Clinical Review & Education

JAMA Insights | CLIMATE CHANGE AND HEALTH

Infectious Diseases in a Changing Climate

Matthew C. Phillips, MD, PhD; Regina C. LaRocque, MD, MPH; George R. Thompson III, MD

Climate change is happening now. Nine of the 10 hottest years on
record have occurred in the past decade and were accompanied by
extreme heat waves, droughts, wildfires, hurricanes, and severe
flooding. Primarily due to greenhouse gases released via combus-
tion of fossil fuels, global aver-
age temperatures between 2011
CME at jamacmelookup.com
and 2020 increased to 1.1 °C
(approximately 1.9 °F) above preindustrial levels and are estimated
to increase to 1.5 °C (approximately 2.7 °F) by 2040.1
Local manifestations of the warming earth, such as shorter
winters, changes in precipitation, and increased frequency of ex-
treme weather events, will cause worldwide changes in patho-
gens, vectors, and the behavior of animal reservoirs and people.
These changes may alter infectious disease epidemiology in the US
and internationally as traditionally accepted regions of disease ac-
quisition lose relevance, seasonal associations change, and new
pathogens emerge. Awareness of changes in the geographic range,
seasonality, and frequency of transmission of infectious diseases be-
cause of climate change is important to help clinicians diagnose, treat,
and prevent infectious diseases in patients (Table).
Vector-Borne Diseases
In the US, climate change is altering environmental conditions and
facilitating proliferation of arthropod disease vectors such as ticks and
mosquitoes. Between 2004 and 2018, the number of arthropod-
associated illnesses reported to the US Centers for Disease Control
and Prevention more than doubled, to a total of more than 760 000
cases. Multiple pathogens, including West Nile, Powassan, and Zika
viruses, have been identified that were not previously seen or com-
mon in the US.2 This increase may be related to improved aware-
ness, diagnostic methods, and case reporting, but climate-related
changes in vector biology are also contributing. For instance, tick
survival over winter months increases with shorter, milder winters,
leading to larger populations and northern extension of their geo-
graphic locations into Canada and the upper Midwest US. Longer sum-
mers result in more months per year when ticks bite, creating more
opportunities to spread diseases such as babesiosis, anaplasmosis,
and Lyme disease. Mosquitoes have a short lifespan and respond rap-
idly to changes in weather. Mosquitoes require water to breed, and
changes in precipitation can significantly alter the size and location
of local mosquito populations. Warmer temperatures increase effi-
ciency of the mosquito breeding cycle, leading females to require
more blood meals to support multiple gestations over their lifetime.3
Higher temperatures have promoted northern extension of loca-
tions of pathogen-carrying mosquito species such as Aedes aegypti,
the primary vector for dengue, chikungunya, yellow fever, and Zika.
Some of these diseases are now locally transmitted in the US, pri-
marily in southern states such as Florida and Texas.3 Malaria, trans-
mitted by Anopheles mosquitoes, also increased during the sum-
mer of 2023 with several locally acquired cases reported in the US.4

Table. Impact of Climate-Related Changes on Infectious Disease Epidemiology

Effect on infectious disease
Disease type Climate-related change epidemiology Examples
Vector-borne Shorter, warmer winters Increased disease incidence Babesiosis
diseases Longer summers Expanding seasonality into winter Lyme disease
Expanding range of vectors, eg, mosquitoes and ticks months Anaplasmosis
Changes in precipitation patterns Expanding geographic range, primarily Powassan virus
northward and westward
Ehrlichiosis
Increased likelihood of onward
transmission Dengue
Zika virus
Chikungunya virus
Malaria
Zoonotic Changes in animal migration patterns, natural ranges, Increased cross-species transmission Avian influenza (H5N1)
diseases and population density events Plague
Habitat destruction Emergence of novel human pathogens Hantavirus
Increased interaction between different animal species Increased disease incidence Tularemia
Increased human-animal interaction Expanding geographic range Emerging coronaviruses
Fungal diseases Expanded thermotolerance in fungal organisms Emergence of novel human pathogens Candida auris
New favorable environments for endemic fungi Expanding geographic range of endemic Sporothrix brasiliensis
mycoses Coccidioides
Histoplasma
Blastomyces
Waterborne Rise of sea level Increased disease incidence after storms Campylobacter
diseases Extreme weather events Expanding seasonality Escherichia coli
Flooding-induced strain on water infrastructure Expanding geographic range, primarily Cryptosporidium
Changes in precipitation patterns northward Vibrio species
Changes in coastal water temperature

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Zoonotic Diseases saprophytic organism dwelling on plant material to a zoonotic dis-

Zoonotic infections are infections that spread between humans and
other vertebrate animals and may be viral, bacterial, or parasitic. Cli-
mate change alters population dynamics and behaviors of host ani-
mals, which can increase zoonotic disease spread. In the western US,
changes in precipitation and temperature affect food availability,
population size, and behavior of rodent hosts for plague and han-
tavirus. These changes result in increased disease incidence and a
geographical shift northward and to higher altitudes.5 Models esti-
mate that more than half of the earth’s animal species are experi-
encing climate-induced alterations of their natural ranges, with many
moving northward as habitat suitability declines in the global south.6
Habitat destruction leads to numerous species coming into close con-
tact, increasing the risk of pathogens (particularly viruses) spread-
ing to other species, potentially including humans. Migratory birds
are uniquely affected by habitat destruction and have been the pri-
mary cause of the current global outbreak of avian influenza (H5N1).
Since January 2022, H5N1 has been detected in all 50 US states, in
more than 7500 birds, and has promoted interspecies transmis-
sion in multiple mammalian species.7 Transmission of zoonotic dis-
eases are increased by globalization; changes in land use, such as
deforestation; and human migration, including international travel.
Fungal Diseases
Fungi are soil-dwelling pathogens and, although there are more
than 1 million recognized species of fungi, only approximately 300
infect humans. Human body temperature is one of the primary
resistance barriers to fungal pathogens, because most are unable
to grow at elevated temperatures.8 However, as these fungal
organisms develop tolerance to the warming environment, the
temperature differential between humans and the environment
narrows and the number of fungal infections, and new pathogens,
may increase. Candida auris and Sporothrix brasiliensis may be early
examples of this phenomenon. C auris was first isolated in 2009
and has emerged as a significant, and often antifungal-resistant,
global pathogen. S brasiliensis appears to have transitioned from a
ease supported by growth at higher temperature. Endemic fungi
have been located outside of their traditionally described geo-
graphic locations. Coccidioides is expanding to northern and east-
ern locations, with cases recently identified in Nebraska; Histo-
plasma has been documented in more Northern and Eastern
locations, including Alberta, Minnesota, and Wisconsin; and Blasto-
myces has moved westward, with a novel species (B helicus) now
seen in the Rocky Mountain region.9
Waterborne Diseases
Sea level rise is inevitable, directly influencing the approximately 40%
of individuals in the US who live in coastal counties. Extreme “once-
per-century” sea level events, such as storm surges and coastal flood-
ing, are anticipated to occur 20 to 30 times more frequently by 2050.1
These events, combined with warming, increase contact with coastal
pathogens (eg, Vibrio species), which can cause gastroenteritis, soft
tissue infections, and sepsis, with mortality rates of up to 50%. Within
2 weeks of Hurricane Ian making landfall in 2022 in Florida, 38 cases
of vibriosis had been diagnosed, leading to 36 hospitalizations and 11
deaths.10 While typically associated with southern coastlines, cases of
V vulnificus have increased in mid-Atlantic states in association with
rising ocean temperatures.3 Other waterborne pathogens, such as
Campylobacter, Escherichia coli, and Cryptosporidium, cause diar-
rheal disease after flooding and are worsening with extreme weather
events and warmer climates.3
Conclusions
Thoughtful preparation for current and future changes in infec-
tious disease epidemiology can help decrease the health effects of
these diseases. Medical education should train clinicians to antici-
pate these changes, and an effective surveillance infrastructure is
needed to understand, measure, and manage climate-related epi-
demiologic shifts. Clinicians also have a responsibility to advocate
for policies aimed at ending fossil fuel dependence to mitigate the
effects of climate change on human health.

ARTICLE INFORMATION
Author Affiliations: Division of Infectious Diseases,
Department of Medicine, Massachusetts General
Hospital, Boston (Phillips, LaRocque); Harvard Medical
School, Boston, Massachusetts (Phillips, LaRocque);
Division of Infectious Diseases, Department of
Medicine, University of California-Davis Medical
Center, Sacramento (Thompson); Department of
Medical Microbiology and Immunology, University
of California-Davis (Thompson).
Corresponding Author: G. R. Thompson III, MD,
Department of Medicine, Division of Infectious
Diseases/Department of Medical Microbiology and
Immunology, University of California–Davis Medical
Center, 4150 V St, PSSB Suite G500, Sacramento,
CA 95817 (grthompson@ucdavis.edu).
Published Online: March 20, 2024.
doi:10.1001/jama.2023.27724
Conflict of Interest Disclosures: Dr Phillips
reported receiving support from NIH T32
AI007061. Dr LaRocque reported being a board
member of the Greater Boston Physicians for Social
Responsibility. Dr Thomspon reported receiving
support from NIH award 5U19AI166798.
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