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Exposure to arsenic even at low levels can lead to adverse health outcomes, however, there is a paucity of research from South Africa in relation to human exposure to arsenic. We investigated long-term exposure of residents in Limpopo province, South Africa, in a cross-sectional study by analysing water, soil and blood arsenic concentrations from two arsenic-exposed (high and medium–low exposure) villages and one non-exposed (control) village. There were statistically significant differences in the distribution of arsenic in water, soil and blood amongst the three sites. The median drinking water arsenic concentration in the high-exposure village was 1.75 µg/L (range = 0.02 to 81.30 µg/L), 0.45 µg/L (range = 0.100 to 6.00 µg/L) in the medium- / low-exposure village and 0.15 µg/L (range = p-value = 0.031). There was also a statistically significant correlation between arsenic concentrations in participants’ blood and soil samples collected from gardens (p-value = 0.051). Univariate quantile regression found that blood arsenic concentrations increased by 0.034 µg/L (95% CI = 0.02–0.05) for each one unit increase in water arsenic concentrations (p p-value = 0.009) demonstrating that blood arsenic is a good biomarker of arsenic exposure. Our findings also provide new evidence for South Africa on the association between drinking water and arsenic exposure, emphasising the need for the provision of potable water for human consumption in areas with high environmental arsenic concentrations.

Global heating is considered one of the greatest threats to human health and well-being. Supporting human resilience to heating threats is imperative, but under-investigated. In response, this article reports a study that drew together results from quantitative data on perceptions of thermal comfort and mechanisms for coping with thermal discomfort among 406 households in a study in Giyani, Limpopo province. Indoor dwelling and outdoor temperatures were also analysed. Most participants perceived their dwellings to be too hot when it was hot outdoors. People relied on recommended heat health actions such as sitting outdoors in the shade or opening windows. While this agency is meaningful, resilience to climate change requires more than personal action. In light of the climate threats and climate-related disaster risks facing South Africa, an all-encompassing approach, including education campaigns, climate-proofed housing, access to basic services, and financial considerations that will help support resilient coping among South Africans, is urgently required.

Prolonged exposure to high temperatures can cause heat-related illnesses and accelerate death, especially in the elderly. We developed a locally-appropriate Healthy Environment Assessment Tool, or ‘HEAT’ tool, to assess heat-health risks among communities. HEAT was co-developed with stakeholders and practitioners/professionals from the Rustenburg Local Municipality (RLM), a setting in which heat was identified as a risk in an earlier study. Feedback was used to identify vulnerable groups and settings in RLM, consider opportunities and barriers for interventions, and conceptualize a heat-health vulnerability assessment tool for a heat-resilient town. Using information provided by the RLM Integrated Development Plan, the HEAT tool was applied in the form of eight indicators relating to heat-health vulnerability and resilience and areas were evaluated at the ward level. Indicators included population, poverty, education, access to medical facilities, sanitation and basic services, public transport, recreation/community centres, and green spaces. Out of 45 wards situated in the municipality, three were identified as critical risk (red), twenty-eight as medium-high risk (yellow), and six as low risk (green) in relation to heat-health vulnerability. Short-term actions to improve heat health resilience in the community were proposed and partnerships between local government and the community to build heat health resilience were identified.

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.

Diarrhea contributes significantly to global morbidity and mortality. There is evidence that diarrhea prevalence is associated with ambient temperature. This study aimed to determine if there was an association between ambient temperature and diarrhea at a rural site in South Africa. Daily diarrheal hospital admissions (2007 to 2016) at two large district hospitals in Mopani district, Limpopo province were compared to average daily temperature and apparent temperature (Tapp, ‘real-feel’ temperature that combined temperature, relative humidity, and wind speed). Linear regression and threshold regression, age-stratified to participants ≤5 years and >5 years old, considered changes in daily admissions by unit °C increase in Tapp. Daily ranges in ambient temperature and Tapp were 2–42 °C and −5–34 °C, respectively. For every 1 °C increase in average daily temperature, there was a 6% increase in hospital admissions for diarrhea for individuals of all ages (95% CI: 0.04–0.08; p < 0.001) and a 4% increase in admissions for individuals older than 5 years (95% CI: 0.02–0.05; p < 0.001). A positive linear relationship between average daily Tapp and all daily diarrheal admissions for children ≤5 years old was not statistically significant (95% CI: −0.00–0.03; p = 0.107). Diarrhea is common in children ≤5 years old, however, is more likely triggered by factors other than temperature/Tapp, while it is likely associated with increased temperature in individuals >5 years old. We are limited by lack of data on confounders and effect modifiers, thus, our findings are exploratory. To fully quantify how temperature affects hospital admission counts for diarrhea, future studies should include socio-economic–demographic factors as well as WASH-related data such as personal hygiene practices and access to clean water.

Cardiovascular diseases (CVDs) have a high disease burden both globally and in South Africa. They have also been found to be temperature-sensitive globally. The association between temperature and CVD morbidity has previously been demonstrated, but little is known about it in South Africa. It is important to understand how changes in temperature in South Africa will affect CVD morbidity, especially in rural regions, to inform public health interventions and adaptation strategies. This study aimed to determine the short-term effect of apparent temperature (T(app)) on CVD hospital admissions in Mopani District, Limpopo province, South Africa. A total of 3124 CVD hospital admissions records were obtained from two hospitals from 1 June 2009 to 31 December 2016. Daily T(app) was calculated using nearby weather station measurements. The association was modelled using a distributed lag non-linear model with a negative binomial regression over a 21-day lag period. The fraction of morbidity attributable to non-optimal T(app), i.e., cold (6-25 degrees C) and warm (27-32 degrees C) T(app) was reported. We found an increase in the proportion of admissions due to CVDs for warm and cold T(app) cumulatively over 21 days. Increasing CVD admissions due to warm T(app) appeared immediately and lasted for two to four days, whereas the lag-structure for the cold effect was inconsistent. A proportion of 8.5% (95% Confidence Interval (CI): 3.1%, 13.7%) and 1.1% (95% CI: -1.4%, 3.5%) of the total CVD admissions was attributable to cold and warm temperatures, respectively. Warm and cold T(app) may increase CVD admissions, suggesting that the healthcare system and community need to be prepared in the context of global temperature changes.

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.

Royal Academy of Engineering and NIHR HPRU in Environmental Exposures and Health at the University of Leicester.

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.

Spectrophotometry is used to estimate melanin density (MD) in Caucasians1 but applicability of the calculation to people with pigmented skin, who also experience sun sensitivity, is not known. Here, we directly compared biopsy melanin concentration (MC) with Melanin Index (MI), Individual Typology Angle (ITA) values,2 calculated Melanin Density (MD) and Self‐Reported Sun Sensitivity (SRSS), with an aim to identify a non‐invasive, reliable melanin assessment technique for deeply pigmented skin

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.

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. South Africa (SA) has to grapple with multiple burdens of disease for which environmental factors have a role to play in both causation and prevention. This article describes a bibliometric review of environmental health indexed literature for SA over an 18-year period. Objectives. To provide an overview of the nature of SA-based published environmental health indexed research and to identify search challenges, frequently researched topics, and gaps and opportunities for future research. Methods. The Web of Science, PubMed and Science Direct were used to search for original, peer-reviewed and review articles with the inclusion criteria ‘environmental health’ and ‘South Africa’ available online and published between 1998 and 2015, inclusively. Results. A total of 230 journal articles were included in the bibliometric analysis. The highest number of articles (n=54) was published in 2015. The majority of the first authors were affiliated with SA institutions (n=160, 69.5%). For the articles where funding was explicitly declared (n=148), the three most frequently occurring agencies that funded the published research were the National Research Foundation in SA (n=17), the South African Medical Research Council (n=13) and the Water Research Commission (n=9). There was little inter-annual/environmental health category variation over time owing to the relatively small sample size. The largest number of retrieved journal articles was in the area of environmental pollution control (n=76), followed by environmental health lifestyle and behaviour-related topics (n=42) and then water monitoring (n=26). Conclusions. Despite the research needed to solve large environmental health challenges in SA, environmental health was only used as a keyword in title, author keywords or abstract for 230 SA-based studies over an 18-year period. This makes it extremely difficult for environmental health research to be located and used to inform the profession as well as the research agenda. Several issues that environmental health practitioners are typically tasked to implement and monitor are not indexed as environmental health topics. The need for authors to use ‘environmental health’ as a keyword is emphasised, particularly if research is to inform decision-making and policy support, as well as guide future research in the country.S Afr Med J 2017;107(10):915-924

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)