Role of extreme weather events and El Niño Southern Oscillation on incidence of Enteric Fever in Ahmedabad and Surat, Gujarat, India.

INTRODUCTION Enteric Fever (EF) affects over 14.5 million people every year globally, with India accounting for the largest share of this burden. The water-borne nature of the disease makes it prone to be influenced as much by unsanitary living conditions as by climatic factors. The detection and quantification of the climatic effect can lead to improved public health measures which would in turn reduce this burden. METHODOLOGY We obtained a list of monthly Widal positive EF cases from 1995 to 2017 from Ahmedabad and Surat Municipalities. We obtained population data, daily weather data, and Oceanic Nino Index values from appropriate sources. We quantified the association between extreme weather events, phases of El Nino Southern Oscillations (ENSO) and incidence of EF. RESULTS Both cities showed a seasonal pattern of EF, with cases peaking in early monsoon. Risk of EF was affected equally in both cities by the monsoon season -- Ahmedabad (35%) and Surat (34%). Extreme precipitation was associated with 5% increase in EF in Ahmedabad but not in Surat. Similarly, phases of ENSO had opposite effects on EF across the two cities. In Ahmedabad, strong El Nino months were associated with 64% increase in EF risk while strong La Nina months with a 41% reduction in risk. In Surat, strong El Nino was associated with 25% reduction in risk while moderate La Nina with 21% increase in risk. CONCLUSIONS Our results show that the risk of EF incidence in Gujarat is highly variable, even between the two cities only 260 kms apart. In addition to improvements in water supply and sewage systems, preventive public health measures should incorporate variability in risk across season and phases of ENSO. Further studies are needed to characterize nationwide heterogeneity in climate-mediated risk, and to identify most vulnerable populations that can benefit through early warning systems.