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Potential health implications of deficient sanitation infrastructure and reduced surface water flows due to climate change are examined in the case study of the Republic of Macedonia. Changes in surface water flows and wastewater discharges over the period 1955-2013 were analyzed to assess potential future surface water contamination trends. Simple model predictions indicated a decline in surface water hydrology over the last half century, which caused the surface waters in Macedonia to be frequently dominated by &gt;50% of untreated sewage discharges. The surface water quality deterioration is further supported by an increasing trend in modeled biochemical oxygen demand trends, which correspond well with the scarce and intermittent water quality data that are available. Facilitated by the climate change trends, the increasing number of severe weather events is already triggering flooding of the sewage-dominated rivers into urban and non-urban areas. If efforts to develop a comprehensive sewage collection and treatment infrastructure are not implemented, such events have the potential to increase public health risks and cause epidemics, as in the 2015 case of a tularemia outbreak.

Potential health implications of water resources depletion and sewage discharges in the Republic of Macedonia