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Background Air pollution is a global, public health emergency. The effect of living in areas with very poor air quality on adolescents’ physical health is largely unknown. The aim of this study was to investigate the prevalence of adverse respiratory health outcomes among adolescents living in a known air pollution hotspot in South Africa. Methods Ambient air quality data from 2005 to 2019 for the two areas, Secunda and eMbalenhle, in the Highveld Air Pollution Priority Area in Mpumalanga province, South Africa were gathered and compared against national ambient air pollution standards and the World Health Organization Air Quality Guidelines. In 2019, adolescents attending schools in the areas completed a self-administered questionnaire investigating individual demographics, socio-economic status, health, medical history, and fuel type used in homes. Respiratory health illnesses assessed were doctor-diagnosed hay fever, allergies, frequent cough, wheezing, bronchitis, pneumonia and asthma. The relationship between presence (at least one) or absence (none) of self-reported respiratory illness and risk factors, e.g., fuel use at home, was explored. Logistic regression was used to estimate the odds ratio and 95% confidence interval (CI) of risk factors associated with respiratory illness adjusted for body mass index (measured by field assistants), gender, education level of both parents / guardians and socio-economic status. Results Particulate matter and ozone were the two pollutants most frequently exceeding national annual air quality standards in the study area. All 233 adolescent participants were between 13 and 17 years of age. Prevalence of self-reported respiratory symptoms among the participants ranged from 2% for ‘ever’ doctor-diagnosed bronchitis and pneumonia to 42% ever experiencing allergies; wheezing chest was the second most reported symptom (39%). Half (52%) of the adolescents who had respiratory illness were exposed to environmental tobacco smoke in the dwelling. There was a statistically significant difference between the presence or absence of self-reported respiratory illness based on the number of years lived in Secunda or eMbalenhle (p = 0.02). For a one-unit change in the number of years lived in an area, the odds of reporting a respiratory illness increased by a factor of 1.08 (p = 0.025, 95% CI = 1.01–1.16). This association was still statistically significant when the model was adjusted for confounders (p = 0.037). Conclusions Adolescents living in air polluted areas experience adverse health impacts Future research should interrogate long-term exposure and health outcomes among adolescents living in the air polluted environment.

Climate change threatens the health and well-being of populations. We conducted a risk assessment of two climate-related variables (i.e., temperature and rainfall) and associated water, sanitation and hygiene (WASH)-related exposures and vulnerabilities for people living in Mopani District, Limpopo province, South Africa. Primary and secondary data were applied in a qualitative and quantitative assessment to generate classifications of risk (i.e., low, medium, or high) for components of hazard/threat, human exposure, and human vulnerability. Climate-related threats were likely to impact human health due to the relatively high risk of waterborne diseases and WASH-associated pathogens. Vulnerabilities that increased the susceptibility of the population to these adverse outcomes included environmental, human, physical infrastructure, and political and institutional elements. People of low socio-economic status were found to be least likely to cope with changes in these hazards. By identifying and assessing the risk to sanitation services and water supply, evidence exists to inform actions of government and WASH sector partners. This evidence should also be used to guide disaster risk reduction, and climate change and human health adaptation planning.

Children spend a significant proportion of their time at school and in school buildings. A healthy learning environment that supports children should be thermally conducive for learning and working. Here, we aimed to study the relations between indoor classroom temperatures and learner absenteeism as a proxy for children’s health and well-being. This one-year prospective study that spanned two calendar years (from June 2017 to May 2018) entailed measurement of indoor classroom temperature and relative humidity, calculated as apparent temperature (Tapp) and collection of daily absenteeism records for each classroom in schools in and around King Williams Town, Eastern Cape province, South Africa. Classroom characteristics were collected using a standardized observation checklist. Mean indoor classroom temperature ranged from 11 to 30 °C, while mean outdoor temperature ranged from 6 °C to 31 °C during the sample period. Indoor classroom temperatures typically exceeded outdoor temperatures by 5 °C for 90% of the study period. While multiple factors may influence absenteeism, we found absenteeism was highest at low indoor classroom Tapp (i.e., below 15 °C). Absenteeism decreased as indoor Tapp increased to about 25 °C before showing another increase in absenteeism. Classroom characteristics differed among schools. Analyses of indoor classroom temperature and absenteeism in relation to classroom characteristics showed few statistically significant relations—although not exceptionally strong ones—likely because of the multiple factors that influence absenteeism. However, given the possible relationship between indoor temperature and absenteeism, there is a learning imperative to consider thermal comfort as a fundamental element of school planning and design. Furthermore, additional research on factors besides temperature that affect learner absenteeism is needed, especially in rural areas.

Background: Measuring national progress towards the Sustainable Development Goals (SDGs) enables the identification of gaps which need to be filled to end poverty, protect the planet and improve lives. Progress is typically calculated using indicators stemming from published methodologies. South Africa tracks progress towards the SDGs at a national scale, but aggregated data may mask progress, or lack thereof, at local levels. Objective: To assess the progress towards achievement of the SDGs in four low-income, rural villages (Giyani) in South Africa and to relate the findings to national SDG indicators. Methods: Using data from a cross-sectional environmental health study, the global indicator framework for the SDGs was applied to calculate indicators for Giyani. Local progress towards SDG achievement was compared with national progress, to contextualize and supplement national scale tracking. Findings: Village scores were mostly in line with country scores for those indices which were computable, given the available data. Low data availability prevented a complete local progress assessment. Higher levels of poverty prevail in the study villages compared to South Africa as a whole (17.7% compared to 7.4%), high unemployment (49.0% compared to 27.3%) and lack of access to information via the Internet (only 4.2% compared to 61.8%) were indicators in the villages identified as falling far short of the South African averages. Conclusions: Understanding progress towards the SDGs at a local scale is important when trying to unpack national progress. It shines a light upon issues that are not picked up by national composite assessments yet require most urgent attention. Gaps in data required to measure progress towards targets represents a serious stumbling block, preventing the creation of a true reflection of local and national scale progress.

Background Climate variables impact human health and in an era of climate change, there is a pressing need to understand these relationships to best inform how such impacts are likely to change. Objectives This study sought to investigate time series of daily admissions from two public hospitals in Limpopo province in South Africa with climate variability and air quality. Methods We used wavelet transform cross-correlation analysis to monitor coincidences in changes of meteorological (temperature and rainfall) and air quality (concentrations of PM2.5 and NO2) variables with admissions to hospitals for gastrointestinal illnesses including diarrhoea, pneumonia-related diagnosis, malaria and asthma cases. We were interested to disentangle meteorological or environmental variables that might be associated with underlying temporal variations of disease prevalence measured through visits to hospitals. Results We found preconditioning of prevalence of pneumonia by changes in air quality and showed that malaria in South Africa is a multivariate event, initiated by co-occurrence of heat and rainfall. We provided new statistical estimates of time delays between the change of weather or air pollution and increase of hospital admissions for pneumonia and malaria that are addition to already known seasonal variations. We found that increase of prevalence of pneumonia follows changes in air quality after a time period of 10 to 15 days, while the increase of incidence of malaria follows the co-occurrence of high temperature and rainfall after a 30-day interval. Discussion Our findings have relevance for early warning system development and climate change adaptation planning to protect human health and well-being.

The incidence of many serious childhood infections can be reduced by vaccination. High sun exposure at the time of vaccination has been associated with a reduced antigen-specific immune response. We hypothesized that providing sun protection advice and equipment to mothers of children who were waiting to be vaccinated would result in a more robust immunization response. We conducted a pilot study in 2015/2016 (data analyzed in 2017-2018) among 98 Black African children (~18 months of age) receiving the booster measles vaccination at two clinics in South Africa. Clinics were randomized to receive (or not) sun protection advice and equipment. We recorded demographic information on children and mothers and data on the child's usual sun exposure. At approximately 4 weeks' postmeasles vaccination, we measured measles immunoglobulin G levels in children. All children with blood results (n = 87, 89%) across both groups had antibody titers higher than 200 mIU mL-1 which was considered the protective antibody concentration. There was no statistically significant difference in titers between groups: geometric difference in mean titers 1.13 mIU mL-1 (95% CI 0.85, 1.51; P = 0.39) and 1.38 mIU mL-1 (95% CI 0.90, 2.11, P = 0.14) for unadjusted and adjusted analyses, respectively. This study demonstrated that a sun protection intervention study could be performed in a developing-world pediatric vaccination setting. Although the sun protection intervention around the time of vaccination was not associated with a higher antibody level, given the potential importance of such an effect, a larger study should be considered.

Background Photodamage is partially mitigated by darker skin pigmentation, but immune suppression, photoaging and cataracts occur among individuals with all skin types. Methods To assess practices and acceptability to Black African mothers of sun protection equipment for their children living in a rural area, participants were recruited at the time of their child’s 18-month vaccinations. Mothers completed a baseline questionnaire on usual sun behaviours and sun protection practices. They were then provided with sun protection equipment and advice. A follow-up questionnaire was administered two weeks later. Results Mothers reported that during the week prior to the baseline questionnaire, children spent on average less than 1 hour of time outdoors (most often spent in the shade). Most mothers (97%) liked the sun protection equipment. However, many (78 of 86) reported that their child did not like any of the sun protection equipment and two-thirds stated that the sun protection equipment was not easy to use. Conclusions Among Black Africans in rural northern South Africa, we found a mismatch between parental preferences and child acceptance for using sun protection when outdoors. A better understanding of the health risks of incidental excess sun exposure and potential benefits of sun protection is required among Black Africans.

Heavy metal pollution in soil poses a serious health threat to humans living in close proximity and in contact with contaminated soil. Exposure to heavy metals can result in a range of adverse health effects, including skin lesions, cardiovascular effects, lowering of IQ scores and cancers. The main objectives of this study were to (1) use a portable XRF spectrophotometer to measure concentrations of lead (Pb), arsenic (As), mercury (Hg) and cadmium (Cd) in residential soils in rural Giyani in the Limpopo province of South Africa; (2) to assess the spatial distribution of soil metal concentrations; and (3) to assess pollution levels in residential soils. There were elevated levels of As at one of the sites where 54% of soil samples exceeded the Canadian reference levels for As of 20 mg/kg. Using the geoaccumulation index (Igeo) to determine contamination levels of As, 57% of soil samples from the most polluted site were found to be moderately to heavily and extremely contaminated with As (Igeo class 2–5). The site is located near the Giyani Greenstone Belt, which is characterized by abandoned mines and artisanal mining activities. Gold ores are closely associated with sulphide minerals such as arsenopyrite, and these have been found to contain high amounts of As. This study highlighted the potential for soil contamination and the importance of site-specific risk assessment in the context of environment and health impact assessments prior to major developments, including human settlement developments.

Pneumonia is a leading cause of hospitalization in South Africa. Climate change could potentially affect its incidence via changes in meteorological conditions. We investigated the delayed effects of temperature and relative humidity on pneumonia hospital admissions at two large public hospitals in Limpopo province, South Africa. Using 4062 pneumonia hospital admission records from 2007 to 2015, a time-varying distributed lag non-linear model was used to estimate temperature-lag and relative humidity-lag pneumonia relationships. Mean temperature, relative humidity and diurnal temperature range were all significantly associated with pneumonia admissions. Cumulatively across the 21-day period, higher mean daily temperature (30 °C relative to 21 °C) was most strongly associated with a decreased rate of hospital admissions (relative rate ratios (RR): 0.34, 95% confidence interval (CI): 0.14–0.82), whereas results were suggestive of lower mean daily temperature (12 °C relative to 21 °C) being associated with an increased rate of admissions (RR: 1.27, 95%CI: 0.75–2.16). Higher relative humidity (&gt, 80%) was associated with fewer hospital admissions while low relative humidity (&lt, 30%) was associated with increased admissions. A proportion of pneumonia admissions were attributable to changes in meteorological variables, and our results indicate that even small shifts in their distributions (e.g., due to climate change) could lead to substantial changes in their burden. These findings can inform a better understanding of the health implications of climate change and the burden of hospital admissions for pneumonia now and in the future.

Background Vulnerable population groups in South Africa, especially those living in poverty, young children, women, the elderly and people with pre-existing diseases, are susceptible to new or exacerbated health threats resulting from climate change. Environmental Health Practitioners (EHPs) can play an important role in helping communities adapt to climate change health impacts, however, effective coordination of this requires further understanding of their roles in implementing climate change-related adaptation actions in communities. Methods A cross-sectional survey using convenience sampling was undertaken at the January 2017 conference for EHPs hosted by the South African Institute of Environmental Health in Cape Town. All EHPs who attended the conference were invited to complete a study questionnaire that requested information on participant demographics, as well as climate change related-knowledge, practices and perceptions. Results Majority of participating EHPs (n = 48; 72.8%) had received formal or informal training on climate change and health. Thirty-nine percent of EHPs indicated that they had a climate change and health-related committee / working group in their department, a policy or strategy (41.0%) and budget allocated for climate change and health-related work (51.5%). A total of 33.3% had participated in climate change-related projects. Majority (62.2%) of EHPs believed that they should play a supportive role in addressing climate change while 37.8% believed that EHPs should play a leading role. Conclusions Recognising the need for raising awareness about climate change adaptation as well as implementing appropriate interventions to combat climate-related ill health effects, especially among vulnerable groups, EHPs are well-placed to adopt significant roles in helping communities to adapt to climate change.

Increased temperatures affect human health and vulnerable groups including infants, children, the elderly and people with pre-existing diseases. In the southern African region climate models predict increases in ambient temperature twice that of the global average temperature increase. Poor ventilation and lack of air conditioning in primary health care clinics, where duration of waiting time may be as long as several hours, pose a possible threat to patients seeking primary health care. Drawing on information measured by temperature loggers installed in eight clinics in Giyani, Limpopo Province of South Africa, we were able to determine indoor temperatures of waiting rooms in eight rural primary health care facilities. Mean monthly temperature measurements inside the clinics were warmer during the summer months of December, January and February, and cooler during the autumn months of March, April and May. The highest mean monthly temperature of 31.4 ± 2.7 °C was recorded in one clinic during February 2016. Maximum daily indoor clinic temperatures exceeded 38 °C in some clinics. Indoor temperatures were compared to ambient (outdoor) temperatures and the mean difference between the two showed clinic waiting room temperatures were higher by 2–4 °C on average. Apparent temperature (AT) incorporating relative humidity readings made in the clinics showed ‘realfeel’ temperatures were >4 °C higher than measured indoor temperature, suggesting a feeling of ‘stuffiness’ and discomfort may have been experienced in the waiting room areas. During typical clinic operational hours of 8h00 to 16h00, mean ATs fell into temperature ranges associated with heat–health impact warning categories of ‘caution’ and ‘extreme caution’.

Background Vaccination is a mainstay of preventive healthcare, reducing the incidence of serious childhood infections. Ecological studies have demonstrated an inverse association between markers of high ambient ultraviolet (UV) radiation exposure (e.g., sunny season, low latitude of residence) and reduction in the vaccination-associated immune response. Higher sun exposure on the day prior to and spanning the day of vaccination has been associated with a reduced antigen-specific immune response independent of skin pigmentation. The South African Department of Health’s Expanded Programme on Immunisation provides free vaccinations in government primary health care clinics. In some areas, these clinics may have only a small waiting room and patients wait outside in full sun conditions. In rural areas, patients may walk several kilometres to and from the clinic. We hypothesised that providing sun protection advice and equipment to mothers of children (from 18 months) who were waiting to be vaccinated would result in a more robust immune response for those vaccinated. Methods We conducted an intervention study among 100 children receiving the booster measles vaccination. We randomised clinics to receive (or not) sun protection advice and equipment. At each clinic we recorded basic demographic data on the child and mother/carer participants, their sun exposure patterns, and the acceptability and uptake of the provided sun protection. At 3–4 weeks post-vaccination, we measured measles IgG levels in all children. Discussion This is the first intervention study to assess the effect of sun protection measures on vaccine effectiveness in a rural, real-world setting. The novel design and rural setting of the study can contribute much needed evidence to better understand sun exposure and protection, as well as factors determining vaccine effectiveness in rural Africa, and inform the design of immunisation programmes. (TRN PACTCR201611001881114, 24 November 2016, retrospective registration)