**12. Conclusions**

There have been a number of previous reviews and publications highlighting potential impacts of climate change and water-related illness in water-related or waterborne disease [37,38,117,172–182]. Some approaches examine the technological means to best represent the data [42,175,177,178,183], some examine outbreaks [28,32] and others focus on effects of the hydrological cycle in particular regions [28,110,174,179], while others have adopted a systematic review approach [37]. This paper has examined a full range of water-related pathogens, providing an evidence base for regarding them as water-related and indicating which studies have provided evidence. In addition to a changing climate, the world will continue to experience an increasing human population, with ever greater inter-connectivity through travel and information technology. Animal infections will continue to contribute to zoonotic disease and we should expect new pathogens to continue to arise. With climate change we need to watch for the rise in cholera worldwide. Although this is predominantly a disease of the poor and is not generally a problem in developed countries that have safe drinking water, it still has the potential to cause pandemic disease if there is general chaos, as can be found in disaster situations. The growth of *Vibrio cholera* in coastal waters means there can be changes in exposure with alterations in rainfall and temperature [150]. There remains a strong need for timely surveillance and rapid epidemiological response to outbreaks and new waterborne pathogens. The needs of developing countries in relation to waterborne diseases are both technical and financial, and ensuring adequate quantities of good quality water will be essential in preventing excess morbidity and mortality in areas that will suffer from substantial changes in climate in the future.

**Author Contributions:** G.N. initiated the paper and reviewed the evidence for waterborne disease and climate change. C.H. provided the climate change overview and I.L. the interface between waterborne diseases and climate change. All three contributed to the manuscript production and producing a final text.

**Acknowledgments:** The research was funded in part by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Environmental Change and Health at the London School of Hygiene and Tropical Medicine in partnership with Public Health England (PHE), and in collaboration with the University of Exeter, University College London, and the Met Office; the UK Medical Research Council (MRC) and UK Natural Environment Research Council (NERC) for the MEDMI Project (https://www.data-mashup.org.uk). Some of the work was conducted while seconded from HPA/PHE to the European Centre for Disease Prevention and Control (ECDC). The views expressed are those of the authors not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or Public Health England. IL is part funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Gastrointestinal Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with University of East Anglia, University of Oxford and the Institute of Food Research.

**Conflicts of Interest:** The authors declare no conflicts of interest in respect of this work.
