assessment of the current public health vulnerabilities ... · 1 brief on climate change and health...
TRANSCRIPT
*This designation is without prejudice to positions on status, and is in line with UNSCR 1244 and the ICJ Opinion on the Kosovo Declaration of Independence
Assessment of the current public health vulnerabilities due to climate change in Kosovo*
The UNDP “Support for Low Emission Development” (SLED) project, funded by Austrian Development Cooperation
11 December 2014 Michele Faberi & Qamile Ramadani
*This designation is without prejudice to positions on status, and is in line with UNSCR 1244 and the ICJ Opinion on the Kosovo Declaration of Independence
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Table of contents
1 Brief on climate change and health ............................................................................ 8
1.1 Health effects related to climatic events .................................................... 8
1.2 The vulnerability assessment process according to WHO ........................ 10
2 Environmental exposure and Climate vulnerability in Kosovo ..................................... 13
2.1 Flood......................................................................................................... 14
2.1.1 Major threats in case of heavy rain events ....................................... 15
2.1.2 Analysis of strengths......................................................................... 16
2.1.3 Analysis of weakness ........................................................................ 16
2.1.4 Forecast ............................................................................................ 16
2.2 Drought .................................................................................................... 17
2.2.1 Forecast ............................................................................................ 18
2.3 Heat waves and cold spells ....................................................................... 19
2.3.1 Heat waves ....................................................................................... 19
2.3.2 Cold .................................................................................................. 19
2.3.3 Population exposure......................................................................... 19
2.4 Air pollution.............................................................................................. 20
2.4.1 Climate change and air pollution ...................................................... 22
2.4.2 Population exposure......................................................................... 23
2.5 Fire ........................................................................................................... 25
2.5.1 Analysis of strengths......................................................................... 25
2.5.2 Analysis of weakness ........................................................................ 25
2.6 Other environmental exposures potentially related to climate change ... 25
2.7 Qualitative VIA summary .......................................................................... 26
2.8 Emergency management.......................................................................... 26
2.8.1 Meteorological service ..................................................................... 29
3 Health status and health system in Kosovo ................................................................ 30
3.1 Health data ............................................................................................... 30
3.1.1 Life expectancy ................................................................................. 30
3.1.2 Morbidity .......................................................................................... 31
3.1.3 Mortality data................................................................................... 33
3.2 Health system ........................................................................................... 36
3.2.1 Operational structure for the public health service provision .......... 37
3.2.2 Health system cost ........................................................................... 37
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3.2.3 Financial resources ........................................................................... 38
3.2.4 Human resources.............................................................................. 38
3.3 Health information system ....................................................................... 39
3.3.1 The Environmental Health Committee ............................................. 40
4 Adaptation policies and future steps .......................................................................... 41
4.1 Urban and peri-urban air pollution........................................................... 42
4.2 Water scarcity .......................................................................................... 43
4.3 Kosovo wide flood and urban flood ......................................................... 44
4.4 Other climate change exposures .............................................................. 45
4.4.1 Heat waves and cold spells ............................................................... 45
4.4.2 Parasites spread, mosquitos spread and related disease ................. 45
4.5 Summary of sectors and related actions to be considered, other than monitoring ........................................................................................ 48
4.6 Monitoring ............................................................................................... 49
4.6.1 Environmental indicators.................................................................. 49
4.6.2 Epidemiological surveillance............................................................. 49
5 Iterative process: next assessment............................................................................. 50
Tables
Tab. 1 Health risks of climate change graded with a confidence rating ........................................................................................................................ 9
Tab. 2 DEPSEEA Scheme of climate change exposure according to WHO ......................................................................................................................... 12
Tab. 3 Areas exposed to flood according to the stakeholders consultation WG 1 ..................................................................................................... 15
Tab. 4 Qualitative assessment of water supply failure during the dry season ...................................................................................................................... 18
Tab. 5 Health effects attributed to air pollution in the Kosovo .............................................. 24
Tab. 6 Qualitative summary of the climate change related events’ concern for the Kosovo.............................................................................................. 26
Tab. 7 Infant mortality rate x 1.000 – 2004/2011 .................................................................. 31
Tab. 8 The number of cases of communicable diseases in Kosovo in 2012 and 2013........................................................................................................... 32
Tab. 9 Non communicable respiratory diseases by age group 2011 ....................................... 33
Tab. 10 Cause of mortality with a code vs un-coded in Kosovo 2006 - 2011.......................................................................................................................... 34
Tab. 11 Standardized mortality (all causes) rates x 100.000 Kosovo and Italy.................................................................................................................... 35
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Tab. 12 Human resources of the health system x 1000 persons ............................................... 39
Tab. 13 Capability of the HIS to be verified / monitored during its implementation ........................................................................................................ 40
Tab. 14 Indicative costs to upgrade the water supply in Pristina ............................................. 44
Tab. 15 Causes of vulnerability to weather events from the point of view of the Health System of the Kosovo ................................................................... 50
Tab. 16 What to care to repeat the assessment ...................................................................... 51
Figures
Fig. 1 Adaptation logical iterative process ........................................................................... 11
Fig. 2 Health risks related to climate changes ...................................................................... 14
Fig. 3 Structure of the Government bodies having responsibility with emergency management, environmental protection and weather forecasts...................................................................................................... 27
Fig. 4 Structure of the EMA Emergency Management Agency of the Kosovo ...................................................................................................................... 28
Fig. 5 Life expectancy 2004-2012 in Kosovo compared with neighbouring and high-welfare countries ................................................................... 30
Fig. 6 Infant mortality (0-1 year) x 1000 – 2004/2011 in Kosovo compared with neighbouring and high-welfare countries ........................................... 31
Fig. 7 Standardized rates for all causes of death per age group male + female .................................................................................................................... 34
Fig. 8 Standardized rates for all causes of death per age group male .................................... 36
Fig. 9 Standardized rates for all causes of death per age group female ...................................................................................................................... 36
Fig. 10 Municipalities in which the Crimean–Congo Haemorrhagic Fever has been recorded and is under monitoring ...................................................... 46
Fig. 11 Municipalities in which the endemic Tularaemia fever has been recorded and is under monitoring ..................................................................... 47
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Abbreviations
CCHF Crimean–Congo Haemorrhagic Fever
CVD cardiovascular disease
DALY disability-adjusted life year
EBRD European Bank for Reconstruction and Development
EMA Emergency Management Agency
EU European Union
GDP gross domestic product
GHG greenhouse gas
GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit
HIS Health Information System
IHR International Health Regulations
IPCC Inter-governmental Panel on Climate Change
KAS Kosovo Agency of Statistics
KEPA Kosovo Environment Protection Agency
KHMI Kosovo Hydrometeorological Agency
KUCC Kosovo University Clinical Centre
MESP Ministry of Environment and Spatial Planning
NIPH National Institute of Public Health
OECD Organisation for Economic Co-operation and Development
PHC primary health care
PM particulate matter
SHC secondary health care
SLED Support for Low Emission Development project
THC tertiary health care
UN United Nations
UNDP United Nations Development Programme
UNFCCC United Nations Framework Convention on Climate Change
UV ultraviolet
VIA vulnerability, impact and adaptation assessment
VOCs volatile organic compounds
WB World Bank
WHO World Health Organization
WHO ECEH WHO European Centre for Environment and Health
WMO World Meteorological Organization
Authors
Michele Faberi, international UNDP consultant: [email protected]
Qamile Ramadani, national UNDP consultant: [email protected]
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Executive summary
The Health vulnerability assessment of climate change in Kosovo has been carried out through a consultation of key stakeholders operating in governmental structure, international organization and cooperation offices, in addition to documents, official and grey literature review. Environmental weaknesses of Kosovo are well known and described by many international cooperation offices. Climate variability and extreme weather events can enhance these environmental adverse exposures. Main concerns are urban air pollution and water scarcity. The exposure to atmospheric pollution can be worsened in presence of methane (CH4) that raises the level of ozone at ground level. Therefore, the environmental problem of the uncontrolled waste dumping and sewage ground dumping in Pristina and other large cities can play a role in the severe health
outcomes brought forward by the emission of atmospheric pollutants. Particulate
m a t t e r can peak above 130 µg/m3 monthly average in the urban monitoring station in Pristina. The monitoring of the atmospheric polluters is poor due to the lack of monitoring stations and standardized data recording protocols. Furthermore, the Health Information System is under revision and is not able to provide data needed to sufficiently compare the burden of disease with higher e c o n o m y countries. The environmental statistics and related indicators, including soil, river and ground water monitoring are to be improved so as to face and to forecast drought events and/or
upgrade the water supply network that represents the 2nd climate-related priority for the Kosovo. Food- and water-borne infectious diseases present high incidence rate and can be worsened by climate events as heat waves, floods - mainly urban - and droughts. Vector-borne diseases are less concerning and appear well monitored. The general affordability of the health system presents a key problem and can increase the vulnerability of Kosovo towards weather events and even hamper expected positive effects of environmental structural improvements.
Foreword and acknowledgment
The present report summarizes the assessment of health system vulnerability in Kosovo due to climate change. The assessment has been carried out on behalf of UNDP Kosovo under the framework of the SLED project (Support for Low Emission Development), by Mr Michele Faberi and Ms Qamile Ramadani in November 2014; it has involved a wide range of public officers, technicians and scientists from the health and environmental protection institutions and academia. A thorough documentation review has been carried out with the contribution of the UN Project’s operating managers in Kosovo. However, the two consultants have faced difficulties in retrieving original environmental and health data as well as original epidemiological studies. As a result, the assessment has analysed data collected by other international organizations and could not quantify vulnerabilities. Actions needed to increase the adaptation capabilities are described in the section 4.
The consultants would like to acknowledge the support provided by the WHO European Centre Environment and Health, in particular Dr Bettina Menne and James Creswick for the methodological inputs, documentation provided and the key participation in the stakeholders’ consultation. The UNDP staff and projects managers
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involved in related emergency and environmental assessment have constantly supported the project team by chairing meetings and providing documentation and contacts. Among others, we would like to thank Ms Lira Ramadani, intern with UNDP, who has assisted the team, organized meetings, retrieved and processed data for the environmental health assessment.
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1 Brief on climate change and health
The technical document “Strengthening Health Resilience to Climate Change”, that has been presented in the framework of the first international conference on Health and Climate Change organized by the World Health Organization (Geneva, August 2014), summarizes well 20 years of research (WHO, 2014). The authors of the document recall the body of evidence stating that the links between climate change and social and environmental determinants of human health and wellbeing is strong and that health is already affected both by climate change and that the overall impact for nearly all populations and for the world as a whole is expected to be more negative than positive. “Climate change progresses, acting as a ‘force multiplier’, exacerbating existing threats and undermining progress in development and global health” This statement summarizes the global problem that both national governments and international organizations are called to tackle. Mitigation and adaptation are the policy tools to be developed and applied at all levels of the environmental and socio- economic governance process. Both policies should however work together since if the effects of greenhouse gas emissions will increase the countries’ adaptation strategy risks to become ineffective, mainly at local level. In fact, the more climate change progresses, the larger the effects, finally resulting in a series of irreversible damages to the environmental and socio-economic determinants of health, in addition to the possible exacerbation of geo-political conflicts due to the loss of land, water, natural resources and thus the increase of displacement of population.
Of course Kosovo’s effort to mitigate its contribution to GHG emission by reducing fossil fuels can b e considered negligible with respect to the global emitters. However it should nevertheless be pursued for 2 key reasons: first, it will allow mainstreaming climate change into the development plans of Kosovo, i.e. pervading the political decision-making process amongst economic sectors including infrastructures and education. Secondly, it will facilitate Kosovo’s way towards health vulnerability reduction, since the reduction of harmful atmospheric pollutants produced by fossil fuel burning will also reduce air pollutants, if the right policies are chosen.
The necessity to mitigate and adapt to climate change has been recognized by the Parties of the UN Framework Convention on Climate Change (UNFCCC), and in the case of health adaptation, through resolutions of the World Health Assembly and WHO Regional Committees.
1.1 Health effects related to climatic events
According to Patz et al IPCC (IPCC 2002) and the framing proposed by WHO Europe, the, climate change can affect health both directly and indirectly. In addition, it can cause losses in property, resources, infrastructures, local production, service provisions in general and thus be responsible for health effects. In fact, climate change can be responsible of socio-economic severe constraint, including undernutrition, occupational stress and mental illness, also in relation to possible population displacement, conflicts rising and so forth, which are strongly affecting the health status. It is worth noticing that adaptation policies increase the resilience of population toward all events related to environmental modification and territorial stress, as natural disaster (earthquakes, volcanoes’ eruption) and wars, i.e. non-climate change related. Finally, climate change can be responsible for slowing down economic growth
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and increasing inequalities and poverty, thus halting Kosovo’s sustainable development process. The reported table below lists the health effects according to
the quoted working documents prepared for the 1st WHO Conference on Health and Climate. The working group, having prepared the technical background paper for the
above quoted conference on climate change and health1, lists only health effects for
which the IPCC 5th Assessment report WG2 (Smith 2014) estimated a “confidence grading” i.e. a qualitative assessment of the probability that the event might occur.
With regard to the adaptation policies, it is worth noticing the classification carried out by the quoted working group according the “media”, i.e. from the point of view of the receivers of the stressing event: 1) human beings, 2) natural environment, 3) human societies.
Fig. 1 Health risks of climate change graded with a confidence rating
Climatic event / exposure
Direct effects Heath risk Heath impact Conf. rating
Increased numbers of warm Excess heat-related mortality; increased Greater risk of injury, Very high days and nights; increase in incidence of heat exhaustion and disease, and death due to frequency and intensity of heat heat stroke, particularly for outdoor more intense heat waves waves; increased fire risk in low labourers, athletes, elderly; and fires rainfall conditions exacerbated circulatory, cardio-
vascular, respiratory, and kidney diseases; increased premature mortality related to ozone, and air pollution produced by fires, particularly during heat waves
Decreased numbers of cold Lower cold-related mortality, reduced Modest improvements in Low days and nights cardiovascular, and respiratory cold-related mortality and
disease, particularly for the elderly in morbidity cold and temperate climates
Climatic event / exposure
Effects mediated through natural systems Heath risk Heath impact Conf. rating
Higher temperatures and Accelerated microbial growth, survival, Increased risks of food- and Very high humidity, changing and persistence, transmission, virulence of water-borne diseases increasingly variable pathogens; shifting geographic and precipitation, higher sea seasonal distributions of e.g. cholera, surface and freshwater schistosomiasis, and harmful algal temperatures blooms; lack of water for hygiene; flood
damage to water and sanitation infrastructure, and contamination of water sources through overflow
Higher temperatures and Accelerated parasite replication and Increased risk of vector Medium humidity, changing and increased biting rates; prolonged borne diseases increasingly variable transmission seasons; re-emergence of precipitation formerly prevalent diseases; changing
distribution and abundance of disease vectors; reduced effectiveness of vector control interventions
1
Nick Watts (University College London), Diarmid Campbell-Lendrum, Marina Maiero, Lucia Fernandez Montoya and Kelly Lao (WHO-HQ).
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Climatic event / exposure
Effects heavily mediated by human systems Heath risk Heath impact Conf. rating
Higher temperatures and Lower food production in tropics; lower Increased risk of High changes in precipitation access to food due to reduced undernutrition resulting
supply and higher prices; combined from diminished food effects of undernutrition and production in poor regions infectious diseases; chronic effects of stunting and wasting in children
Higher temperatures and Outdoor and unprotected workers Consequences for health of High Humidity obliged to work in physiologically lost work capacity and
unsafe conditions, or to lose income or reduced labor productivity livelihood opportunities in vulnerable populations
Source: Protecting health from climate change: vulnerability and adaptation assessment WHO 2014
The incidence and quantification of the listed health effects depends on location and structure of the exposed human society as documented by the IPCC (Smith et al 2014).
The calculated number of DALYs2- which operationally quantifies the health outcome of any exposure – has a huge variation according to the geographic location, age group, poverty index and gender of the exposed population for comparable severity of weather events.
1.2 The vulnerability assessment process according to WHO
The scheme adopted by the WHO in order to assess VIA (vulnerability, impact and adaptation) and the way forward to enhance the adaptation of human society to climate change foresees 5 inter-related steps (WHO 2013a) and WHO ECEH support to the
Kosovo Health System vulnerability assessment. 3
Define scope of assessment • geographically, policy context, project team and stakeholders
Undertake vulnerability assessment of human health risks of current climate variability
• current exposure, observed health effects, vulnerable populations and regions
Undertake impact assessment of projected future health risks and impacts under climate change
• climate-sensitive health outcomes as well as changes to vulnerable populations and regions
Undertake adaptation assessment
• of policies and programs to address current and projected health risks
Monitoring
• Define an iterative process for monitoring and managing health risks of climate change
2 DALYs = Disability Adjusted Life Years The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.
3 James Creswick ([email protected]) Pristina 03 November 2014 presentation
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The present report aims at developing points: 2 (vulnerability), 3 (future impact), 4 (adaptation) and 5 (monitoring). This latter is however described together with the adaptation need of the health information system.
The figure below effectively represents the iterative process suggested in order to test vulnerability and strengthen Kosovo’s adaptation.
Fig. 1 Adaptation logical iterative process
Source: WHO Regional Office for Europe (2013) Protecting health from climate change. A seven-country initiative, Copenhagen (WHO 2013b)
With regard to the scheme reported in Pic. 1, it is worth noticing that the indicated iterative process, i.e. the circular hierarchy of actions, presents what should be undertaken - and often it is – for the implementation of territorial policies other than climate change adaptation as it is the case of the sustainable planning of land use and local resources management. Actually, the WHO scheme recalls the proximity and even the overlapping of adaptation policies with the sustainable development principles. However, there is the need to underline that the process requires an institutional framework allowing key partnership as for instance:
- The scientific community to work with public officers on issues such as monitoring indicators and data interpretation;
- The health sector to be part of the decision-making process;
- The local communities to be part of the policies/development strategy evaluation process;
- The private sector to be incentivized towards energy saving and greening economy;
- The public sector to facilitate and lead the implementation of policies;
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For the sake of completeness, it is worth reporting the WHO interpretation of the DPSEEA (Driving force, Pressure, State, Exposure, Effect, Actions) scheme also to better frame operational possibility.
Fig. 2 DPSEEA Scheme of climate change exposure according to WHO
Problems Actions
D
Energy, agriculture, transport policies; demographic; change; land-use change; urbanization process
International agreements (e.g., UN Conventions: UNFCCC, CBD, CCD)
P
Greenhouse gas emissions
National mitigation policies
S
Climate change
Adaptation policies and programs to manage risks
E
Extreme weather events (droughts, floods, heat waves, cold spells); ecosystem changes; water scarcity; food security; changes in vector distribution
Indicators; monitoring; surveillance systems; public health policies; environmental protection
E
Climate-sensitive diseases including cardiovascular, acute and chronic respiratory, acute diarrheal, mental, vector-borne, malnutrition; injuries
Diagnosis and treatment
Source: Protecting health from climate change: vulnerability and adaptation assessment WHO 2013
The present report aims at elaborating the last three components of the model represented by the grey-shaded area.
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2 Environmental exposure and Climate vulnerability in Kosovo
According to the comprehensive analysis carried out by the University of Gothenburg School of Business, Economics and Law for the Swedish Cooperation, Kosovo vulnerability related to climate change can be summarized in six key issues (Antonia Sanchez-Hjortberg 2008):
- Air pollution (urban air quality);
- Water scarcity,
- Water quality
- Land degradation (soil contamination due to heavy metals, soot dumping, irregular waste dumping, hazardous material and chemical dumping)
- Loss of environmental services (e.g. food quality, forests maintenance, waste management, meteorological forecasts);
- Forest depletion (irregular logging, soil erosion, landslide).
The listed issues stand per se, irrespective of climate change events; nevertheless they represent a severe threat for the economy and the health of Kosovo’s population. In fact, environmental pollution and degradation of natural resources affect livelihood opportunities and hampers poverty reduction and thus affects public health and expenditure on health care.
Moreover, it is easy to see that any natural disaster caused by climate variability, as well as any extreme weather events, are expected to severely enhance these already existing problems, thus pose new threats to Kosovo. In this regard it is worth reporting a general scheme describing how climate change is assumed to expose population and thus generate health outcomes. The scheme has been proposed by prof. Anthony
McMicael4 and further elaborated by Roberto Bertollini5 (Fig. 2).
2.1 Mention on methods
The scarcity of quantitative environmental assessments and other studies aimed at quantifying the environmental exposures in Kosovo suggested to integrate the documental survey with a stakeholder’s consultation. Such a consultation has been carried out through three steps. During a first phase main officers from Kosovo institutions, academia and agencies have been visited and interviewed also with the purpose to gather grey literature and documents produced by their institutions. Secondly, further to the results of the interview, three sets of questionnaires have been laid down according to three class of know-how:
− Emergency responses (WG1)
− Devising health impact of direct and indirect potentially generated by climate change events (WG2)
− Health Information System (WG3)
4
Anthony McMichael: MBBS, PhD Professor Emeritus of Population Health ANU (Australian National University) College of Medicine, Biology and Environment
5 Roberto Bertollini: MD MPH former director of Environment and Health WHO European Region; currently Chief Scientist and WHO Representative to the EU
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The third step has focused on convening the stakeholders in three working groups (WGx) listed above. The WG’s task was to discuss the replies individually given to the questionnaire and agree on a unique assessment. The questionnaire was individually mailed to the invited stakeholders 15 days before the convening of the workshop so as to foster the debate by comparing different assumptions individually reported as replies to the questionnaire.
The gathered information have been then both used as a track to seek further studies also to attempt validating, when possible, their assumptions and directly used to frame the environmental exposure.
Fig. 2 Health risks related to climate changes
Source: personal communication of Dr Roberto Bertollini on a Prof. Tony McMichael’s scheme
The analysis carried out by the stakeholders indirectly confirms the exposure risk sketched by Swedish Cooperation’s study quoted above. A description of the exposure assessment related to climate change, carried out by the stakeholders’ consultation and through the analysis of the retrieved documentation, is reported below.
2.2 Flood
According to interviews and documents, Kosovo floods do not represent a major cause of concern although there are areas recurrently exposed to the adverse event.
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Fig. 3 Areas exposed to flood according to the stakeholders consultation WG 16
Area subject to be flooded N. municipalities Inhabitants
Rrafshi i Kosoves
4
15 000
Drini i Bardhe (White Drini)
5
10 000
Morava e Binces
2
25 000
Total
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50 000
The stakeholders indicated that each year a flood occurs in the indicated areas and sometimes twice or even three times a year. These floods usually last from two to five days.
A more detailed table of municipalities flooded by the White Drini river with recorded damage as reported by municipalities, is described in Annex 1. The White Drini river is considered as the most dangerous (MESP 2006). Although the economic assessment of damages appears scarcely documented, they are anyway consistent as described by the annex. The scarce reporting indicates an average of more than 100 ha flooded per each flood, affecting from nine up to 230 properties flooded in six municipalities, out of ten existing along the Kosovo side of the river basin, which could result in an average of 60 houses per municipality and 3.6007 inhabitants potentially exposed.
There are few assessments for the other two river-basins reported in Tab. 3. The summary of the report from MESP “Water department”, on flooded areas and damage occurred in Kosovo, is in Annex 5.
The stakeholders’ consultation agreed upon several key issues related to flood management:
2.2.1 Major threats in case of heavy rain events
- Urban side: river overflowing the banks (highest score) and urban flood due to absence of maintenance of sewage system and drainage failure also due to waste irregularly dumped;
- Countryside: River banks not maintained, fixed.
In this latter regard, it is worth reporting the conclusion extracted from the quoted “Floods report” issued by the MESP (Department 2006)
“We believe floods in the affected municipalities are as a result of heavy rainfalls. This situation in Kosovo is repeated from year to year. No substantial damages in households but mostly in agricultural lands. Non-maintenance of riverbeds, uncontrolled exploitation of gravel from the rivers, dumping waste in the riverbed,
6 The stakeholders consultation has been organized in 3 working group. The composition of WG 1 grouped officers dealing with emergency management
7 The average of 60 houses per municipality and 6 inhabitants/house have been devised taking into account the summarized report of the Ministry of Environment for all the river basins’ floods (Department 2006)
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closing side channels of roads by illegal constructions; are factors that have contributed to flooding”
2.2.2 Analysis of strengths
- The Legislation for emergency management has been laid down and is currently operating well
- The Deutsche Gesellschaft für Internationale Zusammenarbeit (German Cooperation GIZ) is supporting the enhancement of Early Warning System in the
White Drini river basin8 (It is worth reporting to this regard that the project is expected to equip the watershed with pluviometers that can be of use also for water reserve forecast)
- The “Law on Water” is operational and delegates the responsibility of riverbeds maintenance and warning to local authorities.
- Presence of specialized professional staff at local level.
2.2.3 Analysis of weakness
- Lack of vehicles and tools
- Weak meteorological forecast
- Lack of early-warning system (i.e. modeling of river basins behavior according to rainfall measurement)
- Scarce / absent maintenance of riverbed
- Scarce / absent maintenance of sewers
- Revision and improvement of sewers
- Lack of networking with meteorological institutes and EU database, due to non- membership of Kosovo of the UN and EU, which causes difficulties to benefit and share data with other developed countries.
It is worth reporting that the consultation ranked as most important causes of population exposure in case of extreme rain, three issues:
1) The lack of an agency responsible for maintenance of riverbeds 2) The lack of a system for water treatment 3) The need to enhance the Early Warning System expressed as the need to increase
the monitoring stations and the capacity building programs of staff at the hydro meteorological services
2.2.4 Forecast
The 2nd UNFCCC National Communication of Bosnia Herzegovina draws attention to the changes in rain distribution which is the major cause of droughts and floods. The Communication reports: “An autumn season with the largest increase in precipitation, particularly in northern and central areas. Although the level of annual precipitation
8
It is worth reporting that the Early Warning System being implemented by GIZ in the White Drini watershed will serve the Albania side downstream the river where major floods can occur.
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has not significantly changed, the rainfall regime, i.e. annual distribution, has been greatly altered. The number of days with rainfall above 1 mm decreased across Kosovo while the percentage of annual precipitation due to rainfall above 95th percentile during 1961-2010 was increasing. In other words, although the level of annual precipitation has not significantly changed, a decrease in number of days with rainfall above 1.0 mm and an increase in the number of days with intense rain events have significantly distorted the rainfall regime. Pronounced variability in the annual rainfall regime and temperature increases, are key factors in the occurrence of more frequent and intense droughts in Bosnia and Herzegovina” (UNFCCC 2013)
The 1st National Communication of Montenegro to the UNFCCC does not report precipitation distribution concerns but a future reduction in both scenarios presented (2001 – 2030) of around -5% in rainfall and up to 10% in central areas (UNFCCC 2010).
2.3 Drought
Stakeholders frame drought as one of the most severe environmental threat for Kosovo. It is in particular to be noted that the absence of an organic network of rain gauges hampers the forecast of droughts based on the elaboration of the SPI index (Standardized Precipitation Index). In the report carried out for the Cabinet of the Prime Minister, attention is drawn on the absence of an organic and scientific framing of the danger of droughts in Kosovo (Faulkner 2011). This latter can be done and routinely carried out by taking into account for instance the SPI calculation (Kenneth Strzepek 2010), (Michael J. Hayes 1998). However, the hydrometric system in Kosovo does not seem able to provide reliable SPI. The scarcity of rain gauges and hydrographs has been confirmed by the director of the Hydro-meteorological Institute. The meteorological stations operating in Kosovo are reported in Annex 4 together with the monthly recording of major indicators for 2012.
The importance of the SPI and its use is well described in the guidelines edited by the GIZ office in Pristina for the Kosovo water company in order to manage the risk of drought (Faulkner 2014). The report presents in particular the case-study of the management of the Pristina’s reservoir.
With particular regard to the extreme weather event, it is worth noting that the European Commission has identified the combination of water shortages - due to uncontrolled demand - and the increasing frequency and severity of droughts - due to
climate change – as a severe water stress cause in many regions in the coming decades9. The action of mitigating drought shall therefore focus on the two aspects of water saving and water storage increasing. The first issue also deals with increasing awareness and education, as strongly stressed by the stakeholders.
The assessment of the severity of the possible climate event has been rather difficult since no statistics are available with regard to the litres/person-day reduction during shortage period. A qualitative assessment was however carried out by stakeholders. The severity of the risk run by the water company in failing to supply water in several cities has been scored from 1 to 5 (1=no risk; 5=high risk).
9 European Commission – Environment Portal – Water Scarcity Web Portal http://ec.europa.eu/environment/water/quantity/about.htm
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Fig. 4 Qualitative assessment of water supply failure during the dry season
City Risk of no water supply (1=low; 5=High) Population x 1000 (**)
Prishtina
3
200 (*)
Prizren
-
120
Peja
-
80
Gjakova
-
80
Mitrovica
-
75
Gjilan
5
68
Kamenica
5
36
Vitia
5
48
Total
134
(*) Population data in Pristina does not take into account other municipalities’ resident people living in town for working / studying needs
(**) Projection 2013
The qualitative risk of drought in Pristina is under debate since the medium level risk score 3 has been argued by the National Public Health Institute’s representative to be too weak. In fact, the Institute is receiving an increasing number of requests for authorizing households to dig their own well to pump groundwater. The number of requests appears to have been doubled in the current year i.e. 2014.
With regards to the analysis of strengths and weaknesses, the working group did not produce any operational issues and also appeared to be in contradiction as they pointed out that the possible exploitation of groundwater could be seen as a strength but also reports that its capacity assessment, identification and monitoring as the most important weakness. According to this, it can be assumed that the existing water basins can hardly meet the demand. Hence the need to start investigating the groundwater stock and investing resources for its pumping and storage. This need carries on, however, new concerns related first to the absence of urban sewage treatment - e.g. urban untreated sewage being discharged into rivers - and secondly to the high heavy metal soil contamination due to coal mining, moving, storing, burning, soot dispersion and ash dumping.
2.3.1 Forecast
Please refer to paragraph 2.1.4
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2.4 Heat waves and cold spells
There is no official communication of Kosovo to the UNFCCC that can be adopted in order to devise the possible changes in climate, but data from neighbouring countries can be analysed and adopted.
2.4.1 Heat waves
The 2nd National Communication of Bosnia-Herzegovina holds a general average increase in heat waves. The comparison of 1961–2010 vs 1981 – 2010 shows +0.4°C change in the yearly average temperature and up to 1°C in the period April–September (UNFCCC 2013).
Similar trends are reported in the 1st National Communication to UNFCCC of Montenegro that reports a yearly average temperature increase from 2% to 10% of the temperature of the period (1949 – 2005), which could be assumed as +0.3 °C up to 3°C and a forecasted scenario (2001 – 2030) of an increase of 0.4°C up to 1.3 °C (IPCC 2010).
For the Kosovo regions, a similar trend can be assumed. The exposed population can be assumed as the urban inhabitants, thus around 1 million persons.
Unfortunately there is no “heat wave” definition adopted neither by the WHO nor by WMO. In particular the latter Organization has been committed by other Agencies to elaborate a definition of heat waves, but it did not succeed so far, as well documented by the minutes of the meeting convened in Marrakech (Morocco) in February 2014 in this regard (WMO 2014). For sake of completeness, could be worth reporting the definition of provided by the EuroHEAT who defined a “heat wave” as a period when maximum apparent temperature (Tappmax) and minimum temperature (Tmin) are over the 90th percentile of the monthly distribution for at least two days.
2.4.2 Cold
No data for cold spells have been collected and no definition of a cold spell is available so far. However from the report released by the Red Cross Kosovo emerges a concerning exposure of Kosovo population to this extreme weather event. In 2012, 24 hours of strong winds followed by a heavy snowfall caused the need to rescue around 700 families (4000 persons) with food, fuel and house fixing equipment. The cold in 2012 lasted beyond February causing severe problems to nearly 3800 families (23 000 persons), mostly located in rural areas that were rescued by the Red Cross (Red Cross Kosovo 2013).
2.4.3 Population exposure
With regard to population exposure, there are no epidemiological studies carried out in Kosovo specific to heat waves and cold spells. The WHO carried out assessments in Albania and the Former Yugoslav Republic of Macedonia under the framework of the Seven-Country initiative. A quantitative assessment has been carried out in particular in Macedonia (Kendrovski 2014) and can be assumed to outline the possible exposure
20
in Kosovo since the average temperature increase of 1°C adopted for the study in Macedonia is likely to be affecting Kosovo according to the same pattern.
The study reports that: “Around 10% excess winter mortality has been observed on average during the period 1996–2000 in MKD, which has about 2 050 000 inhabitants. Mortality within the city of Skopje displayed a marked seasonality, with peaks in the winter (and) relative lowering trend in the summer.
The most remarkable anomaly was in 2007, when the government declared a nationwide heat wave emergency. During the summer of 2007, daily temperatures reached 43°C and caused more than 1000 excess deaths at national level (compared to the averages of 1994–2008). In Skopje, the capital, with around 600,000 inhabitants, the July temperatures in 2007 were 3.4°C above the monthly average and deaths were 16.5% higher than the average between 1994–2008”
In conclusion, the adoption of the study as a proxy of the possible exposure in Kosovo suggests an increase of nearly 5% of the general mortality due to continuous days with daily temperatures above 31°C in cities like Pristina. The 5% is to be considered affecting urban population, i.e. 50% of the total in Kosovo, older than 65 year, which are around 7%, i.e. 3.5% of the Kosovo population. The number of continuous days as well as the relative humidity and threshold of the night temperature (i.e. thermal gradient) are not described, either by the study, or by the literature. However, in 2007 the high average temperature in July lasted more than 20 days. As pointed out by the study in the Former Yugoslav Republic of Macedonia, the excess of death reached 16.5% (for age 65+).
With regard to the cold spells, the quoted study reports also the 10% of excess in winter mortality in four years. In this case, the exposed population is assumed to be living in rural area, also as stated by the Red Cross Kosovo report, plus disadvantaged and emarginated family living in urban area, as documented by WHO Europe with the study “Socioeconomic, demographic and ethnic inequalities in environmental risk exposure in the municipalities of Fushë Kosove/Kosovo Polje and Obiliq/Obilić” (WHO 2014) which increased the exposed population above 50%. The age group expected to be subject to the most severe health outcomes is aged 65+.
With regard to heat waves, it is worth reporting the increase of infectious food-borne diseases assessed by the quoted study. For Skopje, an increase in the weekly temperature of 1°C above the baseline of 17.9°C has been associated with a 2.8% increase in salmonellosis cases. This exposure affects mostly disadvantaged people irrespective of urban or rural location and is expected in the age group 0–1 year. Although the assessment is weighting the associated morbidity, it is actually worth reporting the mortality in Kosovo for the age group 0-1 year which is the 4.5% of the general mortality (1% in the EU28).
The food safety issue has been indicated as a high priority by the stakeholder’s consultation.
2.5 Air pollution
The quality of the air in Kosovo urban environment is the major reason of concern as raised both by the international reporting dealing with this issue and scientific
21
community in Kosovo. The principal sources of contaminants are sulphur dioxide (SO2),
nitrogen oxides NO and NOx, ozone (O3)10, carbon monoxide (CO) and dioxide (CO2), VOCs, dioxins, lead and particulate matter. The combustion of coal (lignite) and wood for power generation and heating are considered as the main sources of atmospheric pollution. In addition, road traffic is constantly increasing.
Ambient air quality is particularly bad in Pristina, the Obiliq/Obilić area, the Drenas/Glogovc area and the Mitrovice/Mitrovica area. The two coal-fired power plants Kosovo A and B can be considered the main source of PM in the Pristina region. Kosovo A power plant, that is 3 times more polluting than the more recent Kosovo B in terms of particulate maters, is however going to be dismissed.
There are few environmental measurements and relative air quality monitoring stations in the Kosovo. However data gathered in the Pristina area are of high concern.
The annual average ambient air concentrations are: PM10 = 78 μg/m3 and PM2.5 = 40
μg/m3 (annual average 2013) measured in the urban monitoring station of Rilindja
building. A very high value of sub-urban PM10 = 48 μg/m3 (annual average 2013) is
measured by (KHMI station)11. These data are considered in a report developed by WHO ECEH for a stakeholders’ consultation in 2013 (WHO 2013).
A study carried in October 2013, correlating hospital admission for respiratory diseases and PM concentration, reports for 2012 higher values than those listed above: yearly average PM10=83.1 in Rilindja and 74.3 in KHMI. These data are the double of what is recommended by the EU directive (Antigona Ukëhaxhaj 2013), far above the EU limit
of yearly average of 40 μg/m3 for PM10. The Directive 2008/50/EC Clean Air for Europe considers this limit the maximum threshold to avoid or reduce harmful effects on human health. The limits imposed by the directive are reported in Annex 3. The Directive 2008/50 has been updated in April 2014 by also setting the limit for PM2.5 = 25 μg/m3 for the yearly average, which was not indicated until that date. However, the World Health Organization revised its guidelines in 2005 to new upper limits in: annual average PM10 = 20 μg/m3 and PM2.5 = 10 μg/m3.
The KHMI does not provide hourly and daily averages of the indicated concentration, which are of most importance to report on the number of days in which the threshold
of 50 μg/m3 has been exceeded in the year. The EU directive allows a max of 35 days
exceeding the limit of 50 μg/m3 in one year. However, since the World Bank Environmental Analysis (The_World_Bank 2013) reports on an impressive PM10
concentration from 100 to 129 μg/m3 in the cold season (November to February 2011-
10 Tropospheric ozone
11 With regard to the monitoring stations, the assessment exercise carried out the World Bank in 2013 states: “Air quality monitoring, limited in Kosovo, is carried out by the Kosovo Hydro-meteorological Institute (KHMI), which manages two stations. One is in near the Rilindja building in central Pristina, close to a road heavily used by traffic, and is configured to measure only PM10 , PM2.5 , and PM1
fractions and the other is a suburban station at the premises of KHMI, equipped with automatic analyzers for sulfur dioxide, nitrogen oxides, carbon monoxide, ozone, and fine particulate matter (PM10 or PM2.5 ). Other monitoring stations have been installed by the Institute of Public Health, but
are out of order. Companies with an impact on air quality (KEK, Sharrcem, and Ferronikeli) are obliged to monitor air emissions from their operations and submit them to the Kosovo Environmental Protection Agency (KEPA), though this information is not public.”(The_World_Bank 2013)
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2012), it is worth devising a period of 120 day constantly exceeding the threshold of 50 μg/m3 in Pristina.
2.5.1 Climate change and air pollution
Climate change can enhance adverse health effects in summertime due to the increased UV radiation that facilitates the generation of the ozone in presence of high concentration of NOx and other pollutants as for instance Methane (CH4). The Nitrogen Oxides (NOx) are also responsible of the rise of the fine particulate PM2.5 due to recombination process responsible of the production of the “secondary PM”.
In this regard, i.e. the interaction of high soil temperature and UV radiation with air pollution, there is an ongoing debate in the scientific community. However, the IPCC 5th assessment Working Group 2 in the Chapter 11 reports evidence from many studies and finally draws the attention to the increase of ozone in presence of other polluters in addition to NOx, as the VOCs and methane (CH4) (Smith 2014). Although not enough environmental measurements are available, it is to be noted that this scenario probably fits with the case of the urban and sub-urban areas of the Kosovo. Irregular dumping of urban waste and anaerobic digestion of sewage, due to spontaneous wells, storage/dispersion of waste water – in addition to the diffused husbandry farms – generate methane emissions. The coal burning generates VOCs and NOx.
In particular three pieces of evidence brought forward by the WG2 Chapter 11 of the IPCC are worth reporting:
“If temperatures rise, many air pollution models project increased ozone production especially within and surrounding urban areas”. However, globally: “Enhanced temperature also accelerates destruction of ozone, and the net direct impact of climate change on ozone concentrations worldwide is thought to be a reduction”.
The environmental problem appears thus being related to presence of CH4 and, to be underlined, within the urban environment. IPCC reports:
“Even small increases in atmospheric concentrations of ground-level ozone may affect health. For instance, Bell et al. (2006) found that levels that meet the USEPA 8-hour regulation (0.08 ppm over 8 hours) were associated with increased risk of premature mortality. There is a lack of association between ozone and premature mortality only at very low concentrations (from 0 to ~10 ppb) but the association becomes positive and
approximately linear at higher concentrations12”
The association between tropospheric ozone and heat waves has been devised during the 2003 heat waves that severely touched Western Europe. The possibility that a 50% of premature deaths were related to ozone rather than to the heat itself has been
described (Dear 2005) 13. Actually, it is to be noted that further studies have decreased such a high percentage to 20% max of premature mortality, which however confirms the harmful health effect of the exposure to ozone.
12 Citations and bibliography of the reported evidences are in the IPCC WG2 Chapter 11 pp. 727-729 http://www.ipcc.ch/pdf/assessment-report/ar5/wg2/WGIIAR5-Chap11_FINAL.pdf
13 Reported in IPCC 5° WG2 (Smith 214)
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In the urban areas of Kosovo and from the point of view of the public health, in addition to any consideration related to the GHG emission, the strong mitigation of atmospheric polluters emitted as a consequence of coal and wood burning is a priority. These emissions contains VOCs (Volatile Organic Compounds) that interact with CPA “Climate Altering Pollutants” other than CO2, as the methane (CH4) and the NOx - also particularly emitted by diesel engines - that can worsen the health outcomes of the exposed population. The mitigation of the coal burning and the correct management of urban waste and sewage are thus expected to produce several co-benefits.
2.5.2 Population exposure
The Kosovo Environmental Analysis carried out by the World Bank applies the WHO exposure assessment methods to the PM10 and PM2.5 concentration averages measured by the Kosovo Hydro-meteorological Institute (KHMI) through the only two monitoring stations available. The study assumes the population in Pristina exposed to a yearly
average of 78 μg/m3 PM10 and 40 μg/m3 PM2.5. The concentration of PM2.5 has been obtained by roughly dividing the PM10 by 2 when the measured concentration of PM2.5
is not available. Such an assumption appears however to be too strong in Kosovo’s areas since the PM10 is generated mainly by chimneys soot and wood/coal domestic burning. The assumption PM2.5 = PM10/2 has been tested in European towns, for instance in Italy, in presence of PM10 generated by road vehicles mainly, whose composition is quite different and where the fine particles are mainly generated by recombination phenomena. The need to validate the assumption proposed by the World Bank in Kosovo is to be remarked for the purpose of assessing the health effects since these latter are responsible for long term effects of the polluted air exposure. The World Bank assumed all the urban population in Kosovo being exposed to level similar to those in Pristina, but divided in 2 groups “low” and “high” according to sizes of cities. The area in Obiliq/Obilić, with a population of nearly 21 600 has been assessed separately due to the presence of the coal-fired power plants and related higher pollution levels.
The study sets a baseline of PM2.5 of 7,5 μg/m3 and PM10 of 15 μg/m3 and calculates health effects above these values.
With regard to the mortality rate, the long-term exposure to PM2.5 has been taken into
account. The calculation of mortality due to long-term exposure adopts the following adjusted coefficients according to Ostro (Ostro 2004). Adjustments have been made in order to account the underreporting of the mortality rate that has been assumed being 40% in the World Bank study (mortality data 2009). To this regard, the assessment carried out by the present report with 2011 mortality data describes similar underreporting (paragraph 3.1). Adopted coefficients for the long-term exposure are below reported:
- The crude death rate is 6 per 1,000 people
- Of which cardiopulmonary mortality = 66 % of total mortality (Kosovo Agency of Statistics 2009)
- Of which lung cancer mortality = 3.7 percent of total mortality
With regard to the morbidity, the coefficients reported in the table in the Annex 2 have been adopted per 1 μg/m3 exceeding the baseline above reported.
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Fig. 5 Health effects attributed to air pollution in the Kosovo
Health effect Cases a year DALYs/10 000 Total DALYs a year cases
Cardiopulmonary mortality (PM2.5)
754–825
80 000
6034–6596
Lung cancer mortality (PM2.5)
58–63
80 000
462–501
ALRI mortality (*) (PM10)
2
340 000
57–61
Chronic bronchitis (PM10)
302–333
22 000
663–734
Hospital admissions (PM10)
590–640
160
9–10
Emergency room visits (PM10)
11 300–12.500
45
51–56
Restricted activity days (PM10) (thousands)
1993–2203
3
598–661
Lower respiratory illness in children (PM10)
23 100–25 600
65
150–166
Respiratory symptoms (PM10) (thousands)
6344–7015
0.75
476–526
Total
8500–9313
Source: World Bank Kosovo Environmental Analysis (The_World_Bank 2013) (*) Acute lower respiratory infections.
The summary of the calculated health effects related to the urban air pollution exposure is reported in Tab. 5.
A calculation of relative DALYs has been proposed as well, in order to facilitate the comparison with other countries and/or studies. The DALYs index provides an assessment of years of life lost or lived with disabilities in relation to any health outcome attributed to a given exposure.
The quoted study carried out in Pristina and coordinated by the National Institute of Public Health Kosovo correlates monthly hospital admissions averages for cardiovascular disease with the concentration of PM10 and PM2.5 and found that admissions were
highest during the cold seasons, when particulate concentration reaches very high value. However, CVD mostly depend on a cumulated long-term exposure rather than on acute. Although the described positive correlation lacks biological plausibility, it could indicate respiratory problems during the highly polluted and cold season be the outcome of a cumulated exposure to pollutants and tobacco smoke. In fact the 70% of admission pertains to age group 50+ with slight prevalence of males (Antigona Ukëhaxhaj 2013).
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2.6 Fire
A prolonged hot season, as well as a big number of continuous hot days, is expected to increase the risk of forest fires and their intensity. Climate changes are expected to increase the number of consecutive hot days and also prolong the hot season, thus the risk of forest fires constitutes an environmental potential exposure. The stakeholders’ consultation acknowledges the presence of such a risk in Kosovo and indicated a number of nearly 20 municipalities in the mountain zone and 2000 people, including non-resident population as per the tourists and seasonal visitors of the mountains area, the overall exposure. The mountainous areas of Kosovo are not usually inhabited. Only during holidays there is a higher frequency of people present there.
With regard to the emergency management, the stakeholder reported the high risk of fires in urban settlement, but this event is not related to climate change.
2.6.1 Analysis of strengths
- Each municipality has a firefighting unit, police and emergency medical services who are always the first responders;
- There is an existent cross border cooperation with the former Yugoslav Republic of Macedonia, Albania and Montenegro;
- There is a legislation harmonized with EU standards.
2.6.2 Analysis of weakness
The working group does not carry out a true analysis of weaknesses; it complained quite only the lack of resources and equipment. None of the weaknesses have been raised with regard to the institutional setting. The following three sectors have however been indicated as a priority for actions.
- Insufficient personnel, thus the need to increase number of firefighters per anti- fire unit, in accordance with EU standards: 1 firefighter / 1000 inhabitants.
- No vehicles and tools/equipment to cope with mountainous fires from air.
- Specialized trainings are to be planned for coping with mountainous fires.
2.7 Other environmental exposures potentially related to climate change
The stakeholders’ consultation and interviews carried out made references to landslides and avalanches, but no quantitative assessment of population potentially exposed is possible so far.
With regard to the food-borne diseases spread in the warm period, the food safety issues have been indicated as a high priority by the stakeholder’s consultation.
The spread out of allergens and pollens has also been considered as a potential increasing cause of additional exposure but no quantitative description is available.
The toxic algae blossom in water reservoirs has been raised as a matter of concern during the stakeholders’ consultation in correspondence of droughts and heat seasons.
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The increasing diffusion of mosquitos does not seem to represent a concerning priority amongst the interviewed persons in the Kosovo National Institute of Public Health. Few malaria cases have been reported in Kosovo, but affected persons have not been exposed in Kosovo. No chikungunya cases have been reported so far.
Other “vector-borne diseases” are described in section 4.4.2
2.8 Qualitative VIA summary
From the point of view of the exposed population, the environmental vulnerability of the Kosovo, carried out by the stakeholders’ consultation and devised from the gathered studies and assessments, can be summarized in the following qualitative table (Tab. 6). High and medium/high concerning issues belong to the area of urgent action.
Fig. 6 Qualitative summary of the climate change related events’ concern for the Kosovo
Health Environmental event related to climate change Concern/Priority
Air pollution
High
Water scarcity
High
Floods in Kosovo
Medium / Low
Urban floods
Medium / High
Heat waves
Medium
Cold spells
Not assessed
Food safety, salmonella and other food-borne
High
Parasites spread (ticks, sand-fly), vector-borne disease
Medium
Mosquito distribution and related diseases
Low
2.9 Emergency management
The emergency management in Kosovo is managed by a proper agency and can thus rely on precise institutional setting, as can be noted in the government structural chart displaying Ministries and Agencies (Pic. 2). The KEPA (Kosovo Environment Protection Agency) is under the Ministry of Environment and Spatial planning, from which also the Meteorological Institutions depends.
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Fig. 3 Structure of the Government bodies having responsibility with emergency management, environmental protection and weather forecasts
The agency EMA (Emergency Management Agency) is a department of the Ministry of Internal Affairs and is composed by four operational units (prevention, preparedness, operation and fire/rescue) as reported in the structural chart reported below (Pic. 3). The REOC 112 acts as the information system and concentrates both requests from the local level and inputs to local level.
Amongst different responsibilities undertaken by the Agency, some of them are worth noticing:
- Risk Assessment and National Response Plan’s Development;
- Full implementation of the European Standards on civil preparedness and emergency response in Kosovo;
- Advising Government and public authorities on preparedness and emergency response;
- Raising public awareness about 112 (police emergency telephone number);
- Providing for the organization and operation of the monitoring, notification and warning system;
- Organizing, equipping and training of central structures for protection;
- Monitoring and coordination of the organization of the SPRR and other emergency services;
- Creation and maintenance of national material reserves for natural and other disaster events.
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Fig. 4 Structure of the EMA Emergency Management Agency of the Kosovo
The Agency should act both as risk assessment entity – learning and monitoring entity - for Kosovo and as the emergency services provider. The contact and link with the local peripheral level is the key aspect for the functioning of the Agency, including the “Creation and Maintenance of stock for rescue operation at local level”
During the stakeholders’ consultation, the level of coordination and information with the peripheral level, i.e. the cooperation with municipalities, has raised debate. The Red Cross stakeholder noted the level of poverty and lack of resources of municipalities is an important constraint. In addition, the EMA representative raised the problem of the absence of a network of voluntary persons diffused amongst municipalities to be trained and activated in case of emergency. Moreover, as it can be seen from the description of weaknesses in copying with weather events (section 2), the general lack of vehicles and resources is brought forward.
In conclusion, the Agency created as a department of the Ministry of Internal Affairs, with enough delegation to coordinate other National services and acting as information hub of the peripheral level is well organized, recalls other European Countries Civil Defence Departments and fits the task. Three remarks are however
necessary14:
- First of all there is neither an institutional link with the health sector, nor a description of the delegation of authority in case of overlapping decisions or contradictory information on harmful environmental exposure, as water contamination, cold waves, first aid and so forth.
- Secondly, the Emergency Department should appoint a scientific committee or institution that evaluates the emergency and cooperates with EMA in order to establish the level of risk and thus take care of the correct communication of the risk. In a well running hypothetic configuration, the joint group EMA plus Scientific Committee, has the responsibility to launch the alert. The matter is rather delicate and pertinent to the vulnerability of Kosovo, since the political cooperation, health
14
The review of the strengths and weaknesses of the Emergency Agency has benefited of Ms Olimpia Imperiali’s advices (EU Commission ECHO General direction, emergency sector) as per personal courtesy.
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care and civil society involvement largely depend on a correct communication of environmental and mainly sanitary risks.
- Thirdly, the lack of resources/vehicles/tools at peripheral level could jeopardize the management of emergency. There is the need to assess the stock and fill gaps rapidly.
2.9.1 Meteorological service
The Kosovo Hydrometeorology Institute carries out the meteorological service. This institute is a part of the Kosovo Environment Protection Agency-KEPA, under the framework of Ministry of Environment and Spatial Planning-MESP. The institute does not have the delegation in terms of resources allotment. Both, equipment and personnel, are not enough to lead weather forecast, but only monitoring and data recording, even though with few monitoring stations (Annex 4). Also, the premises of the Institute appear to be neglected and not maintained. However, there is a GIZ project to install an early-warning information system on the White Drini water basin. The project is carried out with the Meteorological Institute and will provide rainfall meters and training.
In conclusion, although it can be argued that weather forecasts require a wide regional scope whose dimension greatly overcomes the Kosovo geographical size, an effective meteorological service fully equipped to monitor atmospheric events should be in the list of the priorities. Two key aspects need to be raised: first of all, the enlargement or integration of the meteorological service with the hydrological service could facilitate the sustainable exploitation of the table water, which appears to be a huge priority itself. Secondly, the weather forecast needs satellite data access, mathematical models, databases and trained staff. These structures are already available at EU as well as at single high-economy country level, thus a series of partnership and membership with the meteorological networks are mandatory. Unfortunately, as reported by the director of the Institute, the Kosovo is not a member of UN and/or EU and thus has huge difficulties in benefiting from international networking.
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3 Health status and health system in Kosovo
3.1 Health data
The document issued by the Ministry of Health on “Strategy for the Health Information System 2010–2020” reports the lack of health statistics or the episodic non-routine collection of data. Therefore international comparisons are difficult: “Common health indicators, as basic demographic indicators; lifestyle- and environment-related indicators; mortality; morbidity; disability; health care resources; utilization; and expenditure are not collected on a routine basis.” (MOH 2010)
In the same document the Ministry of Health reports the concern for the low life expectancy, indicated at “approximately 69 year, compared to 73 in Serbia, 74 in BiH, and nearly 80 in the Western Europe”.
In addition, the key indicator of infant mortality is reported understandably higher than those measured in high-economy countries. Infectious diseases, mainly food and water-borne diseases are expected to generate this burden and thus represent a breach in the resilience of the health system towards climate change. A similar conclusion can be laid down for respiratory diseases, which represent the 30% of the total morbidity burden, as reported by the Ministry of Health in the 2010 document. Causes, such as poor housing, difficult access to energy sources, air pollution and tobacco smoke are increasing their incidence of respiratory disease and breaching the resilience of the Kosovo towards weather events and natural disaster in general.
In order to better describe health status of the Kosovo population and devise the possible role of environmental health determinants, the project team has retrieved morbidity and mortality data and looked also for some comparison with other countries when possible.
3.1.1 Life expectancy
The trend of the life expectancy is visible in Pic. 4. The trend from 2004 is positive since it has passed from 68 years in 2004 to 70 in 2012. The difference with Albania 77 years (2012) and with the two high welfare countries Denmark (80 years) and Italy (83 years) is however significant.
Fig. 5 Life expectancy 2004-2012 in Kosovo compared with neighbouring and high- welfare countries
85
80
Albania 75
Denmark 70
Kosovo
65 Italy
60
2004 2005 2006 2007 2008 2009 2010 2011 2012
Source: WB; statistics internally elaborated
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Fig. 6 Infant mortality (0-1 year) x 1000 – 2004/2011 in Kosovo compared with
neighbouring and high-welfare countries
25
20
15 Albania
Denmark
10 Italy
Kosovo
5
0
2004 2005 2006 2007 2008 2009 2010 2011
Source: WB; statistics internally elaborated
As plotted in Fig. 5, Kosovo has a lower rate of infant mortality than Albania (9.8 vs 14.2 in 2011) that is documenting the good level of assistance of the health system and also good education level of the Kosovo population. Such a rate (i.e. 10 x 1000) is far from those measured in countries with developed public health services such as maternal care and higher wealth status, which are at 3.1 (Denmark) and 3.3 (Italy).
The irregular trend of such an important health indicator for Kosovo can depend from more causes, including the under-reporting of data. It is however useful to report the table with the figures for further investigation.
Fig. 7 Infant mortality rate x 1000 – 2004/2011
2004 2005 2006 2007 2008 2009 2010 2011
Albania 19.1 18.2 17.4 16.7 16 15.4 14.8 14.2 Denmark 4.2 4 3.9 3.7 3.5 3.5 3.3 3.1
Italy 3.8 3.7 3.7 3.6 3.5 3.5 3.4 3.3
Kosovo 11.8 9.6 12.0 11.1 9.7 8.4 8.1 9.8
3.1.2 Morbidity
The table below describes some infectious disease recorded by the NIPH15(NIPH 2014).
15
NIPH, National Institute of Public Health. Internal bulletin released as of courtesy to UNDP consultants
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Fig. 8 The number of cases of communicable diseases in Kosovo in 2012 and 2013
Disease 2012 2013 Possible Climate Change link
LRTI - Pneumonia 14.022 11.087
Cold / poor housing / scarce access to energy sources and health services TBC 968 922
Alimentary Intoxication 899 1020
Food and water-borne diseases, heat waves, water scarcity (drought), urban and rural
flood
Acute Diarrhea 67.548 44.170
Syndrome of diarrhea with blood
64 49
Abdominal Typhus 12 12
Syndrome of haemorrhagic fever
13 26 Vector-borne disease, ticks, “tiger mosquitos” (Aedes albopictus)
West Nile virus 7 2
Tularemia 12 22
Acute Hepatitis A 238 143
Hepatitis B,C 16 80
Chicken Pox 16.807 5.177
Meningitis Syndrome 189 173
Syndrome of eczantematic fever
29 18
Epidemic Mumps 54 13
Pertussis 53 24
Brucellosis 49 63
Herpes Zoster 1 103
Suspected cases of Influence
19.284 35.772
Other Infectious diseases 2.865 1.067
Total 123.130 100.068
Source: NIPH (NIPH 2014)
From the Tab. 8 it is possible to note that the acute diarrhea and alimentary intoxications represent nearly the 51% of the total burden of infectious disease. The reported cluster of diseases is quite large since it should include practically all water and food borne diseases. The respiratory diseases (lower tract) are reported together with pneumonia that does not allow any consideration. However, looking at the “Morbidity analysis of Kosovo 2011” published in 2012 by the NIPH (NIPH 2012), it is
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possible to account a huge burden to respiratory diseases: 22.9% of the total case of identified diseases in 2011. The entire table framing the morbidity is in Annex 6
Fig. 9 Non communicable respiratory diseases by age group 2011
<1
1-5
6-14
15-49
50-64
65+
Total
Num. % Num. % Num. % Num. % Num. % Num. % Num. %
10.572 37.0 40.401 53.2 34.506 35.5 38.320 14.9 11.737 12.1 14.479 14.8 150.015 22.9
Source: NIPH - Morbidity Analysis of Kosovo Population 2011
It is to be noted that the age group 1–5 carries the half of the respiratory disease burden. This burden affects mainly disadvantaged people due to poor housing and scarce access to energy sources (WHO 2014). In addition to this, the survey carried out by the World Bank (Paragraph 3.2.2) reports that the “out of pocket” cost of health services and drugs have contributed to the 7% increase in the number of people living below the poverty threshold. Consequently, marginalized young generations risk not to be cured, cumulate exposures, be unable to access to the labour market when adults and increase thus the poverty; increasing finally the vicious circle: poverty leading to illness leading to poverty. The mechanism is well known, but in Kosovo one of the causes could be related to atmospheric pollution, thus an environmental exposure that can be mitigated. The co-benefits of such an action are evident and distributed over more layers.
3.1.3 Mortality data
The mortality data, including historical series, are not really available for Kosovo. Many archives have disappeared or were destroyed during time of conflicts with Serbia. Further on, the organization of the new State, the Kosovo Agency of Statistics (KAS 2012) started collecting and publishing mortality data. However, only the mortality figure for all causes can be assumed for comparison with other countries since mortality by cause is under-reported or contains ambiguous cause reporting. As of result, the data series appear unreliable and not worth processing for comparisons with other countries. For instance for all cancers mortality, 546 cases are reported for 2006 and 827 in 2011. An increasing trend of tumours of 34% in 5 years is not justifiable.
In this regard, it is worth reporting the number of codified deaths compared to those un-codified from 2006 to 2011. As can be noted, the mortality data recorded without a cause range from nearly half of all deaths to one third (Tab. 10).
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Fig. 10 Cause of mortality with a code compared to un-coded in Kosovo 2006–2011
2006 2007 2008 2009 2010 1011
Deaths % Deaths % Deaths % Deaths % Deaths % Deaths %
Coded
4328
57.84
4094
61.28
5653
82.50
5670
80.65
5522
76.30
5500
72.80
Un-coded 3151 42.16 2587 38.72 1199 17.50 1360 19.35 1712 23.70 2055 27.20
Total deaths 7479 100 6681 100 6852 100 7030 100 7234 100 7555 100
Source: KAS Kosovo Agency of Statistics
With regard to the general mortality, rates x 100 000 per specific age group have been standardized with the European population (EU28) and compared with Italy (male and female) and Albania (males + female). Retrieved specific mortality rates by gender for the Albania appeared not to be reliable.
Comparisons of the general mortality show greater rates of Kosovo and Albania compared to Italy at any age group. However, substantial differences in death rates between Italy and Kosovo and Albania start at the age of 50 (Fig. 6).
Fig. 7 Standardized rates for all causes of death per age group male + female
480
440
400
360
320
280
240
200
160
120
80
40
0
0-1 y 1-9 y 10-19 y 20-29 y 30 - 39 y 40 - 49 y 50-59 y 60 -69 y 70-79 y 80+
Kosovo Albania Italy
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At the age of 60 the difference is almost the double. Difference between Albania and Kosovo are however remarkable in favour of Kosovo for the young and adult groups, aged 1–40 years.
Comparing with Italy and in both genders, it is noticeable the age of 50 as the starting point of greater vulnerability (Pic. 7 and Pic. 8). In the female group, the difference in mortality is less visible than in the male. Rates’ differences rapidly reach values around 40% between the 2 countries. From 20 to 40 years there are no particular differences in rates, mainly in the female group that keeps a smooth difference up to 59 years.
Fig. 11 Standardized mortality (all causes) rates x 100 000 Kosovo and Italy
K - male I - male K - female I female
0-1 y 11,9 3,5 10,7 3,0
1-9 y 3,0 1,0 3,5 0,9
10-19 y 3,4 2,5 2,0 1,1
20-29 y 7,1 6,8 3,1 2,4
30 - 39 y 14,0 9,6 8,7 5,0
40 - 49 y 38,1 24,1 22,7 14,6
50-59 y 111,6 58,8 56,8 33,8
60 -69 y 220,3 124,2 121,3 64,0
70-79 y 409,3 249,8 254,7 139,8
80-84y 258.9 168.9 198,0 123,0
85+ 334.2 245.4 360,0 288,9
The younger generations have, on the contrary, marked differences in rate until the age of 10. In particular the ratio between the 2 rates is greater in the 0-10 years than in the other age groups. This description confirms problems in the infant age and perhaps can support the existence of an environmental exposure to which this age group has a greater vulnerability. The environmental exposure could have less health outcomes in the youth group, but also be responsible of cumulative long-term effects in the adult age. Tables with figures for male and female are respectively reported in Tab. 11
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Fig. 8 Standardized rates for all causes of death per age group male
440,0
400,0
360,0
320,0
280,0
240,0
200,0
160,0
120,0
80,0
40,0
0,0
Kosovo Italy
0-1 y 1-9 y 10-19 y 20-29 y 30 - 39 y 40 - 49 y 50-59 y 60 -69 y 70-79 y 80-84y 85+
Fig. 9 Standardized rates for all causes of death per age group female
400,0
360,0
320,0
280,0
240,0
200,0
160,0
120,0
80,0
40,0
0,0
Kosovo Italy
0-1 y 1-9 y 10-19 y 20-29 y 30 - 39 y 40 - 49 y 50-59 y 60 -69 y 70-79 y 80-84y 85+
3.2 Health system
The Public Health System in Kosovo is organized into three levels: primary health care (PHC), secondary health care (SHC) and tertiary health care (THC). Health care services are organized and provided by hospital, out-of-hospital, household, and emergency services.
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3.2.1 Operational structure for the public health service provision
Primary health care (PHC) includes health promotion, prevention, early detection, diagnosis, treatment and rehabilitation of diseases, disorders and injuries, including dental care and minor surgeries based on the concept of family medicine. PHC public network in Kosovo consists of a total of 429 institutions, of which 29 are Main Family Medical Centres (MFMC), 166 are Family Medicine Centres (FMC) and 234 are Family Medicine ‘Ambulatory’- small clinics. MoH is responsible for the design and monitoring of the service. The “strategy document” laid down by the Ministry of Health notes, in this respect, that there are achievements in terms of developing the necessary professional human resources, but complain about a lack of records for family members for each family physician, which represent an important weakness.
Secondary health care (SHC) includes hospital, out-of-hospital, diagnostic, therapeutic, rehabilitative services, as well as; emergency transportation, dental care, and regionalized services of public health. The network of public hospitals is composed of five general hospitals in the regions (RH-Regional Hospitals), five general hospitals in cities (CH-City Hospitals) including three hospitals in municipalities with Serbian majority (Gracanica, Mitrovica North and Sterpce). SHC level also provides professional mental health services through the institutions of Mental Health Centres, Integrated Community Houses, and the Center for Integration and Rehabilitation of chronic psychiatric patients in Shtime. SHC provides also sports medical support, professional services and provides blood transfusion services.
Tertiary health care (THC) includes advanced hospital, out-patient, public health care, as well as services to tertiary health care level. For Pristina region, tertiary health institutions also function as secondary level health institutions. Consequently, THC is provided by the Kosovo University Clinical Centre (KUCC) under the frameworks of which operate 31 Clinics and Institutes, as well as the University Dental Clinical Centre of Kosovo. Within this level some other important national institutions also operate, such as: the National Centre for Blood Transfusion, National Institute of Labour Medicine; and National Institute of Public Health (NIPH).
3.2.2 Health system cost
Mainly income taxes, taxes, and co-payments finance the health sector in Kosovo; while private payments from the patients are very high and include about 40% of the medical expenses.
The budget allocated by the government for health for 2013 was €152 million or 2.8% of GDP, which results in €86 per person/year 2013. The average of the European Union is the 5% of the GDP for the public health expenditure.
The total expenditure for health in 2013 was €135 per person/year 2013 equal to the 4,5% of the GDP. The difference, (€135 – 86) €49 (36%), represent the health expenditure devoted to the private health sector plus the small fraction for the co- payments of health services provided by the public health system. Out of this crude rate per person expenditure, the uneven affordability of the health costs, must be noted. Indeed, a survey carried out by the Ministry of Finance reports that 88% of patients seeking care in health institutions have paid for drugs, medical material, consultation – including private sector – and food. This means that deprived and poor
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citizens have rare access to health care. The exposed population is quite high since the Ministry of Finance (2013) accounts that 29.7% of the population lives under the poverty threshold (MOH 2014).
The World Bank, in this regard quotes “household out-of-pocket” spending on health in Kosovo at the 40% of the total spending, which is close to the 36% calculated by the Ministry of Health (World Bank 2014). The same WB assessment calculates that 40% of health expenditures have contributed to 7% increase in the number of people living below the poverty threshold. The WB notes that the poor have “self-rationed” care due to the high costs. According to WB, drugs comprise approximately 85% of household private health spending, whereas the survey the Ministry of Finance indicates that they account for 59.5%.
3.2.3 Financial resources
The 2.8% of the GDP allotted for the public health expenditure is to be considered very low, mainly if compared to the 5% allotted by European Union and South Western European Country (World Bank 2014). Moreover, an assessment carried out by the OECD notes that: “The problem of insufficient financial resources for health in Kosovo, is not only as a result of the fact that the government allocates less money for citizens, but that the relative part of these funds is used to pay fixed costs (buildings, energy, and maintenance staff) leaving a small amount of money for direct costs associated with patient diagnosis, treatment, prevention and promotion. Functional distribution of the budget shows that only 32% of the budget allocated for goods and services can be spent directly on patients (Roentgen, RM, CT, lab tests, medications). The rest of the budget, 68%, represents fixed costs that remain the same regardless of the number of patients treated. This means that from the overall public budget, only 28% of the budget can be directly connected to the patients, with only €23 a year, which is available for diagnosis and treatment per capita”
The recent approved “Law on Health Insurance” by the Kosovo Parliament in April 2014, establishes a public insurance fund that is expected to raise the resources available for the health expenditure up to the 5% of the GDP. It is based on a mixture of mandatory health insurance – actually a purpose-tax – and voluntary health insurance. According to the World Bank, this latter will also have the purpose of supporting the
health system in general thus provide resources for taking care of deprived persons16.
3.2.4 Human resources
The total number of staff in the PHC working in the public health sector is 5453 of which 4579 are medical staff while 842 employees are non-medical staff. Out of a total of 4579 medical staff, 850 are hospital doctors, 476 are family physicians, 3050 are nurses, of which 2118 are trained family nurses. In addition to this, in 2013 the number
16 The WB “Kosovo Health Project”, a six-year project in collaboration with the Swiss Agency for Development and Cooperation (SDC) and Luxemburg Development Cooperation.
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of doctors in SHC and THC (health institutions in secondary and tertiary level) was 1441, while the number of nurses 3966.
In total, the Kosovo public health sector in 2013 accounted 2767 doctors and 7016 nurses. In private health institutions a total of 3472 employees are accounted, of whom 1806 are doctors and 1666 nurses.
Fig. 12 Human resources of the health system x 1000 persons
Kosovo Italy OECD
Doctors x 1000 pp
2.5
4.1
3.1
Nurses x 1000 pp
4.8
6.3
8.7
Source: MOH Kosovo and OECD statistics
3.3 Health information system
The “strategy” document released by the MOH in order to plan the implementation of an operation Health Information System (HIS) is dated 2010 and is quite old in the fast changing environment that operates in Kosovo. The documents indicate 2014 as the implementing year, i.e. the year in which both registration and recording systems would be implemented. The major support to implementation comes from EU Cooperation with the support of WHO. It is therefore probable that the recording will follow up the IHR protocol; however this information is not confirmed. Currently the information system is managed by the NIPH (National Institute of Public Health) through the Health Statistics System. The strategy document foresees to structure the existing “master database” operating at the NIPH and also merge into this file data coming from other sources as family doctors, drugs delivering and so forth. The interviews carried out at the NIPH have however raised more concerns on this matter. It is not very clear so far, who is responsible for the process between MOH and NIPH. Actually, the strategy document also indicates that NIPH is responsible for reporting and issuing statistics. However, in the strategy document there is no indication of data access procedures.
No indication as well is available with regard to indicators in use and basic recording information. Aspects as the epidemiological surveillance are not explicated. The NIPH is routinely recording into its master database infectious diseases, but have recently started to record CVD, neoplasms and other non-communicable diseases. These latter data, together with mortality by cause’s data, are however collected by hospitals and other health services, apparently by using both paper and Excel sheet recording system and are stored in the Kosovo Agency of Statistics and / or at the Ministry of Health. The few data of mortality by causes described in this report come from the Kosovo Agency of Statistics and Ministry of Health.
Finally the below reported list of questions (Tab. 13) extracted from the questionnaire of the WHO Regional Office for Europe to assess vulnerability to climate change (WHO 2012), remains without answer. Due to the key importance of the HIS to increase the
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resilience of the Kosovo against extreme weather events, the list in the table must be object of future monitoring of HIS implementation.
Fig. 13 Capability of the HIS to be verified / monitored during its implementation
Summary of main Question / Issues
1
Health information system to be set according to International Health regulation (IHR)
2
Do mechanisms exist for carrying out rapid health-needs assessments?
3
Does the national health information system provide disaggregated data for health related emergency management at the national and subnational levels?
4
Does the information-management system facilitate reporting according to IHR and other mandatory reporting requirements?
5
Do emergency managers have access to relevant data (including data on trauma and injuries, communicable diseases, vector-borne diseases, water quality, nutrition, non - communicable diseases and food safety)?
6
Does the surveillance system have standardized protocols defining roles, responsibilities and procedures related to the standardization, collection, management, analysis and dissemination of data?
7
Is the surveillance system able to provide sufficiently trained staff?
8
Does the surveillance system provide for data-sharing with agricultural, veterinary and environmental disease surveillance systems?
Sources (WHO 2012)
With regard to the particular question n.5, it is to be noted that the EMA (Emergency Management Agency) has no explicit link and/or connection with the Health System and / or no clarification with regard to the delegation of coordinating authority.
3.3.1 The Environmental Health Committee
With regard to climate change related exposures, it is to be reported the recently appointment of the “Environmental Health Committee” that can be part of the data processing for the environmental health and thus also act as revisers of the environmental data and advisers in the decision making process, resources allotment and so forth.
Actually the terms of reference of this Committee are quite large and well-designed since they include also the mandate to review legislative aspects pertaining to the environmental health. The Committee’s Terms of Reference are in the Annex 7.
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4 Adaptation policies and future steps
The vulnerability assessment has brought forward three environmental exposures of high concern and one medium-high risk exposure. The exposures of high concern are:
- Urban air pollution;
- Water scarcity;
- Food safety.
An additional fourth brought forward is the urban floods risk.
Thus, four environmental health-related exposures, which are subject to be exacerbated by extreme weather need fast policy planning. Respiratory and infectious diseases altogether represent more than 70% of the morbidity and could be partially responsible for the high infant mortality rate (9.8 x 1000 - 0-1Y) reported by the National Institute of Public Health, in addition to poverty and health system affordability.
Amongst causes generating the environmental impact, the lignite-fired power plants, domestic lignite and wood burning, solid waste disposal, coal ashes disposal and sewage discharge or dumping without control appear to be the most concerning. There are no sufficient environmental statistics available to attempt devising the attributable quota of road traffic in the overall urban air pollution. In order to devise the fraction of the atmospheric pollution caused by the engine vehicles, indicators as CO and SO2
hourly average concentration plus other polluters’ concentration, as the PM in specific calendar day, would have been necessary. In this regard the environmental monitoring needs are to be empowered and properly designed.
With regard to climate change, the rise of temperature and prolonged days of UV radiation can play a role in increasing the harmful exposure to the daily current urban air pollution. The generation of ozone and, in particular condition, of more fine particulate matter PM2.5, due to the NOx recombination, could be the cause of the over exposure. Water scarcity and prolonged warm days can generate and spread the exposure to infectious diseases (food and water-borne diseases). Cold spells, although only generically reported, are expected to worsen the adverse exposure at out-door air pollution and increase the incidence of respiratory diseases.
The information health system is under construction and thus its effectiveness in providing data for decision-making is not assessable. The strategic document released by the MOH does not provide the description of indicators expected to be gathered and other key feature of the system as the accessibility (paragraph 3.3). The environmental and hydro-meteorological information systems need to be designed according to both the climate change adaptation challenges and population health care (paragraph 4.6).
From the point of view of the sustainable development, it appears evident that any policy undertaken in order to reduce the vulnerability to climate changes, will imply several co-benefits and would participate to the fair developmental framework of the Kosovo. On the other way round, any policy undertaken to smooth the environmental impact works also to increase the resilience of Kosovo to extreme weather events. For instance, the construction of a proper sewage treatment plant is expected to reduce
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the BOD (Biochemical Oxygen Demand)17 in table water and rivers and reduce the
emission of Methane (CH4) in the atmosphere18 with evident environmental gains. However, it implies potential important co-benefits:
- Make available, in the needed time-period (years), the table water to supply the public network, i.e. would support the water scarcity exposure;
- Make available huge quantity of water for agriculture;
- Produce organic fertilizer that can also increase the carbon sequestration capacity of soils, thus mitigate the GHG emission stock of the agriculture;
- Make available biogas for thermal energy use;
- Restore the habitat and the biodiversity of rivers
4.1 Urban and peri-urban air pollution
International donors and development banks as the EBRD and WB are supporting the electric power generation in Kosovo, which currently is considered the major source of atmospheric and soil pollution since is based on lignite-burning to generate steam. Kosovo also has a deficit in kW generation and relies on the abundance of coal in the northern part of the Kosovo. Amongst the technical solutions being adopted to reduce the releases of polluters, the dismissing of the old plant Kosovo A appears to be planned along with the implementation of a district-heating system by transporting and selling the steam condensation recovered heat. The huge infrastructure will provide thermal energy to heat houses. This policy is meant to reduce the intake of electricity and lignite-wood burning for domestic heating and thus effectively mitigate the GHG and other polluters’ emissions.
In addition to this, a pre-treatment of the coal to produce coke would be worth exploring. Although, no advantages exist in terms of CO2 equivalent emission
reduction, coke as a domestic fuel could be adopted for heating houses, by banning the free combustion of lignite for civil uses. The policy would reduce the locally dispersed emission of SO2 and VOCs - whose exposure is related to severe respiratory diseases and anticipated mortality - and control the soot/tar production by concentrating them in one factory, i.e. one place, for treatment. The purpose is to facilitate the treatment of smokes, the collection of tar and dangerous ashes. In this regard and in attrition to the above, municipalities should plan a mandatory ashes- collection system in order to hamper the free dumping of them.
Concerning the health care, an accurate air quality monitoring is needed. The collaboration between the main health institutions, such as NIPH with MESP (Ministry of Environment and Spatial Planning) and KEPA (Environmental Protection Agency) should be formalized and institutionally regulated. In this regard, the recently appointed Environmental Health Committee (paragraph 3.3.1 ) could be in charge of
17 The BOD and the free oxygen (O2) concentration in water basins are powerful indicators of the organic pollution
18 It is worth noticing that the CH4 in the atmosphere has a global warming power 70 times greater than that of the CO2. In the calculation of the “equivalent” CO2 emissions, one ton of CH4 accounts per 70 tons of CO2
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information provision and environmental health assessment, including the costs of the exposure.
Concerning the health system, the stakeholders, consultation brought the attention to the below reported issues to be implemented:
- Support interdisciplinary curricula of Environmental Health sciences for higher education;
- Support scientific research;
- General awareness raising at all levels, including academia, with regard to air monitoring and air quality, environmental exposure, energy, energy and health;
- Vulnerability assessment of population with special focus on disadvantaged people and young generations, mainly in non-affluent families;
- Strengthening inter-sectorial links, i.e. define the role of commissions as a legacy of this exercise to support climate adaptation for health in Kosovo.
4.2 Water scarcity
GIZ in its “Technical Guidance” for the preparation of the “Water Company Drought Risk Management Plans 2014” (Faulkner 2014) describes technical and administrative measures to be taken to face emergency. Regarding the adaptation policies, two aspects emerge and are in relation to climate change. The need to increase the drought forecast capability by adopting index as the SPI (Standard Precipitation Index, paragraph 2.2.1), which imply the empowerment of the Hydrographic Meteorological Institute (paragraph 2.8.1). Secondly, the report recommends the revision of the network, mainly for the point of view of leakages, but also from that of fares, counters and plugging. The report correctly draws the attention to the increasing supply policy that also implies that leakages will increase. The maintenance of the network should thus come prior of the supply increase.
Measures are listed according four scenarios of increasing gravity. In summary the study describes the need for an assessment of the baseline real input of water, split needs from supply concepts, review/increase fares, pipes and meters review, involve citizens in a saving plan and ask for their collaboration. Section 4 of the GIZ’s report also provides formula to calculate need and supply. The communication measures are of course part of the emergency management.
With regard to the health system, adaptation policies focus on the monitoring of shortages and the progressive supply of the whole population to the public network, which covers currently more than 60% of the population. The monitoring of toxic algae blossom in the existing lakes during summer is the third issue pertaining probably to the NIPH. Human resources and equipment need are to be assessed to this regard.
The increasing demand in Pristina, forces and urges the construction of new reservoirs and/or start exploiting the groundwater to feed the network. This latter policy implies a comprehensive urban waste treatment revision, which cannot be postponed any longer. Sewage, solid urban and industrial waste, ashes and so forth collection and treatment need legislative setting and resources investments for plants, equipment and human resources.
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The stakeholders’ consultation draws the attention on a similar set of policies to be undertaken:
- Public awareness increasing for the proper use of water, i.e. awareness and educational campaign;
- Maintenance of pipes of the network, repair and widening the network;
- Research of new/alternative water sources, also aiming at underground water exploitation;
- Monitoring and rationally using water resources (i.e. split the concepts of demand and need).
The stakeholders’ consultation indicated the costs reported below in order to secure the Pristina population from the water scarcity:
Fig. 14 Indicative costs to upgrade the water supply in Pristina
Action Euro Million
Feasibility analysis for underground water
1
Rehabilitation of the water network
30
Source: EMA
4.3 Kosovo-wide flood and urban flood
High concerns have been raised by the stakeholders with the risk of urban flood, mainly due to drainage failure, irregular dumping of urban waste and lack of maintenance.
Although less concerning, due to the minor number of potentially exposed families, the risk of Kosovo wide flood has been related to lack of maintenance of riverbanks, illegal dumping and excessive gravel and sand extraction from the riverbeds.
For both the risks of floods, the main and recurrent issue raised up has been the need to install early-warning systems, requiring a policy aimed at implementing a fully operational hydro-meteorological system. In this case, we recall the need of a SPI indexing system for the forecast of water scarcity risk (paragraph 4.2).
The summary of the recommended actions by the stakeholders, in order to reduce the risk of urban and Kosovo flood, is reported below.
- Undertake urgent measures for regulation (legislative ban of irregular dumping / use) of riverbeds. Among others, it is the urgent need to stop uncontrolled extraction of inert materials from riverbeds in Kosovo;
- Maintenance and cleaning of riverbeds;
- Undertake measures for the maintenance of urban drainage system
- Increase the level of cooperation with the municipalities level on prevention, protection and preparedness for the floods.
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In addition to this, two policies aiming at involving the civil society have been indicated:
- Increase the public awareness for maintaining the riverbeds (e.g. not dumping garbage) and consider them a key public goods;
- Launch an educational project on the co-existence with risks: living and coping with floods.
From the point of view of the health system, both the functioning of the EWS (Early Warning System) and EMA (Emergency Management System) represent key issues. EWS does not exist so far. Weaknesses and strengths of EMA are described in the paragraph 2.8.
4.4 Other climate change exposures
4.4.1 Heat waves and cold spells
The food contamination represents the major concern for the health system in relation to the prolonged hot days, mainly for disadvantaged families.
Respiratory diseases in the cold season, poor housing and scarce affordability of energy sources represent the main concern for the health system in relation to cold spells.
Both issues are related to the sick people and families’ affordability of the health service, in addition to the epidemiological surveillance. Thus, the vulnerability of the health system is quite clear, but its progress toward the capability to provide care is linked to the ongoing reform of the public health insurance (paragraph 3.2.3)
4.4.2 Parasites spread, mosquitos spread and related disease
A document issued by the Ministry of Internal Affairs in 2009 reports on outbreaks that occurred in Kosovo since 1950, including some vector-borne disease. The extracted part internally translated in English is in the Annex 8. Among those described, the Crimean Congo Haemorrhagic Fever and Tularaemia can be spread by climate change since they can be transmitted by ticks whose diffusion depends on temperature increase.
The Crimean–Congo Haemorrhagic Fever (CCHF) is reported as a concerning communicable disease. The report states: “From 1989 to 2008 nationwide, have been recorded 403 confirmed cases of CCHF with 46 dead. Only after the war (ended in 1999) 105 cases were reported with 8 deaths disease. It is a disease that occurs every year in our country”
The endemic zones are reported in the map reported in Pic. 9. The concern of health authorities is described in this report extract summary: “There is no dilemma that Crimea Congo is a major Kosovo health problem, especially for Kosovo public health. From 1989 this fatal disease was recorded sporadically in parts of Central Kosovo and South-West Kosovo. This disease is registered now in 55% of Kosovo's territory, which makes it an even more alarming situation”
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Fig. 10 Municipalities in which the Crimean–Congo Haemorrhagic Fever has been recorded and is under monitoring
The report concludes: “In general we can conclude that there are 82 hyper endemic zones with permanent outbreak risk or vulnerable settlements in Kosovo to Crimean– Congo Haemorrhagic Fever thus these settlements are research priorities”
The monitoring of the diseases in the recent period has been published in a informal report edited by the author (Fajs, 2014). The reports states the diagnosis of 228 cases in 27 years and describes changes in the viral population, hinting such a change being in relation to changes in temperature and climate. An extract is below reported:
“Based on the records from the Kosovo Institute of public health, from 1995 to August 2013, 228 cases of CCHF have been reported in Kosovo, with the mortality rate of 25%.
We show that ecological factors such as temperature could play a role in the composition of the viral population.
With regard to the temporal changes in virus population we observed changing dynamics of viral variant abundances from 2011 to 2013. From 2001 to 2011 we steadily detected both major phylogenetic groups (A1 and A2) regardless of the number of cases in each year. However in 2011 we detected only the A1groups (out of the two major groups) and in 2012 we detected only the A2 group. Such a rapid change in relative abundances is somewhat surprising. We could not determine any link with the geographic distribution of the cases nor to any demographic changes in this period. These observations lead us to believe that the underlying cause for the shifts probably lie in the ecology of the disease. There is limited ecological data for Kosovo available, so we could not perform an in-depth analysis. What we have found is that average yearly temperatures in 2010 and 2011 were below average and that average minimum temperatures in 2012 were below average. Data suggest that weather conditions in 2010-2013 changed in relation to previous years. Since climate greatly influences both the vector and the reservoir of the disease, the changing climate patterns could explain the changes in the viral populations. Our results suggest that relative abundances of viral variants are dynamic and are prone to great variations and that ecological factors can play a role in shaping these populations.
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Our results also suggest that the population of viral variants is prone to significant changes in different endemic years. Further studies are however needed to determine the factors responsible for these changes”
With regard to the Tularaemia, the reports states: “The first cases of the disease in Kosovo were registered in Gjakova region, village Brovina in 2000. While disease had spread in Dukagjini area first, in subsequent years cases were registered in other Kosovo areas. Today Tularemia is spread in whole territory of Kosovo. So far in Kosovo were registered two waves of the epidemic, 1999-2000 with 245 cases and in 2000- 2001 with 338 cases. In subsequent years there were sporadic cases of the disease, but is considered high the number of 784 cases with average of morbidity rate of 6.7 sick persons per 100 000 inhabitants”. The endemic areas are reported in Pic. 10
Fig. 11 Municipalities in which the endemic Tularaemia fever has been recorded and is under monitoring
The health system in Kosovo is monitoring the incidence of the above reported diseases and has specific offices and dedicated human resources at the NIPH (National Institute of Public Health). No specific action is needed.
With regard to Leishmaniasis, no epidemiological studies have been retrieved for the Kosovo. The Leishmaniasis Emergence in Europe’s report indicates the SE Balkan region as an area in which the presence of the parasite has been detected (Ready 2010). The NIPH to this regard has only provided a list of municipalities with presence of the associated vector, the Phlebotomus, which is a small sand-fly that can transmit the parasite:
Areas with presence of Phlebotomus:
- Llovcë, Pogragjë, Zhegër (Gjilan municipality)
- Pozharan, Sllatinë and Kllokot (Viti municipality)
- Frashër (Mitrovica municipality),
- Isniq, Turjake and Junik (Deçan and Peja municipalities)
- Kaçanik i Vjeter, Begracë and Tankosiq ( Ferizaj region)
- Zhur, Vermicë and Hoçë ( Prizren municipality)
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- In Vushtrri (municipality) periferics
Other vector-borne diseases transmitted by mosquitos as malaria and Chikungunya do not represent a matter of concern for the Health authorities. Cases of malaria have been recorded but have been classified as imported cases. No cases of Chikungunya have been recorded. Any increasing spread of mosquitos in the Kosovo is not reported.
4.5 Summary of sectors and related actions to be considered, other than monitoring
The increase of the resilience of Kosovo Health System to weather events requires some policies implementation as described above. Priority actions per sector, other than monitoring, can be summarized according to the vulnerability assessment carried out in the report:
Health Information System Under construction, indicators, methods and access are not assessable
Health System reform Under construction, particular concern is in relation to its affordability and inequalities management
Maintenance Water supply network, urban drainage, riverbeds, sewage system
Awareness raising School programs on environmental risks, citizen campaign on resource use, environmental health, waste management, environmental pollution, emergency behaviour
Early Warning System Only partially ongoing for flood forecast in the White Drini basin; it needs a wide design for the forecast of drought and extreme weather event mainly in urban area
Emergency management A technical-scientific body, including environmental health experts, is to be designed and integrated for risk sizing, alert responsibility, risk communication to citizen. Resources and equipment are probably not enough, mainly at municipal level. Capacity building and operational cooperation with municipalities could require support.
General developmental issues The urban waste and sewage collection and treatment, with production and storage of biogas for thermal energy use.
Regional cooperation A system facilitating public officers, medical doctors, academia researchers, technical operational staff and so forth to network with European Institutions and Countries for the early warning system, wide weather forecasts, emergency management, environmental health exposures, environmental monitoring and so forth is to be designed and implemented
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4.6 Monitoring
4.6.1 Environmental indicators
The environmental monitoring system should focus on air, water and soil pollution monitoring.
With regard to air quality monitoring all cities above 100 000 inhabitants should include at least 2 monitoring stations, one “traffic” downtown and the second in the peripheral area. An additional monitoring station should be installed in Pristina, in the municipalities hosting the power plants (e.g. Obilić). With regard to basic indicators, those listed by the EU Air quality directive are to be recorded. The directive EC2008/50 and its amendment for PM2.5 (2014) is in the Annex 3. The indicators are to be recorded at least as “hourly” average per any calendar day. The database shall allow the retirement of hourly averages per any specific calendar day. The database shall include the meteorological parameters. The days that have been subject to the phenomenon of the thermal inversion shall be edited / retrieved by the meteorological institute.
Soil and ground water monitoring should be carried out routinely. Among others, and in addition to organic and microbiological pollution, heavy metals, hydrocarbons and sulphates should be constantly measured.
The Hydrogeological and Meteorological institute shall be equipped with the effective pluviometers network in order to monitor the potential drought risk through the calculation of the SPI index (Standard Precipitation Index)
4.6.2 Epidemiological surveillance
With regard to increasing climate change resilience in Kosovo, in addition to the currently undertaken surveillance, a specific monitoring should focus on respiratory and food-water borne infectious disease, mainly in relation to socio-economic conditions, housing, safe water and energy access of potentially exposed persons. This action is not explicitly quoted in the design of the Health Information System, but it should be, also by indicating the health institution in charge. The surveillance of the vector borne disease is operational as of many years. This latter action is currently carried out by the National Institute of Public Health (NIPH) and is part of the planned implementation of the Health Information System.
50
5 Iterative process: next assessment
The vulnerability and impact assessment will need to be repeated according to the description reported on paragraph 1.2. The key point is the launch of the institutional cooperation amongst the institutions and function involved in the adaptation plan and recalled by this report. A technical/scientific body should be appointed to gather monitoring data and merge institutional delegations in order to lead the assessment in the next years. This body could be identified with the Environmental Health Committee recently appointed by the governments of the Kosovo (Terms of Reference in the Annex 7), which is composed by members of academia, Ministry of Health, National Institute of Public Health, Kosovo Environmental Protection Agency and Hydrogeological and Meteorological Institute of the Kosovo.
To this regard, an official commitment from the ministries of health and environment to this committee is recommended and would constitute a key part of the iterative process suggested by the WHO.
Members of the Environment and Health Committee have carried out a workshop with the UNDP consultants on 25 November 2014, with the precise purpose to explore, analyse and discuss environmental heath vulnerabilities in the Kosovo and trace the way forward.
A schematic list of the causes of the vulnerabilities described in the report is in Tab. 15. A
list of what should be achieved by the Kosovo Government in order to allow the Committee or any other technical scientific body to carry out the environmental health assessment is reported in table Tab. 16. The list also represents possible tasks for the Environment and Health Committee in terms of monitoring achievements, facilitating action and policy and providing advice.
Fig. 15 Causes of vulnerability to weather events from the point of view of the Health System of the Kosovo
- High “out of pocket” cost of health care and health services
- Absence of a routinely, reliable, informative Environmental monitoring
- Absence of Early Warning System
- No water scarcity forecast system (absence of a network pf pluviometers and related indexing method SPI for instance) forecast
- Health information system not yet operational and intuitionally tested (Institute in charge)
- Incidence of infectious, food and water borne, respiratory disease very high; infant mortality very high
- Health care provision to disadvantaged people below the expected needs
- Emergency Agency without an institutional link and clear delegation with an environmental health scientific body to evaluate and communicate risks.
-
51
Fig. 16 What to consider in the repeat assessment
- Cost and affordability of the health system (The WB assessed +7% increase in the number of poor family due to health system costs)
- Accurate environmental information with regard to air pollution
- Early Warning system operational especially for SPI index for water scarcity forecast
- Heath information system fully operational mainly from the point of view of accessibility and data analysis (Institute in charge)
- Incidence of infectious, food and water borne, respiratory disease rapidly decreasing
- Health care provision to disadvantaged people, primary health care, housing, access to energy facilities and urban services
52
Annexes
Annex 1 Floods Report from White Drini River Municipalities, 2003 - 2006
Annex 2 Urban air pollution exposure-response coefficients for morbidity health effects adopted by the World Bank
Annex 3 EU Limits of atmospheric concentration of main pollutants - Directive 2008/50/EC
Annex 4 Meteorological station in Kosovo and “Average values of elements and meteorological occurrences for 2012”
Annex 5 MESP “Water department”, report on flooded areas
Annex 6 Complete framing of Morbidity data 2011 by NIPH
Annex 7 Terms of Reference of the Environmental Health Committee
Annex 8 Outbreaks and epidemiological surveillance of vector borne diseases
53
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Kenneth Strzepek1, Gary Yohe2,4, James Neumann3, and Brent Boehlert3. 2010. “Characterizing Changes in Drought Risk for the United States From Climate Change.” ENVIRONMENTAL RESEARCH LETTERS 044012
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OSTRO, BART. 2004. “Outdoor air pollution: ssessing the environmental burden of disease at national and local levels.” environmental BURDEN OF DISEASE SERIES NO. 5
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THE WORLD BANK,. 2014. “Counttry Snapshot.”
THE WORLD BANK. 2013. Kosovo country environmental analysis. Washington 2013.
KOSOVO, WATER TASK FORCE OFFICE OF THE PRIME MINISTER –. 2011. “Kosovo Drought Risk Management Framework an Action Plan for Policy, Procedures and Coordination.”
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1/2
Annex 1
Floods Report from White Drini River Municipalities, 2003 - 2006
Municipality
Location
(Urban -
Rural)
Year /month
/season
Number of
Flooded
Houses /
Damages
Agriculture
Damages
Infrastructure
Damages
Total
damages(€)
Skenderaj
Urban and
rural areas
Autumn2003
/Spring 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
More than
200 houses
106.480€
449.964€
487.300€
1.042.745€
Istog
Urban and
rural areas
Autumn 2004 /
Spring 2005
45 houses
No
assessment
No
assessment
No
assessment
Klina
Urban and
rural areas
Feb/Mar 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
No
assessment
No
assessment
More than
200.000€
In Feb 2006
No
assessment
Peja
Urban areas
Autumn2003
/Spring 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
No
assessment
No
assessment
No
assessment
No
assessment
Gjakova
Urban and
rural areas
Autumn2003
/Spring 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
230 houses in
2005/2006
400ha
in 2005/2006
In
2005/2006
343.504€
Malisheva
Urban and
rural areas
Autumn2003
/Spring 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
39 houses
48.000€
In Feb 2006
750ha in
2004/2005
No
assessment
No
assessment
of total
damages
2/2
Annex 1
Municipality
Location
(Urban -
Rural)
Year /month
/season
Number of
Flooded
Houses /
Damages
Agriculture
Damages
Infrastructure
Damages
Total
damages(€)
Rahovec
Urban and
rural areas
1967,’79,’93,’94
Autumn2003
/Spring 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
981.580€
In Feb 2006
285ha
285.000€
In Feb 2006
211.299€
In Feb 2006
1.477.879€
In Feb 2006
Prizren
Rural areas
Jul-‐Aug2002
Spring 2004
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
24 houses in
2002 and
2006 floods
385ha flooded
in all floods
35.000€ in
2006 flood
No
assessment
No
assessment
for total
damages
Theranda
Urban and
rural areas
Autumn2003
/Spring 2004
Autumn2005
/Spring 2006
9 houses in
2006 flood
72.830€
80-‐100ha
flooded in
2004 flood
Damage in
2006 flood
117.000€
No
assessment
No
assessment
for total
damages
Dragash
Urban and
rural areas
1970,1979,1999
Autumn2004
/Spring 2005
Autumn2005
/Spring 2006
No
assessment
No
assessment
No
assessment
No
assessment
Source: Ministry of the Environment of the Kosovo Republic – Water Department
Annex 2
Urban air pollution exposure-response coefficients for morbidity health effects
Health impact (PM10) Unit Impact per 1 μg/m3
Chronic bronchitis 100,000 adults 0.9
Hospital admissions 100,000 population 1.2
Emergency room visits 100,000 population 23.5
Restricted activity days 100,000 adults 5,750
Lower respiratory illness in children 100,000 children 169
Respiratory symptoms 100,000 adults 18,300
Source: Ostro 1994; Abbey and others 1995 in The World Bank 2013 Kosovo Country Environmental Analysis
Annex 3
EU Limits of atmospheric concentration of main pollutants
Directive 2008/50/EC on ambient air quality and cleaner air for Europe
Averaging period Limit value
SO2
One hour 350 μg/m3, not to be exceeded more than 24 times a calendar year
One day 125 μg/m3, not to be exceeded more than three times a calendar
year
NOx One hour 200 μg/m
3, not to be exceeded more than 18 times a calendar year
Calendar year 40 μg/m3
CO Maximum daily eight-‐hour mean 10 μg/m3
Pb Calendar year 0.5 μg/m3
PM2.5 Calendar year 25 μg/m3(*)
PM10 One day 50 μg/m
3, not to be exceeded more than 35 times a calendar year
Calendar year 40 μg/m3
Source: http://eur-‐lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2008:152:0001:0044:EN:PDF
(*) new directive released on 14 April 2014
Annex 4
Environmental Protection Agency of Kosovo
Hydrometeorology Institute
Average values of elements and meteorological occurrences for 2012
Meteorological station in Prishtina
2012 I II III IV V VI VII VIII IX X XI XII Annual
avg.
Tmax. 2.3 0.0 13.6 16.8 20.7 28.5 31.7 31.8 27.6 21.6 14.1 3.0 17.6
Tmin. -5.2 -7.9 1.1 4.9 9.4 13.7 16.6 15.0 12.1 7.5 4.7 -3.0 5.7
Tavg. -1.7 3.7 7.1 11.1 15.5 22.2 24.9 24.2 20.0 13.8 8.6 -0.6 12.4
Humidity% 83 81 62 68 66 57 54 47 58 68 79 86 67.4
Atmospheric Pressure
945.7 945.5 950.4 939.4 944.5 947.2 946.8 948.5 947.5 945.8 947.4 943.2 945.9
Wind/ms 1.8 2.2 2.2 2.6 1.9 1.2 1.6 1.3 1.4 1.5 1.5 1.7 1.7
Percipitation 105.7 36.1 12.8 51.5 102.0 6.2 53.3 3.9 13.7 60.4 29.6 65.9 541.1
Meteorological station in Peja
2012 I II III IV V VI VII VIII IX X XI XII Annual
avg Tmax . 2.7 0.2 14.1 17.2 21.1 28.9 32.1 32.6 22.6 18.1 16 6.4 17.7
Tmin. -4.9 -7.5 1.3 5.1 9.8 14.2 17.5 16.3 11.8 7.9 5.3 0.6 6.4
Tavg. -1.5 4.1 7.6 11.8 16.3 23.1 25.3 26.0 16.8 11.6 8.5 4.1 12.8
Humidity% 89 86 83 79 73 72 59 53 72.1 86 83 87.3 76.8
Atmospheric Pressure
943.6 948.3 940.2 946.3 951.2 956.8 961.7 963.1 958.3 955.4 952.8 953.2 952.5
Wind/ms 1.2 1.8 1.6 1.9 1.3 0.8 1.2 0.9 0.8 1.4 1.3 1.1 1.3
Percipitation 121.6 41 13.2 58.4 96.3 5.8 40.6 0.3 24.7 34.5 65.4 70.3 572.1
Meteorological station in Prishtina
2012 I II III IV V VI VII VIII IX X XI XII Annual
avg.
Tmax. 1.9 0.2 12.6 16.4 20.0 27.9 31.9 31.0 26.2 20.9 12.7 2.4 17.0
Tmin. -5.7 -7.4 0.6 4.2 8.7 11.9 15.2 14.6 11.7 7.0 -4.4 -3.1 4.4
Tavg. -2.2 -3.1 6.8 10.5 14.4 21.1 24.2 23.8 18.7 13.2 7.8 -0.6 11.2
Humidity% 87 83 66 71 75 65 60 53 68 78 87 88 73.4
Atmospheric Pressure
946.0 945.5 951.0 939.5 944.3 947.5 947.1 48.9 942.7 945.9 947.6 943.6 870.8
Wind/ms 1.2 2.4 1.4 1.9 1.4 1.2 1.8 0.9 1.4 1.1 1.8 1.8 1.52
Percipitation 67.4 41.7 17.1 64.5 132.5 3.8 14.1 48.2 26.6 27.9 30.7 50.8 525.3
Annex 5
The following are reports on floods
FLOODS REPORT OF THE DATE 01/07/2010
Damages reported by municipalities are listed in the table below
Flooded area depicted in yellow:
Annex 5
AnnexS
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Annex 5
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t.5.f3.0
\ \
0
'
Annex 5
Region
Municipality Location (Neighborhood -
Village) Nr. Flooded
homes Nr. of families
evacuated
Number of Residents The value of damages in €
Mitrovica Region
Mitrovica
Bosniaks neighborhood 9 9 63 Village Lisica 8 8 48 2 July (Left side of the river) 19 19 97 2 July (Right side of the
river)
17
17
118
Livestock market 2 2 17 "NTP" Interplast 1 1 Old Railway Station 7 7 50 Vaganicës neighborhood 13 17 78
In total 76 80 471
Vushtrri
Pestova 3 3 15 Nadakovc 1 1 4 Prilužje 5 5 25
In total 9 9 44
Skenderaj
Gllademi 2 2 30 Fidanishte 18 18 90 The Mill 3 3 17
In total 23 23 137
Total Region 108 112 652
Prishtina Region
Drenas
Shopping center I, II 1 8 Village. Nekovc 8 40 Kishna Reka 70 350 Terstenik 1 118 Çikatovë new neighborhood 2 14 Dobrashevc 60 300
In total 142 830
Obiliq
Obiliq 6 20 Plemetin 8 12
In total 14 32
Kosovo Polje
Lower Miradi Henc 26 130 Little white man 7 35 Kuzmin 7 23 Lismir 123 615 Grabovc 14 70 Great White 12 60 Pomozotin 5 21 Meadows of Bresje 15 75 Nakarade 15 75
In total 235 1159 Lipjan Pitfalls small 1 1 10
In total 1 1 10
Total Region 392 1 1999
Reg Peja jioni
Gjakova
Street "Shefki Shasivari" Gjakova
1
€ 2,865.00
Village. Demjan 1 € 700.00
Houses damaged by floods 230 € 21,500.00
In total 232 € 25,065.00
Total Region 232 € 25,065.00
Prizren Region
Prizren
Village. Virgin 1 Pirana 1 Korishe 1
In total 3
Suharekė
Semetište 1 Përbishtë 3 Studenqan 4
In total 8
Annex 5
11 55
Annex 5
Orahovac
Gexhë 3 3 R atkoc 2 2 Dabidol 3 3 Reti 1 1 Minor Hoqe 1 1 Fort 23 10 Celina 4 4 Sopniq 4 4 Orahovac 1 1
In total 42 29
Malishevė
Malishevė 2 + 8 6 69 € 12,000.00
Domanek 3 3 29 € 8,800.00
Bath 4 3 13 € 3,700.00
Astrazub 7 16 122 € 33,000.00
Mleqan 3 1 5 € 2,000.00
Maxharrë 2 1 11 Bubel 1 1 Carralluka 3 1 Temeqinë 1 1 Turjakë 2 1 Gurëbardh 1 1 6 € 1,000.00
Bellanicë 2 1 In total 33 36 255 € 60,500.00
Total Region 86 65 255 € 60,500.00
Sub-Total Kosovo 818 178 2906 € 85,565.00
Annex 5
Economic damages caused by floods in crops and agricultural lands depicted by
regions
• Prishtina region
CROPS
Areas affected by crop / ha
Wheat 774
Meadows 125
Fallow 100
Forage plants 298
Total: 1297
• Prizren Region
CROPS
Areas affected by crop / ha
Wheat 612
Meadows 200
Fallow land 55
Total: 867
• Gjilan Region
CROPS
Area affected by crop / ha
Wheat 250
Meadows 690
Total: 940
Annex 5
• Mitrovica Region
CROPS
Areas affected by crop
/ ha
Wheat 152
Greenhouses (planted with
spinach)
0:31
Alfalfa 23
Meadows 15
Fallow Lands 19
Total: 209.03
Photo by floods: BASTION village, Rahovec
Annex 5
Conclusions and Recommendations
Based on the data provided by the commissions of the affected municipalities, we can
conclude that the damages are large, as in households also in agricultural lands, a
situation which is continuously being repeated yearly in Kosovo.
We believe that flooding happened as a cause of heavy rainfall, however there were other
factors that have contributed, such as: unmaintained riverbeds, uncontrolled extraction of
gravel from rivers, as well as waste disposal in riverbeds.
In order to prevent and cope with flooding, Steering Committee for Flood Crisis
Management, recommends the Government to undertake the following steps:
• Establish a special financial fund on the central level, to cope with emergency
situations;
• Assist municipalities with funds to address specific emergency situations caused by
atmospheric precipitation, in order to help people when in emergencies. Also
assemblies to create special funds for coping with emergency situations;
• Take measures to regulate, maintain and clean river beds;
• Stop the uncontrolled use of inert materials from riverbeds in Kosovo;
• Bann waste disposal in the river bed;
• Take precautions to cope with floods (regulation of riverbeds).
• Undertake measures for the maintenance of pipelines for atmospheric water discharge;
• Undertake measures for the maintenance of dams.
Annex 6
Tab.5 Structure of diseases by groups of diseases and age groups -Kosovo 2011
Groups of diseases <1 1-5 6-14 15-49 50-64 65+ Totali
N % N % N % N % N % N % N %
Gr I. Certain infectious and parasitic diseases (A00-‐‐B99) 1194 4.2 6242 8.2 5264 5.4 7016 2.7 1818 1.9 1618 1.7 23152 3.5
Gr II. Neoplasm (C00-‐‐D48) 24 0.1 71 0.1 96 0.1 993 0.4 1090 1.1 1049 1.1 3323 0.5
Gr III. Diseases of blood and blood-‐‐forming organs and certain disorders involving the immune mechanisms (D50-‐‐D89) 520 1.8 2492 3.3 787 0.8 2876 1.1 705 0.7 727 0.7 8107 1.2
Gr IV. Endocrine, nutritional and metabolic diseases (E00-‐‐E90) 280 1.0 148 0.2 162 0.2 2725 1.1 7449 7.6 6981 7.2 17745 2.7
Gr V. Mental and behavioral disorders (F00-‐‐F99) 0 0.0 109 0.1 1153 1.2 12893 5.0 4432 4.6 1385 1.4 19972 3.1
Gr VI. Diseases of the Central Nervous System (G00-‐‐G99) 31 0.1 303 0.4 963 1.0 5771 2.2 1815 1.9 1513 1.5 10396 1.6
Gr VII. Eye diseases (H00-‐‐H59) 399 1.4 1078 1.4 2237 2.3 4585 1.8 2201 2.3 3333 3.4 13833 2.1
Gr VIII. Diseases of ear and mastoid process mastoid (H60-‐‐H95) 774 2.7 1375 1.8 1557 1.6 3326 1.3 1299 1.3 1622 1.7 9953 1.5
Gr IX. Diseases of blood circulatory system (I00-‐‐I99) 1 0.0 7 0.0 182 0.2 12623 4.9 17613 18.1 23292 23.9 53718 8.2
Gr X. Diseases of respiratory system (J00-‐‐J99) 10572 37.0 40401 53.2 34506 35.5 38320 14.9 11737 12.1 14479 14.8 150015 22.9
Gr XI. Diseases of digestive system (K00-‐‐K93) 866 3.0 5070 6.7 21071 21.7 31726 12.3 7478 7.7 6712 6.9 72923 11.1
Gr XII. Diseases of the skin and under-‐‐skin tissue (L00-‐‐L99) 934 3.3 2849 3.8 4182 4.3 10160 3.9 2205 2.3 2072 2.1 22402 3.4
Gr XIII. Diseases of musculoskeletal system and connective tissue
(M00-‐‐M99) 0 0.0 5 0.0 821 0.8 18284 7.1 9049 9.3 7752 7.9 35911 5.5
Gr XIV. Diseases of the genitourinary system ((N00-‐‐N99) 352 1.2 1963 2.6 2811 2.9 19862 7.7 6088 6.3 5798 5.9 36874 5.6
Gr XV. Pregnancy, childbirth and the puerperium (O00-‐‐O99) 1 0.0 0 0.0 0 0.0 6153 2.4 3 0.0 0 0.0 6157 0.9
Gr XVI. Certain conditions originating in the perinatal period (P00-‐‐P96) 723 2.5 1 0.0 2 0.0 1 0.0 0 0.0 0 0.0 727 0.1 Gr XVII. Congenital malformations, deformations and chromosomal abnormalities (Q00-‐‐Q99) Gr XVIII. Symptoms, signs and abnormal clinical and laboratory findings, not elswere classified (R00-‐‐R99) Gr XIX. Injury, poisoning and certain other consequences of external causes
605 2.1 253 0.3 38 0.0 14 0.0 1 0.0 5 0.0 916 0.1
828 2.9 4263 5.6 7435 7.7 15140 5.9 4245 4.4 3937 4.0 35848 5.5
(S00-‐‐T98) 267 0.9 2147 2.8 5564 5.7 12263 4.8 2388 2.5 1942 2.0 24571 3.8
Gr XX. External causes of the morbidity and mortality (V01-‐‐Y98) 19 0.1 272 0.4 517 0.5 1518 0.6 351 0.4 238 0.2 2915 0.4 Gr XXI. Factors that are influencing health condition and the contact with health care service (Z00-‐‐Z99)
9972 34.9 6683 8.8 7456 7.7 50265 19.5 14923 15.3 12690 13.0 101989 15.6
Unknown 240 0.8 166 0.2 266 0.3 1522 0.6 499 0.5 471 0.5 3164 0.5
Total 28602 100.0 75898 100.0 97070 100.0 258036 100.0 97389 100.0 97616 100.0 654611 100.0
Source: ‘Morbidity Analysis of Kosovo Population in 2011’, published in 2012-‐NIPH
Annex 7
Terms of Reference of the Environmental Health Committee
The Committee of Environmental Health consisting of senior representatives of the policymaking structures, professional institutions, and international organizations that are directly and indirectly involved in the activities related to Environmental Health, are going to be responsible for:
• Initiating and implementing Environmental Impact on Health Assessment at country level;
• Based on the results of this assessment, drafting the strategic long-term document regarding the proper and effective addressing of Kosovo health issues caused as a result of environmental impact on population’s health;
• Preparing long-term and one-year Action Plan for addressing the Environmental Impacts on Health, as well as, implementing the foreseen activities in the Plan;
• Identify the International Norms and Standards for safe implementation of different programs and activities as requested by the approved strategies;
• Identify similarities and actions in the state policies for environmental health and health policies in this field;
• Conduct evaluation of the environmental health legislation together with the regulations and administrative guidelines, that describe the norms, standards and procedures on regular basis and inquire for advice from specialized technical groups regarding this issue;
• Identify regional mechanisms for regional cooperation for environmental health;
• Define the necessary methodology to ensure the monitoring of activities of environmental health;
• Propose administrative structures that will tackle the environmental health problems.
Annex 8
Extract form:
Ministry of Internal Affairs, Agency for emergency management
Assessment natural and other disasters Risk
UNDP Kosovo coordination1
Pristina 2009
Internally translated from Albanian
XVI.Epidemiological RISKS
Infectious diseases
• Pandemic flu: bird flu, new flu (swine)
• Bio terrorist Diseases (hemorrhagic fever, Brucellosis, Tularemia)
• Unexpected Outbreaks
• Mass poisoning of water and food
XVI. 1 PANDEMIC FLU -‐ BIRD FLU
Avian Flu
Taking into account that the infection has so far passed from birds to man and not man to man, the higher the
risk for now is in areas where poultry farms located.
Background
Avian influenza is infection which causes Avian Influenza virus. The flu virus usually occurs in birds, but can be
presented as pure avian virus (avian) that adapts to humans through gradual mutations. In theory a number of
avian viruses have the potential to develop into pandemic virus.
To date have been recorded three major pandemics in the world:
• Spanish flu of 1918/19 year,
• Asian flu of 1957-‐1958 years
• Hong Kong flu of 1968-‐1969 years
Based on historical experience and biological characteristics of influenza virus, the other a global pandemic is
inevitable. Therefore, preparation and response prevention enables the prevention of the outbreak or at least
postpone massive pandemic outbreaks. Impact of pandemic will be felt in human terms as well as
1 The working group has started with the updating of the assessment. Figure may changes in the revised document
-‐‐ 1 -‐‐
-‐‐ 2 -‐‐
Annex 8
economically. In theory a number of avian viruses have the potential to evolve into a pandemic virus, however,
what concerns us most is H5N1.
Deterioration factors
The deterioration factor is not regular veterinary control of existing farms.
Characteristics of flows
The largest number of cases of the disease may occur during the season of arrival of migratory birds from
places where they are recorded cases of avian flu.
Most likely scenarios
Both scenarios are adopted, ie easy and severe pandemics for planning purpose. These scenarios are based on
experiences gained in past pandemics. According easy scenario 30% attack rate, the number of patients 660
000, 0:23% mortality rate, deaths 1518. According tough scenario 30% attack rate, the number of 660 000
patients, the mortality rate 2.1% , 13860 deaths.
Periods of risk
The risk of an outbreak is permanent, but may be more pronounced during periods of arrival of migratory
birds.
XVI. 2. NEW FLU H1N1 (SWINE)
The new H1N1 flu from a sick person to a healthy person spreads by airborne, so the number of people
infected in an epidemic can be great.
Background
According to experts the new flu virus mutation is considered to be the four subtypes of the virus A. The virus
spreads by airborne during coughing, sneezing and by contact with contaminated objects. The source of
infection is the sick person. For the first time the virus has been reported in pigs and bears in North America
through people infected by contact with sick pigs. It is important now that the infection is transmitted directly
from human to human. The first cases of flu were announced in Mexico in May 2009 and the disease has taken
epidemic character.
In early June, when there were cases of H1N1 virus infection in many countries, WHO has declared a pandemic
of new influenza noting that the virus is far more dangerous.
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The first confirmed case of H1N1 flu in Kosovo was registered in July 2009. From July 2009 until November 15,
2009 recorded 39 confirmed cases of influenza (including 3 cases are from countries inhabited by Serbian
population).
Deterioration factors
Given that infection may take pandemic proportions (includes many states) factors of deterioration are
gathering in public places and the movement of people from one place to another.
Characteristics of flows
The largest number of cases is expected to be during the late fall and winter, although from the first case up to
now there were cases that also occurred during the summer months.
Scenario 1
Rough scenario -‐‐ attack rate is 30%, the number is 660 000 patients, the mortality rate 2.1%, the death toll
13860. Mortality rate in Kosovo, a country with a young population, may be relatively high since pandemics in
the past have particularly affected young population.
XVI. 3. CRIMEA CONGO Hemorrhagic Fever -‐‐ CCHF
From 1989 to 2008 nationwide, have been recorded 403 confirmed cases of hemorrhagic fever -‐‐ Crimean
Congo with 46 dead. Only after the war were reported 105 cases with 8 deaths disease. It is a disease that
occurs every year in our country.
Background
CCHF is contagious viral disease characterized by hemorrhagic stress syndrome (bleeding), appear in natural
foci after tick bites (ticks) during spring-‐autumn season.
Hemorrhagic Fever -‐‐ Crimea Congo, is serious contagious disease caused by a virus of the same name. The
disease ranks among the most deadly infectious diseases recently, after Ebola. Letalitety rate of this disease
ranges from 20-‐50%. The disease is spread by ticks from Hyaloma family (known as Hyaloma Marginatum) and
with the blood of persons affected by this disease. A characteristic of these tick bite is painless, and endure
hunger for months to three years and carry the infection in transovarial way (from generation to generation).
CCHF is characteristic for countries with mild climate, with developed farms, areas with shrubs that fully
responds to Central Kosovo, including the municipalities of Malisheva, Orahovac, Therandë, Kline, Drenasit,
Prizren, Djakovica, Pec and Skenderaj.
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Crimean-‐Congo for the first time in Kosovo is recorded in the village of Therandë Nishor (former Suva Reka) in
1954 in a family with eight (8) dead family members.
In 1989, CCHF appeared again in the village Kijeva of Klina municipality(nowe municipality of Malisheva) in a
family of four (4) sick and two (2) dead. Cases of this disease occurred also during 1991 and 1992.
In 1995, Kosovo had a massive outbreak-‐‐ epidemic with 65 suspected cases of CCHF, spread in 47 locations
with the highest incidence in the following municipalities: Malishevė, Kline, Rahovec, Skenderaj and Dreanas.
CCHF endemic areas in Kosovo
Deterioration factors
There is no dilemma that Crimea Congo is a major Kosovo health problem, especially for Kosovo public health.
From 1989 this fatal disease was recorded sporadically in parts of Central Kosovo and South – West Kosovo.
This disease is registered now in 55% of Kosovo's territory, which makes it even more alarming situation.
Characteristics of flows
From 1995 until 2008, CCHF is registered in 13 municipalities or 37% of the territory of Kosovo. It should be
emphasized that these municipalities consist of 720 rural settlements. During these years, in 70 rural
settlements recorded Crimea Congo Hemorrhagic Fever, or 9.7% of them. In the affected areas are living
around 900 000 inhabitants (estimate).
In general we can conclude that there are 82 hyper endemic zones with outbreak permanent risk or vulnerable
settlements in Kosovo to Congo Crimean hemorrhagic fever thus these settlements are research priorities.
From the above data it can be concluded that in areas affected by Crimea Congo Hemorrhagic Fever live about
half of the Kosovo population and this makes this problem even more serious.
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Annex 8
In the future all preventive activity should be concentrated in these settlements if we want to keep the disease
under control and avoid outbreaks.
Scenario 1
Usually the number of patients is 14% out of the total number of persons bitten by ticks.
Rough Scenario -‐‐ 7000 persons bitten by ticks, the number of patients-‐‐ 980 (14%), 20% mortality rate, number
of deaths-‐196.
Risk Period
The disease is characterized by seasonal appearance, usually during the spring and summer months. The highest
number of cases of the disease occurs from June to September when the density and biological activity of ticks
is extremely significant. Cases of the disease begin to appear from May.
XVI. 4. Brucellosis
It is a disease that can easily be used for bio terrorism. Given that in Kosovo, a considerable part of the
population is engaged in farming and health educational level is not satisfactory, the Brucellosis and its
consequences endanger public health in Kosovo permanently. This disease if not detected in time and not
adequately treated can leave lifelong disability.
From this disease are at higher risk for veterinarians, shepherds and housewives. Also at risk are those dealing
with the processing of products from sick animals as butchers, slaughterhouse workers, animal leather workers
and hunters. Brucellosis can also spread after consuming contaminated raw milk products (especially goat
milk).
So far in Kosovo are not registered death cases from this disease. However, losses are large in the economy
(absence from work, disability of patients, and elimination of sick animals.
Background
Brucellosis is a systemic infectious disease caused by bacteria from Brucella group. The disease is characterized
by acute or hidden flow, intermittent temperature with different duration. This disease is a zoonosis, which
primarily occurs in domestic animals (goats, cattle, sheep, pigs and horses) .The disease is not considered
contagious because it cannot be transmitted from human to human, but is transmitted from animal to human.
The disease has been known since the time of Hippocrates. Scientific data to date from this disease have been
registered in the second half of the nineteenth century. The disease was first described in 1800 on the island of
Malta. The disease is spread around the whole world. Prevalence rate is directly related to livestock
development and application of preventive measures.
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Annex 8
Epizootic and epidemic situation deteriorated significantly during the 90s. The whole territory of Kosovo is
considered to be an endemic zone for brucellosis. The NIPH data from 1985 until 2008, reported 1798 cases of
brucellosis with 1 dead in 1993 in Therandë.
Brucellosis endemic areas in Kosovo
Deterioration factors
The deterioration factor is irregular veterinary control of existing farms and households holding these domestic
animals.
Uncontrolled animals’ market, meat, milk and their products as well as inadequate processing of these
products.
Characteristics of flows
The disease is seasonal, although recorded throughout the year.
Scenario 1
Attack rate is 0:03%, the number of patients is 600. Antibiotics’ availability and higher level of health education
can reduce morbidity.
XVI. 5. Tularemia
Given that the disease is endemic in Kosovo, the risk of an outbreak is permanent, especially when considering
the fact that can easily be used for bio-‐terrorism.
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Background
Tularemia is a disease primarily of animals, particularly rodents. In natural conditions, the disease occurs in
more than twenty species of wild and domestic animals. The disease is transmitted to people through the
water / contaminated food, polluted air and ticks. The disease affects all age groups. For the first time the
disease was described in 1653 in Norway. Tularemia has never been present in Kosovo earlier, with the clear
clinical symptoms or as atypical form. The first cases of the disease in Kosovo were registered in Gjakova
region, village Brovina in 2000. While disease had spread in Dukagjini area first, in subsequent years were
registered in other Kosovo areas. So today Tularemia is spread in whole territory of Kosovo. So far in Kosovo
were registered two waves of the epidemic, 1999-‐2000 with 245 cases and in 2000-‐2001 with 338 cases. In
subsequent years were sporadic cases of the disease, but is considered high the number of 784 cases with
average of morbidity rate of 6.7 sick persons per 100 000 inhabitants.
Endemic areas of Tularemia in Kosovo
Characteristics of flows
The disease is mainly seasonal. More occurs in autumn, winter and early spring, but there is a possibility of the
appearance of cases throughout the year.
Scenario 1
Attack rate is 0:05%, the number of patients is 1,000.
XVI. 6. Unexpected Epidemics (Poisonings) caused by water and food
Water born diseases
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According to the NIPH and UNDP, the World Bank (2006), 58% of the population in Kosovo are connected to
the water network, 64% were supplied with drinking water from wells and 33% are connected to the sewage
network.
Kosovo is and remains endemic area of water and food born diseases. Only in 2008 the diseases caused by food
and water are registered as acute diarrhea 55%, HAV(??) 43% of the total number of recorded infectious
diseases in Kosovo.
460 cases of alimentary intoxications (food poisonings) were registered in 2008. Also in this year were recorded
56 domestic and collective outbreaks of Hepatitis A, alimentary intoxications and Gastroenterocolytis.
Verification of risk assessment during hydro epidemics in emergency situations, consists of three phases:
• Identification stage
• Description stage and
• Evolution stage.
Hydric epidemics in emergency situations are affecting a large number of people (or threaten them), and
contamination of water may also be by purpose (as terrorist act). Hydro epidemics can be caused by:
• Lack of sufficient quantities of regular hygienic water;
• The possibility of contamination of existing water quantities by chemical, radiological, biological micro-‐‐
organisms.
Background
Infectious diseases of the digestive system are among the most cosmopolitan and massive in number. Due to
specific epidemiological characteristics, this group of diseases is quite complex as by clinical symptoms,
epidemiological, fighting measures and also health, economic and social consequences. This group of diseases is
present mainly in underdeveloped countries and developing countries. These are mostly the countries that have
not solve the problem of supply with drinking water and food quality control. Unfortunately there are many
other factors that contribute to the appearance and spreading of these diseases (unsanitary elimination of
waste, the large number of insects, natural disasters etc.) The fact is that a certain number of these diseases are
present in Kosovo despite the taken measures.
Since many pathogen microbes retain their life abilities, at least a few days in the water, the transmission
through the water is quite common route of spread of infectious diseases.
Hydric outbreak of Cholera is known by John Snow in 1854 in London, 1802 by Robert Koch in Hamburg with
17 000 sick persons and 8605 deaths.
In Kosovo an outbreak of abdominal typhus appeared in Mitrovica and Shtime, in 1984 , as a result of
penetration of sewage in the water network.
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Supply with drinking water in Kosovo
Pristina has the water supply from Lake Batllava, Badovc and Kuzmin, Mitrovica from Gazivoda lake, Peja from
"Hidrodrini" (Black Water and Drini spring), Gjakova from Lake Radoniq, Prizren from underground drilled
wells, Gjilan from Prelepnica lake and ‘Guri i Hoxhes’ and Ferizaj from Nerodimka.
In relation to water, according to WHO, hydro diseases are divided into:
CATEGORY -‐‐ I
Diseases, the causes of which deal with contaminated water, diarrhea, cholera, typhus abdominal, worms, Viral
Hepatitis etc.
CATEGORY -‐‐ II
Diseases caused by inadequate quantity and access to water "low sanitation"
Scabies, Viral Hepatitis A, Lice typhus, pyodermatitis, Trahoma etc.
CATEGORY -‐‐ III
Diseases, the causes of which are coming in the body through body lesions: Tularemia, leishmaniasis.
CATEGORY -‐‐ IV
Vector diseases, the cause of which, a part of their life cycle is associated with water: Malaria, Tularemia, -‐Loa
Loa, Deng Fever, Yellow Fever, Hemorrhagic Fever.
Deterioration factors
Factors outside health:
not well regulated infrastructure of water and sewerage system in Kosovo, (this is the duty and obligation of
the relevant factors at municipal and state level). Poor hygienic and sanitation conditions (especially in
preschool institutions, schools, families and community, where sanitation is in low hygienic level.) Supply with
unhygienic drinking water (due to frequent water and electricity cuts, and supply with alternative drinking
water from different uncontrolled sources)
The supply with contaminated and uncontrolled food, (a consequence of inadequate way of preparing and
preserving food and its products, unhygienic ways of feeding children with breast feeding and other foods, etc.)
Inadequate exposure of waste (especially in rural areas). Lack of health education of the population about
personal and family hygiene (habits, vices, etc.), especially in washing hands before eating and after using the
toilet, etc.)
While these causes continue to be present, unless we have good regulation of water and sewerage
infrastructure that would have "domino effect" in raising the quality of drinking water.
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Characteristics of flows
When using unsafe water may come to the spread of the epidemic in other population groups. Sonce these
diseases are unexpected, they are not related to the season.
Periods of risk
The appearance of epidemic risk is permanent, but may be more evident during periods of water shortage,
water restrictions for longer time and use of the water from unhygienic wells.
XVI. 7. Alimentary (food) Epidemics
Identification of risk
Food products are undoubtedly ideal medium for pathogen micro-‐organisms, saprophytes and conditionally
saprophytes, so food is ideal route for the transmission of infectious diseases.
Contaminated food with pathogenic microorganisms can cause these diseases:
1. Alimentary infections -‐contamination of food with pathogenic micro-‐organisms, which after entering in the
body, after a certain incubation time, the infectious disease appears such as Abdominal Typhus and Para-‐‐
typhus, Cholera, Dysentery, Hepatitis accuta-‐IA, Tuberculosis, Brucellosis etc..
2. Toxico-‐alimentary (food) infections resulting from consumption of contaminated food by microorganisms
that broken down in the intestine by releasing their endo-‐toxins. The most frequent causes are Sallmonella,
Shigella, E. Coli, Bacteria Faecalis Alkaligenes, Proteus Bacteria etc.
3. Alimentary intoxications (Food poisonings)-‐‐ are contamination of food with pathogenic microorganisms
which are releasing Exo-‐toxins in the food such as Staphylococcus aureus, Clostridium botulinum.
4. Alimentary invasions-‐‐ are contamination of food with parasites such as Trychinella spyralis parasite,
Ehynococcus granulosus. During food poisoning probably special attention should be paid to old people,
pregnant women, the sick and children. To this category of people should be offered the physiological
optimum of calories, protein (especially animal), and all protective substances such as vitamins B complex.
Deterioration factors
The deterioration comes as a result of non-‐‐ implementation of hygienic measures -‐‐ sanitary, in social and
private premises. The epidemiological situation in Kosovo with these poisonings is uncertain due to severe
socio-‐economic conditions, low levels of mass hygiene culture, not respecting basic hygiene principles in the
handling of foodstuffs.
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We have no reliable data on food poisonings since there is no accurate and regular recording of these cases
and since most of these cases are treated as outpatients.
Characteristics of flows
Alimentary epidemics erupt explosively. A large number of persons who have consumed contaminated food
are sick. During these epidemics may become sick 30-‐40% of those who consumed contaminated food.
Epidemics can take dramatic character since are included a large number of patients
Periods of risk
Appearance of these diseases is more frequently during the summer season where we have concentrations of
larger groups of people in the hotels, student canteens, the use of dairy products (ice cream), and fast food.