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1st draft (Nov 16, 2010)

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

1
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, 7-
3-1 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 swimming-
associated 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 Inundation depth Impacts
I 0-50 cm most houses will stay dry and it is still possible to walk through
water
II 50-100 cm there will be at least 50 cm of water on the ground floor
III 100-200 cm the ground floor of the houses will be flooded
IV > 200 cm 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.

6% 11 %

0-4 year-old
19 %
5-14 year-old
15-59 year-old
over 60 year-old
64 %

Figure 2. Distribution of

4
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 US-
EPS 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 District Area (ha) Population density
(persons/ha) (persons/ha)

1 865.13 682 8 158.91 38

2 66.11 176 9 67.26 111
3 84.69 291 10 259.58 298
4 163.85 253 11 278.69 230
5 309.01 347 12 166.00 476
6 774.71 455 13 315.28 80
7 91.37 184 14 337.45 526

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

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

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

5. QUANTIFYING THE HEALTH RISKS OF FLOODS

5.1 DAILY RISKS

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

7
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, 100-
200 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 Total
(person)
0-50cm 50-100cm 100-200cm >200cm
1 590,307 142 223 37 0 402
2 11,619 1 10 10 0 21
3 24,615 4 13 46 0 63
4 41,517 6 7 6 0 19
5 107,154 33 29 12 0 74
6 352,329 83 105 119 6 313
7 16,798 0 5 55 0 60
8 5,969 2 1 0 0 3
9 7,466 1 0 0 0 1
10 77,398 28 1 0 0 29
11 64,184 9 42 22 0 73
12 79,003 11 19 193 0 223
13 25,243 5 0 0 0 5
14 177,480 41 34 208 0 283

5.2 ANNUAL RISKS

Table 5. Single risk and annual risk associated with pathogen exposure during flooding
period, for different group of people
Group of Age Risk Inundation depth (cm)
< 50 50-100 100-200 >200
0-4 daily risk 0.001491 0.002968 0.005879 0.005879
total risk 0.029407 0.057715 0.111231 0.111231
5 to 14 daily risk 0.000598 0.001194 0.005879 0.011536
total risk 0.011898 0.023615 0.111231 0.207095
15 to 59 daily risk 0.000598 0.001194 0.005879 0.011536
total risk 0.011898 0.023615 0.111231 0.207095
>60 daily risk 0.000150 0.000299 0.001491 0.001491
total risk 0.002992 0.005972 0.029407 0.029407
Total daily risk 0.000674 0.001345 0.005631 0.010328
total risk 0.013398 0.026556 0.106796 0.187491

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.

APPENDIXES
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 Symbol Unit Distribution/notes
Concentration A mean value of 30,000
E.Coli CE MPN/100 MPN/100mL (18,000-50000)
ml was taken for E.Coli
concentration in flood water
(Nga, Master thesis, 1999)
Water Ingestion Rate during walking ml/hour
Age <4 50 ml/h
Age 5-14 10 ml/h
Age 15-59 10 ml/h
Age >60 10 ml/h
Water Ingestion Rate during swimming ml/hour
Age 5-14 100 ml/h
Age 15-59 50 ml/h
Time spent outdoor T hours/da
Age <4 y Assumed 1 hour
Age 5-14 Assumed 4 hours
Age 15-59 Assumed 4 hours
Age >60 Assumed 1 hours
Fraction of outdoor time spent in water F % Assumed, varies according to
inundation levels
Dose-response model (Hass equation)
N50 8.6x10^7
α 0.1778