Introduction
China has faced greater environmental challenges than many other countries (Liu and Diamond 2005) and has experienced a remarkable transition in cause-specific mortality over the past three decades (Zhou et al. 2016). Major concerns relate to ongoing complex environmental degradation, including the deteriorating quality of air, fresh water, and soil (Liu and Diamond 2005). Attention has focused on the link between environmental factors and ill health as well (Yang et al. 2013). High levels of fine particulate matter (PM 2.5 ) have been associated with negative health effects (Yin et al. 2017; Chen et al. 2017). Among the world’s ten most populous countries, as of 2015, China had the largest number of deaths and disability-adjusted life-years (DALYs) attributable to PM 2.5 pollution (Cohen et al. 2017). In 2013, more than 16% of the national soil monitoring sites in China reported exceeding the limits of soil pollution standards, with 83% of this pollution caused by inorganic pollutants (MEPPRC and MLRPRC 2014). This soil pollution led to widespread heavy metal pollution in surface sediment (Ma et al. 2013). Soil pollutants such as arsenic have been associated with cancer incidence (Putila and Guo 2011) and mortality (Chen et al. 2015) in humans. In 2017, 8.3% of China’s surface water was still evaluated as the worst level in Chinese surface water quality standards (MEPPRC 2018), and serious surface water pollution in China’s main river basins was shown to be associated with cancer deaths (Ren et al. 2014; Yang and Zhuang 2014). Against the background of global warming, extreme weather occurred more frequently in China during the second half of the 20th century (Committee of National Assessment on Climate Change 2015). Unfortunately, the extreme temperature anomalies had a significant negative influence on the health of the Chinese population (Gasparrini et al. 2015).
Accordingly, the physical environment has become an important driver of health concerns in China, a country that has a varied geography, population, and landscape (Yang et al. 2013). The experiences of other developed countries in preventing and mitigating complicated health problems related to environmental degradation (Health Canada 2017; Public Health England 2017; U.S. CDC 2017) suggest that China could benefit greatly from integrating data from the surveillance of environmental hazards with information concerning health outcomes (Kyle et al. 2006; Litt et al. 2004; Strosnider et al. 2014; Thacker et al. 1996; Zhou and Jerrett 2014).
To integrate useful data resources, many developed countries have fostered national, regional, and international tracking systems that monitor environmental public health. Such systems include, among others:
The National Environmental Public Health Tracking Network (NEPHT) of the U.S. CDC (U.S. CDC 2017);
The Environmental Public Health Program in Canada (Health Canada 2017);
The European Environment and Epidemiology Network (E3) of the European Centre for Disease Prevention and Control (European Centre for Disease Prevention and Control 2017);
Apheis (Air Pollution and Health: A European Information System) (Medina et al. 2009);
The Aphekom (Improving Knowledge and Communication for Decision Making on Air Pollution and Health in Europe) surveillance systems in Europe (The Aphekom Project 2017);
The Environmental Public Health Surveillance system in the United Kingdom (EPHSS) (Public Health England 2017).
The International Network on Public Health and Environmental Tracking promoted by multiple countries is already in its early stage of development (INPHET 2014).
These national and multinational tracking systems aim to build an environmental public health network among various national authorities. They also intend to strengthen data support for environmental epidemiological research concerning local environmental health issues. These organizations endeavor to collect, integrate, analyze, interpret, and share environmental health data, and to explore the links between environmental hazards and public health. The integration of national data focused on the environment and public health has become part of a new, essential solution to urgent environmental health issues worldwide. Although environmental surveillance and health sectors (Table S1) in present-day China use various tracking systems, the systems are isolated from each other, leading to a gap in knowledge about the environment and public health because it is hard to link these systems due to the lack of information sharing mechanism across different departments. The integrated tracking framework simultaneously focuses on environmental hazards and health outcomes to better provide environmental public health information at the same spatiotemporal scale. The existing international experiences suggest that setting up such a network in China could reduce the gaps in knowledge.
The Chinese Environmental Public Health Tracking (CEPHT) project ( https://cepht.niehs.cn:8282/official.html) is an important effort recently initiated by the National Institute of Environmental Health, Chinese Center for Disease Control and Prevention (NIEH, China CDC). This project is officially endorsed and continuously funded and operated by NIEH, China CDC. This tracking project’s tasks include collecting, integrating, analyzing, and interpreting environmental and health data at various administrative levels ranging from provinces and cities to counties and villages. The intent of the project is to share information with related authorities to improve the national and local strategies for protecting public health. The CEPHT project has been included in China's environmental health development plan (2016–2025). As part of this planning effort, we have introduced the early stages of CEPHT’s constructive work and will continue to provide perspective regarding its future development.
The initial goal of CEPHT was to build an appropriate indicator framework for national environmental public health surveillance, with the intent to make these indicators readily available, transparent, testable, and scientifically sound (WHO 1999). To support this goal, the authors, who are part of CEPHT, conducted a large-scale review of the existing environmental epidemiology literature and environmental public health tracking systems across the world. To identify reliable indicators, we conducted a wide review of two types of literature: a) environmental epidemiological studies and b) studies of environmental health indicators. We used the results of the review to identify the basic elements of the framework, including exposure factors, health outcomes, and relative risk factors. Although interest in a wide range of health outcomes in environmental epidemiology is growing, only a few health outcomes have been connected to known environmental causes (Litt et al. 2004). To keep our work consistent and comparable with existing tracking indicators, we also conducted an Internet search to identify indicators used in those international tracking systems. We searched public health websites in the United States, United Kingdom, Canada, Australia, and the World Health Organization, using the terms “environmental public health tracking” or “environmental health tracking.” To ensure the availability of the indicators, we also interviewed the local Centers for Disease Control and Prevention in seven Chinese provinces and consulted several Chinese environmental epidemiologists to validate the candidate indicators. From this survey, we also obtained information on the priorities, resources, and shortages in local environmental public health, which should give us an opportunity to strengthen the practicality of the indicator system.
The current framework of environmental public health indicators (Figure 1) consists of environmental hazards, health outcomes, population, and other risk factors that together provide an integrated view of the growing number of complex environmental public health issues. The indicators were ranked in order of their value in supporting current scientific research in each category (environmental hazards, health outcomes, and population and risk factors). Ideally, all the indicators are sufficiently important to be included in CEPHT surveillance because they provide useful supporting data regarding various environmental health issues. However, at the current stage of CEPHT’s development, only essential indicators (as determined by the focus of scientific attention) and data-accessible indicators (that have mature surveillance systems) have been incorporated in CEPHT, such as air pollution and climatic factors, mortality of different causes, morbidity of specific diseases, and social-demographical indicators. (See the indicators shown in bold in Figure 1). CEPHT also provides a comprehensive and detailed list of publicly available data sources to quantify these environmental health indicators (Table S1). CEPHT’s ongoing work aims to integrate available datasets to support environmental health researchers interested in developing improved environmental health practices. In turn, this meaningful support may lead to an increased number of researchers entering the field and heightened interest on the part of policymakers.
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Environmental Hazards
As part of our work for the development of CEPHT, our review of previous findings indicated that air pollution, drinking water, soil pollution, and weather conditions are four outstanding issues related to public health. Each requires much targeted scientific research and management, and the abundant number of existing surveillance systems in China could provide data support. Air pollution indicators are more easily obtained than other indicators because an air pollution monitoring network already covers China’s main cities (Figure 2). The air quality monitoring data are available now for public download from the websites listed in Table S1. The pollution of drinking water has been monitored in China since 2007 (NHFPCPRC 2007). However, this data set is an internal resource available within a public health organization only, and it is not open to the public. This restriction demonstrates that collaborations are essential for obtaining data and quantifying the relative indicators. Data obtained from monitoring surface water quality in China are publicly available. The Ministry of Environmental Protection (MEPPRC 2017) regularly publishes weekly, monthly, and yearly water quality evaluation reports.
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During 2005–2013, China conducted a national-scale soil-quality monitoring initiative organized by the Ministry of Environmental Protection (2014). In 2011, China began national rural environmental health monitoring for biochemical and heavy metal pollutants across the whole country (China CDC 2011). The monitoring data fully captured yearly variances in soil pollutants. The framework shown in Figure 1 includes all the current monitoring factors related to soil pollution as indicators to promote future environmental epidemiological studies. Different data sources (Table S1) lead to a large range of meteorological data with high availability, which helps capture the differences between temperature-related health effects in various regions of this large and geographically diverse country. Figure 3 shows the spatial distribution of Chinese national-level monitoring sites. Differences among data from different sources always occur due to variations in data monitoring and processing; therefore, evaluation of data quality should focus on when to use which data.
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Health Outcomes
Environmentally related mortality and morbidity are identified when environmental hazard exposure becomes a contributing cause of deaths and hospital admissions (English et al. 2009). Therefore, the indicator framework suggests several important health outcomes that have drawn increasing attention, including cardiovascular diseases (Cao et al. 2011), respiratory diseases (Lai et al. 2013), mental disorders (depression and anxiety) (Jacobs et al. 1984; Pun et al. 2017; Wang et al. 2014; Wang et al. 2018), negative impacts on births, such as preterm births and low birth weights (Fleischer et al. 2014; Li et al. 2017; Qian et al. 2016; Wang et al. 2018; Xu et al. 1995), and cancers (Chen et al. 2016).
Regarding related mortality rates, China CDC’s Death Surveillance Point System has been collecting death data reported annually from 605 surveillance sites since 2013, covering 24.3% of the total population in China (Liu et al. 2016). For morbidity, hospital admission case data capture the acute effects of exposure to environmental hazards. In some developed regions in eastern China, morbidity surveillance of five chronic diseases (heart disease, stroke, hypertension, diabetes, and cancer) by public health departments also provide regional tracking data for each of the five diseases. However, the records are confidential, and usually the resulting data are shared only within the particular surveillance system.
Similarly, data reflecting reproductive outcomes are confidential. Since 2010, China has maintained the National Free Preconception Health Examination Project to follow a national cohort of pregnancy outcomes across 1,714 counties in 31 provinces (Peng et al. 2014; Wang et al. 2018). An electronic system was built and implemented at each of the tracking sites to gather information about the participants’ basic characteristics, clinical records, and follow-up records. Issues regarding data availability are the result of the confidential nature of the information.
Population Data and Risk Factors
Ideally, population characteristics and risk factors derived from daily life can be used to identify at-risk groups, evaluate vulnerabilities, and understand factors that might amplify or reduce health effects related to environmental hazards (U.S. CDC 2017). These factors may be included in epidemiological research as confounders or modifiers to identify accurately the exposure–response relationships. The 10-y census data are useful for tracking population information, including demographic characteristics and local population structures (Table S1). Risk factors associated with personal living environments and lifestyle choices may be obtained from various social surveys [Figure 4 shows the areas surveyed in a national survey, (The University of North Carolina 2019)]. Because social surveys are carried out by various organizations, the survey data often are distributed in a manner too scattered to be collected. Therefore, we listed several national-scale surveys, based on our extensive search of websites and the literature (Table S1). Most of the data covering individual lifestyles are open to the public, but some sources charge fees or require data use agreements. Geographical information data sets can reveal the risks brought by living surroundings. Several open data sets tracking lifestyle factors by geographical location are listed in Table S1 (Figure 5 presents the distribution of national GDP in 2000).
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Discussion
As described above, CEPHT plans to build a complete system that will integrate current existing data sets relevant to important environmental health issues (which has been completed), provide data sharing, and offer data-processing technical support to environmental health researchers in future decades. CEPHT aims to explore the relationships between environmental hazards and health effects and to offer solutions for effective public health strategies. By now, further progress has been made by the CEPHT since the framework was established. First, based on the current framework, CEPHT’s electronic data tracking system has been developed ( https://cepht.niehs.cn/iehs/goto/blogin). Twenty-nine Chinese local CDCs participated in this tracking work (Figure 6). Environmental hazard data and health effects data from 29 Chinese counties during 2013–2017 have been reported through the electronic system by local CDCs. To ensure the compatibility of data from different counties, the workforce undergoes training once annually, in which a unified data uploading table (data template) for each category of data is introduced and standardized data reporting processes are emphasized. Second, we have also added data quality checking tools to CEPHT’s electronic data system. Using these tools, surveillance data can be checked and cleaned automatically based on which data quality scores can be calculated and ranked quickly among the 29 participating counties. This capability will allow us to improve and promote data collection using feedback from the system. As indicated by the result of data quality checking on the collected data sets, a high rate of absence of some key factors (e.g., missing rate could be 100% in emergency data in most counties) is the main quality issue. Relatively high compatibility of the data is attributable to the use of the data template. Third, multiple data sets about various environmental hazards and health outcomes are collected, and they could be easily linked by county name, which may facilitate future studies of environmental health. More data sets will be collected because there is sustainable funding support from NIEH, China CDC.
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Gaps and Future Needs
The comprehensive nature of environmental hazards and environmental health effects makes clear that CEPHT needs to develop a wider scope, but it also leads to a higher possibility of accomplishing this expansion. Nonetheless, several current critical gaps pose barriers and limitations that could block CEPHT from achieving all the potential of the proposed framework. In the following section, we will discuss the current gaps in data availability, based on our literature search and working experience.
Gaps Exist in Data Availability
The lack of access to data, combined with inadequate data quality, especially health data, makes it difficult to link environmental hazards to their effects on public health in China. First, wide coverage and high spatiotemporal resolution of air pollution is necessary for designing scientific epidemiological investigations. However, national site-monitoring data on air pollution in China have been publicly available only since 2013. Although some models of PM 2.5 data were established before 2013 (Ma et al. 2016), limited high-resolution PM 2.5 data are available. For this reason, it is difficult to match accurate concentrations of PM 2.5 exposure and assess long-term health effects caused by PM 2.5 . To fill the geographical and temporal data gaps, current trends focus on developing future statistical models that will use multiple parameters to estimate ground-level concentrations at high spatiotemporal resolution (You et al. 2016; Zhan et al. 2017; Zhan et al. 2018). Satellite-retrieved data, land use data sets, meteorological characteristics, pollutant emissions inventory, and monitored site data will be included in these models to provide higher efficiency in predicting concentrations. This input can result in more precise spatiotemporal resolution of concentrations (Di et al. 2017; Zhan et al. 2017). Besides, in China currently, research based on the collection of real-time air pollution data is emerging, aiming to provide accurate individual exposure data for epidemiological studies (Sun et al. 2018). Portable equipment has been introduced and locally developed to capture real-time personal exposure to air pollutants such as PM 2.5 and black carbon (Cai et al. 2013; Sloan et al. 2016). Furthermore, web-based real-time personal exposure monitoring systems that integrate monitoring equipment, global position system (GPS) technology, and wearable devices recording health status and time–activity patterns, are developing as a low-cost and low-labor method to gather valuable individual exposure data and possibly support large-scale environmental epidemiological studies (Sun et al. 2018). We have no doubt that when the technology is sufficiently mature, integrating the above future trends, related systems, and equipment into CEPHT to support these statistically modeled data sets will benefit individuals, researchers, and decision-makers. The data inclusion may be implemented gradually in the next development stage of CEPHT.
Data regarding the risk factors are still scarce, and there is substantial uncertainty about the health effects of many common risk factors (such as smoking and physical activity) (Chen et al. 2011). Domestic air conditioning use is not tracked, but it is an important indicator modifying heat-related health effects and influencing heat vulnerability and adaptation (Reid et al. 2009). Lifestyle indicators, such as smoking and dietary practices, are investigated in certain areas only. Although the national-scale survey on smoking prevalence was conducted in 336 sites covering 31 provinces (China CDC 2016), city-specific smoking rates were published in only 14 Chinese cities (Liang 2015). The famous Kadoorie Study of Chronic Disease in China [also known as the Chinese Kadoorie Biobank (CKB cohort)] followed the lifestyle habits of over 0.5 million adults in 10 Chinese cities, including both urban and rural regions (Chen et al. 2011). Based on the Kadoorie study, new results are continually reported in academic articles (Chen et al. 2011).
Considering that the shortage of data regarding risk factors is a common limitation in environmental health studies, we think it would be beneficial if the Chinese national census were to expand the scope of data collection to include more risk factors on a county-by-county basis in the future. However, such an improvement could not be realized in the near term, so adoption of open resources may be explored further, as listed under “Population and risk factors” in Table S1. These data sets support data applications, and they provide individual-level information for environmental epidemiology studies. In these open data sets, coarse address data of the participants, such as the province, county, and city where the participants are located, could be used to link exposure and health effects. Data indicating province, city, or county could be obtained by providing detailed data application materials. To date, home addresses are not available, but should that information become available in the future, CEPHT will give careful consideration to the issues involved in sharing individual private data.
With respect to data quality, the ongoing disease surveillance systems do not offer effective coverage of all the environmentally related diseases that occur in China’s large, heterogeneous population, so the data gathered by these systems thus far have limited application (Peng et al. 2005; Zhang et al. 2018). In particular, population morbidity data are not sufficiently applicable. First, lack of a standard national medical information network leads to scattered and ineffective access to population morbidity data (Shan et al. 2017). Second, lack of standardized design among medical electronic systems leads to inconsistency in data quality. One key barrier is inconsistent adoption of the International Classification of Diseases (ICD) codes among recordkeeping systems in various hospitals (Zhang et al. 2018). Based on our field survey of medical data quality in local CDCs, hospital records in undeveloped areas might not even use ICD coding, making morbidity data difficult to identify or apply.
In our experience, another problem is that inconsistency across electronic database designs hampers attempts to directly integrate morbidity data that has been gathered from different medical organizations. The county-level prevalence of noncommunicable diseases is unclear as well. In the long term, a nationally standardized disease tracking network and the use of electronic records of citizens’ medical care may provide a useful solution to solve this challenge. In the near term, the development of data cleansing techniques to extract critical information from hospital case data, identify disease categories, and link them with exposure to environmental hazards may be helpful to overcome this barrier. Instead of hiding all the original case data, the ongoing surveillance systems may improve their data-sharing strategies. Incidence or prevalence rates and periodical numbers of mortality or morbidity, as derived from case data, could be opened to all relevant groups, such as researchers in the domains of epidemiology, public health, clinical studies, and the environmental sciences.
Gaps Exist between CEPHT and Advanced Tracking Systems
Based on our survey of international tracking systems, we have identified gaps in environmental public health tracking between China and the developed countries. First, as an integrated approach to monitoring the relationships between environmental hazards and public health, tracking systems in developed countries include more indicators so that a greater number of environmental health issues can be addressed. In comparison with CEPHT, with four thematic environmental hazards in its primary development stage, the U.S. NEPHT focuses on nine environmental hazards (U.S. CDC 2017). The additional five elements of NEPHT are pesticide exposure, community design, community characteristics, drought, and sunlight/UV exposure. The tracking system of Canada also considers food security, solid waste, facilities inspections, and housing health (Health Canada 2017). These indicators are more detailed to link exposure and public life. The less-thematic tracking by CEPHT results mainly from the limitations of data availability. Currently, including data that cover all environmental hazards and health outcomes is difficult. The CEPHT will eventually increase the number of surveillance indicators to include noise, radiation, and the mortality and morbidity of heatstroke, which are associated with urbanization and climatic extremes and have contributed to disease burden. Furthermore, the developed countries have systems that track and share data with the public by supporting local data queries and views in maps, tables, and charts (U.S. CDC 2018a) and allowing downloading of specific datasets (U.S. CDC 2018b). For example, NEPHT could provide data sets for future projections of extreme heat and offer modeled air pollution data in locations that lack monitoring sites. Although not all the tracking systems provide data-sharing services, as the first successful tracking network, NEPHT supports quick data queries and data visualization (U.S. CDC 2019), which may be a good model for CEPHT’s data sharing.
Next Steps to Fill the Gaps
Overall, to address the identified data limitations and close the gaps, we propose that the following three changes be implemented as part of the next steps of the CEPHT.
1. Proper Data Sharing Schemes Is Planned to Be Constructed
CEPHT has already taken the initial step by building a system that links and integrates data from various ongoing environmental monitoring and health surveillance projects. Environmental health data from 29 counties has been accumulated already. As the next step, data applications should be enabled in this system to support the use of data for epidemiological research. Shared data sets will be available to the public. Research communities and other agencies from different fields will be able to access the data by filing a formal application for data access that would be required and checked by CEPHT, so that data could be shared for significant research work. Data sets that might be shared during this early stage could include ambient air pollution monitoring data, modeling air pollution data of specific Chinese regions, meteorological data, and some national lifestyle survey data. We are now planning the data sharing schemes and preparing the datasets to be shared.
Furthermore, to address data security concerns, data sharing can be indirect, as demonstrated by the U.S. CDC’s NEPHT system. Although the original data in NEPHT is not open, data queries and mapping visualizations are provided to the public (U.S. CDC 2019). Similarly, the number and categories of data sets to be shared by CEPHT for different stakeholders will be decided by considering different levels of authority. Currently, CEPHT is working on developing new functionality for data visualization in the electronic data system.
Another approach would be to share environmental health data in a scientific and uniform manner by using data set products. Our literature review indicated that many relevant data sets are available as products (English et al. 2009), such as satellite-derived PM 2.5 data sets (Ma et al. 2016) and meteorological data sets in the United States (NOAA 2018). These products could present data that are formatted cleanly after preprocessing, provide data visualization, and support individualized data queries and downloads. Such data products are still uncommon in China. Their development and use will be the focus of a critical effort conducted by CEPHT in the next step. Actually, some of our modeling work has been done recently (Zhao et al. 2019), and the simulated regional air pollution data will be considered for sharing later. An important consideration is that, because of the confidential nature of some of the data, especially individual health information, data-sharing efforts will need to adopt mechanisms and protocols to ensure that the information being exchanged is accessible to authorized users only. Technology to enforce security will need to be developed and would be essential for protected data sharing. Possible means of effecting this may include sharing individual data after de-identifying sensitive information, such as individual names, home addresses, and phone numbers.
2. Close Attention to Information Sharing and Exchange among Different Organizations
The link between environmental hazards and health effects in a broader geographic, socioeconomic, and cultural context could produce timely, accurate, and systematic conclusions regarding public health problems. This approach could drive efficient policies for public health protection (Jian et al. 2017), enhancing the practice of environmental health by increasing collaboration between environmental departments and public health authorities. To date, CEPHT has collaborated with 29 county-level CDCs and linked with several universities and institutions. This type of interdisciplinary collaboration generally results in the development of reasonable data-sharing agreements among different official agencies, including environmental and medical organizations, academic institutions and universities, and nongovernmental organizations, to replace the practice of keeping data proprietary.
3. Improvement in Data-Handling Techniques to Enhance Data Quality and Application
Providing technical tools and guidelines for data cleaning and processing may help to promote the full use of these available public data resources by researchers and policymakers at the local and national levels. The technical tools for primary data quality assessment and cleaning have been applied in CEPHT’s electronic data system. In the next step, we plan to develop techniques to extract valuable information from multiple data sources and to link environment and health data. Multiple-center studies related to environmental health risk assessment in the current counties may be proposed in the near future.
Because the CEPHT has been listed as a key participant in China’s environmental health development plan (2016–2025), this tracking work will be continuously funded by NIEH, China CDC. In the near future, more local CDCs may participate in CEPHT, and the tracking networks are expected to spread eventually. In this way, CEPHT can be used to reduce recognized gaps.
Conclusion
Environmental health research and public health policies may benefit from the fundamental indicator framework and the results of the exploration of data sources summarized in this article. This work offers researchers an important opportunity to be informed about available data and improve their data collection strategies.
Acknowledgments
This work was funded by grants from the National Natural Science Foundation of China (grant 91543111), Beijing Natural Science Foundation (7172145), National High-level Talents Special Support Plan of China for Young Talents, and Environmental Health Development Project of the NIEH, China CDC.
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Abstract
Many developed countries use environmental public health tracking to gain a better understanding of the link between environmental hazards and public health. To respond to complicated environmental health issues, the National Institute of Environmental Health (NIEH), Chinese Center for Disease Control and Prevention (China CDC), has begun to build a Chinese Environmental Public Health Tracking (CEPHT) system. On behalf of the CEPHT, authors provide insight into the CEPHT’s development, current status, and future plans. In the initial stage of CEPHT, an indicator framework linking environment and public health that included a list of publicly available data sources regarding environmental hazards, public health outcomes, and risk factors in China was developed. An analysis of data availability, along with a comparison between CEPHT’s indicator system and other tracking networks, revealed the existence of barriers and gaps in data integration that affect China’s ability to track environmental public health. The lack of access to data, combined with inadequate data quality, has led to difficulties linking environmental hazards to their effects on public health. Current CEPHT efforts will help integrate environmental factors and exposure data with public health outcomes. For the near future, CEPHT plans to focus on increasing collaboration among data tracking agencies, improving data quality, and expanding proper data sharing.
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