Di 

Napoli et al. BMC Public Health (2022) 22:663

https://doi.org/10.1186/s12889-022-13055-6

RESEARCH IN PRACTICE Open Access

Tracking the impacts of climate change

on human health via indicators: lessons
from the Lancet Countdown
Claudia Di Napoli1,2*  , Alice McGushin3, Marina Romanello3, Sonja Ayeb‑Karlsson4,5,6, Wenjia Cai7,
Jonathan Chambers8, Shouro Dasgupta9,10,11, Luis E. Escobar12, Ilan Kelman3,4,13, Tord Kjellstrom14,
Dominic Kniveton5, Yang Liu15, Zhao Liu7, Rachel Lowe16,17,18, Jaime Martinez‑Urtaza19, Celia McMichael20,
Maziar Moradi‑Lakeh21, Kris A. Murray22,23, Mahnaz Rabbaniha24, Jan C. Semenza25, Liuhua Shi15,
Meisam Tabatabaei26,27, Joaquin A. Trinanes28, Bryan N. Vu15, Chloe Brimicombe2 and Elizabeth J. Robinson9 

Abstract 
Background:  In the past decades, climate change has been impacting human lives and health via extreme weather
and climate events and alterations in labour capacity, food security, and the prevalence and geographical distribution
of infectious diseases across the globe. Climate change and health indicators (CCHIs) are workable tools designed to
capture the complex set of interdependent interactions through which climate change is affecting human health.
Since 2015, a novel sub-set of CCHIs, focusing on climate change impacts, exposures, and vulnerability indicators
(CCIEVIs) has been developed, refined, and integrated by Working Group 1 of the “Lancet Countdown: Tracking
Progress on Health and Climate Change”, an international collaboration across disciplines that include climate, geogra‑
phy, epidemiology, occupation health, and economics.
Discussion:  This research in practice article is a reflective narrative documenting how we have developed CCIEVIs
as a discrete set of quantifiable indicators that are updated annually to provide the most recent picture of climate
change’s impacts on human health. In our experience, the main challenge was to define globally relevant indica‑
tors that also have local relevance and as such can support decision making across multiple spatial scales. We found
a hazard, exposure, and vulnerability framework to be effective in this regard. We here describe how we used such
a framework to define CCIEVIs based on both data availability and the indicators’ relevance to climate change and
human health. We also report on how CCIEVIs have been improved and added to, detailing the underlying data and
methods, and in doing so provide the defining quality criteria for Lancet Countdown CCIEVIs.
Conclusions:  Our experience shows that CCIEVIs can effectively contribute to a world-wide monitoring system that
aims to track, communicate, and harness evidence on climate-induced health impacts towards effective intervention
strategies. An ongoing challenge is how to improve CCIEVIs so that the description of the linkages between climate
change and human health can become more and more comprehensive.
Keywords:  Climate change, Public health, Indicators, Climate data, Policy making

*Correspondence: [email protected]
1
School of Agriculture, Policy and Development, University of Reading,
Reading, UK
Full list of author information is available at the end of the article

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Di Napoli et al. BMC Public Health (2022) 22:663 Page 2 of 8

Background Countdown has been providing a global monitoring sys-

Climate change affects global health via multiple direct tem that tracks the complex, reflective ways in which cli-
and indirect pathways [1, 2]. Every year, disasters involv- mate change affects health [27–32]. It accomplishes this
ing weather- and climate-related hazards result in thou- through a set of CCHIs spanning five domains of the cli-
sands of deaths worldwide and contribute to the global mate-health system: climate change impacts, exposures,
burden of disease [3, 4]. Direct health consequences may and vulnerability; adaptation planning and resilience for
derive from changes in temperature and precipitation, health; mitigation actions and health co-benefits; eco-
and human exposure to heatwaves, wildfires, floods, and nomics and finance; and public and political engagement.
droughts [5–9]. These include an increase in cardiovas- One of the five Lancet Countdown thematic working
cular mortality during events of extreme heat; a higher groups, namely Working Group 1 (WG1), is tasked with
incidence of chronic kidney disease among outdoor identifying and tracking indicators that trace the links
workers in hot areas; and fatalities and multiple nega- across “climate change impacts, exposures, and vulner-
tive health consequences of fire smoke inhalation dur- ability”. This research in practice article aims to provide
ing wildfires [10–13]. Indirect impacts may be triggered guidance for the development and tracking of CCHIs
by climate change-induced environmental and ecosys- through a detailed case study of how WG1 authors devel-
tem alterations, such as crop failures, reduced marine oped these indicators, referred to from here on as climate
food capture, geographic range expansion of disease vec- change impacts, exposures, and vulnerability indicators
tors, and reduced labour capacity [14–17]. Other indi- (CCIEVIs), that contribute to the Lancet Countdown’s
rect effects may be mediated through social systems and overall objectives. As such, this article is equally rel-
responses to climate change. Examples include reduced evant for those individuals and policy makers wanting
labour capacity in vulnerable occupations due to increas- to develop their own climate change and health indica-
ing heat, migration of populations related to sea-level rise tors specific to a country or region, and those wanting a
and food insecurity, as well as other drivers of human more detailed understanding of specific indicators used
mobility [18–20]. in the Lancet Countdown, and particularly WG1. Here-
As understanding and awareness grow regarding the after, we describe (i) the aim, design, and characteristics
health dimension of climate change, there is an increased of CCIEVIs, as employed in the Lancet Countdown, (ii)
demand for feasible and efficient tools that can inform their main components, (iii) underlying data and meth-
climate change mitigation and adaptation strategies to ods, and (iv) plans for future improvements.
deliver benefits to human health at all levels. Climate-
health linkages are complex, with multiple interactions, Climate change impacts, exposures,
synergies, and feedback loops. Understanding their char- and vulnerability indicators
acteristics and relationships is challenging and poses a Designing CCIEVIs
level of complexity that could render the development of Lancet Countdown CCIEVIs have been developed to
such tools unfeasible. A reasonable alternative is to deploy monitor the health impacts related to anthropogenic
a subset of measures describing the key aspects of the climate change, their trends to date, and the extent to
state, extent and change of the climate-health system [21]. which progress (or backsliding) is occurring over time.
Climate change and health indicators (CCHIs) are They are presented from a historical starting date up to
summary measures, often quantitative, that represent the year for which the most recent complete data are
the heterogeneous set of factors and relationships link- available. The indicators provide evidence along differ-
ing climate change with health [22–26]. Their purpose is ent dimensions – some indicators are positioned closer
three-fold. First, to assess long-term trends and changes to the climate change hazard and some closer to the
in climate-induced impacts on population health. Second, health impact – as to whether, and to what extent, cli-
to effectively communicate relevant evidence to research- mate change is affecting health, for better or for worse. In
ers, health professionals, policymakers, and the general the Lancet Countdown, CCIEVIs start tracking climate
public. Third, to support and monitor decision making for change-health linkages from the 1980s, and are grouped
successful intervention strategies and plans that address into five thematic clusters: heat; weather and climate
the human health consequences of climate change. extremes; infectious diseases; food security of terrestrial
In the past decade, CCHIs have represented the build- and marine assets; global mean sea-level rise.
ing blocks for a variety of initiatives tracking the cli- To ensure that CCIEVIs are reproducible, relevant, and
mate-health system across multiple spatial and temporal useful to scientific and policy-making communities, they
scales [24, 25]. One high profile and current CCHI ini- must satisfy five quality criteria that mirror the World
tiative is the “Lancet Countdown: Tracking Progress Meteorological Organisation guidelines for climate indi-
on Health and Climate Change”. Since 2015 the Lancet cators [33]:
 Di Napoli et al. BMC Public Health (2022) 22:663 Page 3 of 8

1. Representativeness: a CCIEVI should track an aspect the Intergovernmental Panel on Climate Change [34, 35].
of both climate change and health, particularly focus- Specifically:
ing on the relationship between the two; it should
do this across a timescale and geographical coverage • Hazard is any physical event with the potential
sufficient for long-term global trends to be observed. to cause disruption or damage in vulnerable and
2. Relevance: a CCIEVI should be clear and understand- exposed elements;
able to a broad range of audiences; global CCIEVIs • Exposure is who or what is present in the area where
may also have value at local (i.e. national, regional) a hazard may occur;
level for policy and decision makers. • Vulnerability is the factors or constraints of an eco-
3. Robustness: a CCIEVI should use data and meth- nomic, social, physical, or geographic nature, which
ods that are robust, reliable, and valid to track the reduce the ability of exposed elements to prepare for
relevant aspect of climate change and health; data and cope with the impact of the hazard.
from publicly available databases, and especially
those developed by international organisations, In Lancet Countdown CCIEVIs, each of these com-
governmental bodies, or academic institutions, are ponents represents a dimension or layer of the multi-
preferred; methods should be supported by a high facet climate-health system. For the hazards, the Lancet
standard of evidence from the scientific literature. Countdown CCIEVIs target extremes in temperature and
4. Reproducibility: a CCIEVI should be calculated precipitation, namely heatwaves, drought, and floods, as
using an internationally agreed and published sci- well as phenomena mediated by these two environmen-
entific method as well as open-access and quality- tal variables, i.e. wildfires and suitability of vector-borne
controlled data; the methodology underlying an indi- diseases (malaria, dengue). Similarly, health hazards in
cator should be clearly laid out, including details of the ocean system are identified in changes of global mean
the process of data collection and processing, which sea level as well as sea surface temperature and salinity.
must be done in a systematic and unbiased way; sta- The second layer tracks the exposure of populations, cul-
tistical analysis of the data should be carried out to tivated areas, and health systems to hazards. This reflects
support the interpretation of the data. the purpose of representing climate change-health path-
5. Timeliness: a CCIEVI should be calculated regularly, with ways that are both direct (e.g. on people) and indirect
a short lag between the end of the period under consider- (e.g. food mediated). Lancet Countdown CCIEVIs also
ation and the publication of the data; the calculation must track vulnerabilities to extreme heat, incorporating the
be practicable with existing and future resources. proportion of the population over 65 years of age, the
prevalence of predisposing chronic diseases (i.e. diabe-
WG1 indicators have evolved over the five years that tes and cardiovascular, respiratory, and renal disease),
they have been reported in the annual Lancet Countdown the proportion of the population living in urban areas,
publications so to fulfil above-listed criteria. For exam- and the number of outdoor workers. In the 2021 report,
ple, in 2020, there were twelve WG1 Lancet Countdown the vulnerability of children younger than 1 year to life-
CCIEVIs, almost double the number of when they first threatening heatwaves was added [36]. Lancet Count-
appeared in 2016 [28, 32]. As well as new indicators being down CCIEVIs also consider vulnerability linked to the
introduced each year, established indicators are revised capacity of local health services to respond to public
to reflect the latest evidence in the scientific literature health risks and emergencies.
and the needs of new and emerging stakeholders [30,
31]. The revision of Lancet Countdown CCIEVIs occurs Data and methods for developing CCIEVIs
annually by experts across a broad range of relevant dis- Hazards, exposures, and vulnerabilities change over
ciplines, including climate, geography, epidemiology, time and across space as do their interactions as a result
and occupation health. The publication of an appendix of changes in the climate. Consequently, climate change
alongside each Lancet Countdown annual report ensures amplifies or diminishes existing health impacts, and
that the data and methods underlying every CCIEVI are induces or suppresses new ones with a high degree of
explicitly cited and described along with possible caveats. spatial and temporal variability. Geographic information
systems, and more specifically geospatial data, have long
Main components of CCIEVIs been identified as useful analytical tools for monitoring
Lancet Countdown CCIEVIs focus on three main com- the health-climate system at all spatial levels, from local
ponents: hazard, exposure, and vulnerability. These are to global [37].
defined according to the terminology provided by the Many relevant sources for CCIEVIs provide the data as
United Nations Office for Disaster Risk Reduction and rasters, i.e. grids of cells. This allows information, such
Di Napoli et al. BMC Public Health (2022) 22:663 Page 4 of 8

as variations in climate-relevant variables like air tem- ship can also foster the development of CCIEVI-
perature, to be represented in a spatially continuous and based initiatives in locations where these are cur-
consistent way across the Earth’s surface. Usefully, rasters rently missing but are perceived as useful [42–46].
can be stacked to assess cumulative hazards in a given Over the long term, partnerships can expand the
region or to produce spatially resolved time series of a areas where CCIEVIs drive decision-making as well
given variable. as increase workforce preparedness via the inclusion
Environmental data are nowadays available as rasters of climate change curriculum into health professional
across a wide range of spatial and temporal scales. This education [47–50].
makes them an ideal tool for constructing relationships 2. Iterative process: To satisfy the timeliness criteria of
between hazards, exposed elements, and associated vul- CCIEVIs, their design and utility must be revised
nerability anywhere in the world, low and middle income periodically [21]. Every year, Lancet Countdown
countries included [38]. For instance, one of the Lancet CCIEVIs indicators undergo a thorough quality
Countdown CCIEVIs tracks the climatic suitability for check and improvement process before being con-
the transmission of Plasmodium falciparum, the parasite sidered for the annual report. In this process, inde-
causing malaria. Following the work by Grover-Kopec pendent experts assess the quality and suitability of
and colleagues [39], the indicator tracks the number of each indicator and provide constructive feedback to
months per year suitable for malaria transmission as the aid their development and improvement. Addition-
coincidence of precipitation accumulation greater than ally, new CCIEVIs can be developed and added to the
80 mm, average temperature between 18 °C and 32 °C, original indicators suite to provide a more complete
and relative humidity greater than 60%. The number of description of the climate-health system.
suitable months in a year is calculated for each grid cell 3. Going local: Because CCIEVIs are provided as geo-
by overlaying precipitation, temperature, and humidity spatial data, they are down-scalable and able to
raster layers across twelve months. Year-by-year changes identify priority areas for public health intervention
in the number of suitable months generate a time series, across the globe. Location-specific CCIEVIs can
which can be spatially aggregated (e.g. for highland vs assist local health departments in tracking varia-
lowland areas). tions in community exposure and vulnerability to cli-
CCIEVIs can be explored via an online visualization mate change, uncovering health impacts at regional
platform. For example, maps represent a powerful way to or sub-regional level (including their linkages to the
visualise and communicate climate information, and har- surrounding urban/natural environment), designing
ness the latter for action [40]. CCIEVIs can be displayed interventions to enhance community resilience and
as a set of world-wide maps that can be navigated via an evaluating the effectiveness of implemented inter-
interactive, user-friendly interface to show year-specific ventions [51, 52]. With this motivation, the Lancet
data or to highlight countries or geographical areas of Countdown CCIEVIs structure has been replicated
interest, as has been done by the Lancet Countdown [41]. to produce the Australia and China reports with
indicators being provided at national to regional and
Perspectives and improvements for CCIEVIs city scales [53, 54]. These local reports may serve as
Climate change is an evolving phenomenon and our a guidance for disseminating progress on CCIEVIs
understanding of it is also evolving. Only with the most from other countries in a uniform format. Every year,
up-to-date data, methodologies, and expertise, CCIEVIs the Lancet Countdown report is also followed by a
can provide the quantitative underpinnings of a compel- range of resources, such as briefs for policymakers
ling narrative on the health impacts that climate change and translations of the executive summaries, tailored
imposes across the globe. Based on our experience from to specific cities, countries and geographical areas
the Lancet Countdown, we here report the main points [55–57].
CCIEVIs might consider to be meaningful and useful in 4. Data: CCIEVIs typically have to rely on differ-
their purpose. ent sources for the provision of health, climate, and
demographics data. They therefore may well differ
1. Partnership: The cross-cutting nature of CCIEVIs in the spatial resolution, the time period covered,
demands a combination of skills, knowledge and data and the reference baseline used for the definition
that span across institutions, disciplines, countries, of extreme events. Notwithstanding this, consist-
and geographical regions. Creating and maintaining ency in climate data and demographics among Lan-
a long-term collaboration among a group of diverse cet Countdown CCIEVIs has been attempted and
experts is crucial to guaranteeing the robustness and achieved wherever possible so that indicators are
reliability of developed CCIEVIs over time. Partner- compatible and comparable with each other. It is
 Di Napoli et al. BMC Public Health (2022) 22:663 Page 5 of 8

worth noting that protocols are in place for the effec- ers of hazard, exposure and vulnerability. It can also
tive archival, management, analysis, delivery, and use be applied to different CCIEVIs to assess multiple cli-
of climate data, whereas health data standardisation mate change impacts in a single location. This could
is an open topic [58, 59]. The collection and reporting allow for a one health perspective if CCIEVIs at the
of public health data, for instance, vary greatly across human–animal–environment interface are imple-
nations and healthcare organizations [60]. Data mon- mented [67, 68]. For instance, concerning food secu-
itoring on disease incidence or health outcomes that rity of terrestrial assets, a CCIEVI tracking changes
are standardised at a global level is in general lacking. in crop yield potential due to rising temperatures
In most cases, health impacts are therefore tracked could be overlayed with CCIEVIs monitoring ani-
using epidemiological models rather than measured mal-source foods and/or the effects of environmental
records. Furthermore, their geographical resolu- changes on diseases of livestock and crops. In either
tion is generally lower than climate data (i.e. country case, the identification and tracking of climate-health
level rather than at raster cell level). Unlike climate hotspots and incorporation into a monitoring sys-
data, health records are generally not publicly avail- tem, could improve further public health action, par-
able. Creating open-access online databases for pub- ticularly in the context of reducing the likelihood of
lic health data would help foster knowledge exchange systemic health crises [69].
between the climate and the public health commu- 3. Inequality and inequity: Global indicators generally
nity, as well as promote its applicability at all scales. do not provide a nuanced picture of the differenti-
ated impacts of climate change on health by country
CCIEVIs can be used as a starting point for broader and region, or across populations within countries.
explorations of the linkages between climate change and Disaggregating indicators by relevant socioeconomic
health that have relevance for policy making. Here we and occupational characteristics (e.g. income, gen-
suggest six specific areas for future research, many of der, race or ethnicity, disability, occupation, and age)
which are currently being pursued by WG1 authors. is necessary to measure inequalities in exposure to
climatic risk factors and health outcomes attribut-
1. Looking to the future: In the Lancet Countdown, able to these exposures. For heatwaves, for instance,
CCIEVIs are used to track the current health impacts these may consider pregnancy and mental health [70,
of climate change, and contextualise them with 71]. With this approach, climate change and climate-
respect to the recent past. These indicators there- related risk factors are positioned as both environ-
fore hint at how the future will likely evolve without mental and social determinants of health.
efforts to mitigate and adapt to climate change. How- 4. Mental health: Mental health issues are closely inter-
ever, the methodology described in this research in twined with people’s geographical, social, environ-
practice article is time-agnostic and can be applied mental, financial, and political context, and any cli-
to indicators predictive of the future. Designing, mate-induced impact on physical health is also a risk
developing and implementing future projections of factor for mental health [72]. As such, factors linking
CCIEVIs presents additional research challenges, climate change to health may affect mental health
such as the choice of the climate prediction model and underlying mental health status can affect the
and its verification, but has the potential to provide capacity to adapt to (or to mitigate) climate change.
actionable information to support policymaking [61]. The description of the climate-health system, there-
2. Identifying hotspots: Climate change often affects fore, requires the inclusion of CCIEVIs that address
people and places in multiple ways. We define cli- the mental health consequences of climate change.
mate-health hotspots as locations where climate A growing body of literature is currently examining
affects people negatively through multiple pathways. these linkages [73–79], inspiring the development of
This definition builds upon work already established future CCIEVIS on the topic.
in the climatology field on mapping hotspots, i.e. 5. Attribution: In recent years, formal methods have
geographical areas where the combined occurrence been developed to identify changes in the occur-
of multiple weather extremes (compound events) is rence of adverse health outcomes, and to determine
observed [62, 63]. As adverse health effects occur the extent to which those changes may be attrib-
in populations that are already at risk from climate uted to climate change [80]. Multi-step attribution,
extremes and lack adequate health infrastructure for instance, consists of a) attributing an observed
[64–66], the overlay method described in this work change in a variable of interest to a change in cli-
can be adapted to identify climate-health hotspots mate or other environmental variable and b) attrib-
and trace them overtime by overlapping multiple lay- uting the change in climate to external drivers such
Di Napoli et al. BMC Public Health (2022) 22:663 Page 6 of 8

as greenhouse gas emissions [81]. The 2020 Lancet to which individuals and countries are able to adapt and
Countdown report showcased the attribution of build resilience. By unveiling the challenges underpin-
76 extreme weather events to climate change, and ning the evolution of the climate-health system in time
the effects that a selection of these have had on the and in space, CCIEVIs can be the pillars of a new public
health of the population [32]. Future CCIEVIs could health that safeguards and advances global wellbeing in
be based on attribution to quantitatively understand the decades to come.
how climate change makes extreme events associated
Acknowledgments
with health outcomes more likely. The authors are grateful to the three anonymous reviewers and the editor for
6. Embracing the unquantifiable: There are important their constructive comments.
aspects of the relationship between climate change
Authors’ contributions
and health that cannot be quantified or are very dif- CDN, AM, MR, SAK, WC, JC, SD, LEE, IK, TK, DK, YL, ZL, RL, JMU, CM, MML, KAM,
ficult to quantify meaningfully. One example of this is MR2, JCS, LS, MT, JAT, BNV, CB, and EJR authors planned and designed this
human migration [18]. Local-level studies find wors- manuscript. CDN prepared the first draft; CDN, AM, MR, SAK, WC, JC, SD, LEE,
IK, TK, DK, YL, ZL, RL, JMU, CM, MML, KAM, MR2, JCS, LS, MT, JAT, BNV, CB, and
ening food security where people move away from EJR provided input into subsequent drafts. CDN, AM, MR, SAK, WC, JC, SD, LEE,
places affected by sea level rise and saltwater intru- IK, TK, DK, YL, ZL, RL, JMU, CM, MML, KAM, MR2, JCS, LS, MT, JAT, BNV, CB, and
sion, or adverse psychosocial impacts of disrupted EJR authors read and approved the final manuscript.
lives, social networks and livelihoods for those on the Funding
move in a changing climate. It is extremely challeng- This work is supported by an unrestricted grant from the Wellcome Trust
ing, however, to attribute human mobility to climate (209734/Z/17/Z).
change (and quantify its magnitude), or to develop a Availability of data and materials
global CCIEVI that can quantify links between cli- Not applicable.
mate impacts, human mobility, and health.
Declarations
Ethics approval and consent to participate
Conclusions Not applicable.
In developing climate change impacts, exposures, and Consent for publication
vulnerability indicators (CCIEVIs), several key challenges Not applicable.
have to be addressed around the idea of representing
Competing interests
highly complex systems by a discrete set of quantifiable The authors declare that they have no competing interests.
indicators that are updated annually. One challenge is
to find globally relevant indicators, with data available Author details
1
 School of Agriculture, Policy and Development, University of Reading, Read‑
across a sufficiently large number of countries, that also ing, UK. 2 Department of Geography and Environmental Science, University
have local relevance. of Reading, Reading, UK. 3 Institute for Global Health, University College
A hazard, exposure, and vulnerability framework London, London, UK. 4 Institute for Risk and Disaster Reduction, University
College London, London, UK. 5 School of Global Studies, University of Sussex,
has proven to be an effective structure within the Brighton Falmer, UK. 6 United Nations University, Institute for Environment
Lancet Countdown initiative. Around such a frame- and Human Security, Bonn, Germany. 7 Ministry of Education Key Laboratory
work, Lancet Countdown CCIEVIs have been crafted, for Earth System modeling, Department of Earth System Science, Tsinghua
University, Beijing 100084, China. 8 Institute for Environmental Science, Univer‑
based on both data availability and the indicators’ sity of Geneva, Geneva, Switzerland. 9 Grantham Research Institute on Climate
relevance to climate change and human health. Over Change and the Environment, London School of Economics and Political
time these indicators have been improved and added Science (LSE), London, UK. 10 Centro Euro-Mediterraneo sui Cambiamenti
Climatici (CMCC), Venice, Italy. 11 Università Ca’ Foscari, Venice, Italy. 12 Depart‑
to, as data become available and methodologies are ment of Fish and Wildlife Conservation, Virginia Tech, Blacksburg, VA, USA.
refined. An ongoing challenge is how to incorporate 13
 University of Agder, Kristiansand, Norway. 14 Health and Environment Inter‑
those linkages between climate change and health national Trust, Nelson, New Zealand. 15 Rollins School of Public Health, Emory
University, Atlanta, USA. 16 Barcelona Supercomputing Center, Barcelona, Spain.
that are clear and well documented but at the same 17
 Catalan Institution for Research and Advanced Studies (ICREA), Barcelona,
time difficult to measure, quantify, and fit within this Spain. 18 Centre on Climate Change & Planetary Health and Centre for Mathe‑
framework. matical Modelling of Infectious Diseases, London School of Hygiene & Tropical
Medicine, London, UK. 19 Department of Genetics and Microbiology, Univer‑
Together, Lancet Countdown CCIEVIs present a com- sitat Autònoma de Barcelona (UAB), Barcelona, Spain. 20 School of Geography,
pelling visualisation of how climate change is increasingly Earth and Atmospheric Sciences, The University of Melbourne, Melbourne,
exposing people to the negative health impacts of climate Australia. 21 Preventive Medicine and Public Health Research Center, Psycho‑
social Health Research Institute, Iran University of Medical Sciences, Tehran,
change, both direct and indirect, across land and water. Iran. 22 MRC Centre for Global Infectious Disease Analysis, Imperial College
Ultimately the impact of climate change on human health London, London, UK. 23 MRC Unit The Gambia At London School of Hygiene
depends not only on the exposure and vulnerability of and Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia. 24 Iranian Fisher‑
ies Science Research Institute, Agricultural Research, Education, and Extension
populations to climate hazards, but also on the extent
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Organisation, Tehran, Iran. 25 Heidelberg Institute of Global Health, University 20. Kjellstrom T, Holmer I, Lemke B. Workplace heat stress, health and
of Heidelberg, Heidelberg, Germany. 26 Higher Institution Centre of Excellence productivity - an increasing challenge for low and middle-income
(HICoE), Institute of Tropical Aquaculture and Fisheries (AKUATROP), Universiti countries during climate change. Glob Health Action. 2009;2.
Malaysia Terengganu, 21030 Kuala Nerus, Terengganu, Malaysia. 27 Henan Prov‑ 21. Kenney MA, Janetos AC, Gerst MD. A framework for national climate
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Zhengzhou 450002, China. 28 Department of Electronics and Computer Sci‑ Environmental health indicators of climate change for the United
ence, Universidade de Santiago de Compostela, Santiago, Spain. States: findings from the state environmental health Indicator collabo‑
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