7 0.1778

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