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Global warming, the increase in heatwaves and periods of intense heat, is a major problem across the world, including in South Africa. Heat exposure has adverse health impacts, ranging from dehydration and heat stroke to death. The transport sector and its users are vulnerable to heat exposure both in vehicles and in places where they wait for transport. We investigated the heat perceptions and experiences of minibus commuters and the minibus taxi industry in minibus taxis and minibus taxi ranks to inform an intervention to prevent adverse health impacts from heat exposure in the City of Tshwane. Commuters (n = 279), drivers and marshals (n = 46) reported feeling hot in minibus taxis and minibus taxi ranks, experiencing sweating, headaches, exhaustion and dizziness. Some participants reported opening windows and doors, drinking water/cold drinks, removing a jersey and fanning themselves to try and cool down. All participants suggested solutions to address heat exposure in minibus taxis and minibus taxi ranks, including more shelters and trees for shade, the provision of water, benches and potentially an air-conditioned building for waiting/holding periods between trips. In consultation with our stakeholders, we prepared educational awareness materials about heat risks to health and actions to take when it is hot, and these were distributed through the minibus taxi sector in the City of Tshwane. Future research needs include measuring temperatures in these settings and rolling out large-scale interventions to protect health and well-being in a changing climate. Significance: Heat exposure has adverse health impacts, ranging from dehydration to death. The transport sector and its users are vulnerable to extreme heat. We investigated the heat experiences and perceptions of minibus commuters and the minibus taxi industry to inform an intervention to prevent adverse health impacts from heat exposure in the City of Tshwane. We prepared educational awareness materials about heat risks to health and actions to take when it is hot, and these were distributed through the minibus taxi sector. Future research needs include measuring temperatures in these settings and rolling out large-scale interventions to protect health and well-being in a changing climate.

Climate services for health can facilitate health resilience and adaptation to climate change, particularly if they are well-calibrated to promote wellness and save lives. In this study, the status of climate services for health in South Africa’s Agincourt sub-district, Mpumalanga province, was assessed. A qualitative case study methodology encompassing multiple methods of data collection was used. The results show that climate services for health in the Agincourt sub-district, albeit essential, are fragmented and underdeveloped. Scientifically informed heat-health services are non-existent. Notwithsatnding this gap, healthcare and allied professionals are aware of the importance of climate services for health. The main barrier to climate services delivery is the paucity of interagency coordination; for example, coordination to plan and respond to climate-health information between the South African Weather Services and the Departments of Health and Education is lacking. Inclusive climate services for health are essential for positive prevention and treatment outcomes. Future studies must provide an investment case for climate services for health, demonstrating the benefits of acting and the costs of inaction.

Abstract 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.

Abstract Heatwaves can have severe impacts on human health extending from illness to mortality. These health effects are related to not only the physical phenomenon of heat itself but other characteristics such as frequency, intensity, and duration of heatwaves. Therefore, understanding heatwave characteristics is a crucial step in the development of heat-health warning systems (HHWS) that could prevent or reduce negative heat-related health outcomes. However, there are no South African studies that have quantified heatwaves with a threshold that incorporated a temperature metric based on a health outcome. To fill this gap, this study aimed to assess the spatial and temporal distribution and frequency of past (2014 – 2019) and future (period 2020 – 2039) heatwaves across South Africa. Heatwaves were defined using a threshold for diurnal temperature range (DTR) that was found to have measurable impacts on mortality. In the current climate, inland provinces experienced fewer heatwaves of longer duration and greater intensity compared to coastal provinces that experienced heatwaves of lower intensity. The highest frequency of heatwaves occurred during the austral summer accounting for a total of 150 events out of 270 from 2014 to 2019. The heatwave definition applied in this study also identified severe heatwaves across the country during late 2015 to early 2016 which was during the strongest El Niño event ever recorded to date. Record-breaking global temperatures were reported during this period; the North West province in South Africa was the worst affected experiencing heatwaves ranging from 12 to 77 days. Future climate analysis showed increasing trends in heatwave events with the greatest increases (80%—87%) expected to occur during summer months. The number of heatwaves occurring in cooler seasons is expected to increase with more events projected from the winter months of July and August, onwards. The findings of this study show that the identification of provinces and towns that experience intense, long-lasting heatwaves is crucial to inform development and implementation of targeted heat-health adaptation strategies. These findings could also guide authorities to prioritise vulnerable population groups such as the elderly and children living in high-risk areas likely to be affected by heatwaves.

Introduction: Climate factors influence the state of human health and wellbeing. Climate-related threats are particularly being experienced by vulnerable populations in Africa. A Question (Q)-Storming session was convened at an international climate adaptation conference. It promoted dialog among a diverse spectrum of researchers, climate and medical scientists, health professionals, national government officials, civil society, business, and international governing organizations. The session identified approaches for the effective integration of health within African national climate adaptation policies. Materials and methods: Two organizations partnered to convene the session at the Adaptations Futures 2018 Conference in Cape Town. Q-storming (which is an inverse approach to brainstorming) was applied to extract ideas from all participants. Four topics were presented during the session: (i) adaptive capacities related to climate change and infectious diseases; (ii) adaptive capacity of African governments in relation to health and climate change; (iii) making climate science work to protect the health of vulnerable populations; and (iv) making climate-health research usable. Results: Nine cross-cutting adaptation themes were generated (i.e. key definitions, adaptive capacity, health sector priorities, resources, operational capacities and procedures, contextual conditions, information pathways, and information utility). The Q-Storming approach was a valuable tool for improving the understanding of the complexities of climate-health research collaborations, and priority identification for improved adaptation and service delivery. Conclusion: Concerted recognition regarding difficulties in linking climate science and health vulnerability at the interface of practitioners and decision-makers is required, for better integration and use of climate-health research in climate adaptation in Africa. This can be achieved by innovations offered through Q-Storming.

Background: Africa faces diverse and complex population/human health challenges due to climate change. Understanding the health impacts of climate change in Africa in all its complexity is essential for implementing effective strategies and policies to mitigate risks and protect vulnerable populations. This study aimed to outline the major climate change-related health impacts in Africa in the context of economic resilience and to seek solutions and provide strategies to prevent or reduce adverse effects of climate change on human health and well-being in Africa. Methods: For this narrative review, a literature search was conducted in the Web of Science, Scopus, CAB Abstracts, MEDLINE and EMBASE electronic databases. We also searched the reference lists of retrieved articles for additional records as well as reports. We followed a conceptual framework to ensure all aspects of climate change and health impacts in Africa were identified. Results: The average temperatures in all six eco-regions of Africa have risen since the early twentieth century, and heat exposure, extreme events, and sea level rise are projected to disproportionately affect Africa, resulting in a larger burden of health impacts than other continents. Given that climate change already poses substantial challenges to African health and well-being, this will necessitate significant effort, financial investment, and dedication to climate change mitigation and adaptation. This review offers African leaders and decision-makers data-driven and action-oriented strategies that will ensure a more resilient healthcare system and safe, healthy populations—in ways that contribute to economic resiliency. Conclusions: The urgency of climate-health action integrated with sustainable development in Africa cannot be overstated, given the multiple economic gains from reducing current impacts and projected risks of climate change on the continent’s population health and well-being. Climate action must be integrated into Africa’s development plan to meet the Sustainable Development Goals, protect vulnerable populations from the detrimental effects of climate change, and promote economic development.

Background: Water and sanitation are vital to human health and well-being. While these factors have been studied in relation to heath, very little has been done to consider such environmental risk factors with child development. Here, we investigated possible relations between household water access/storage and early childhood development in four low-income settlements in the City of Cape Town, Western Cape province of South Africa. Our objectives were 1) to determine water access/storage practices in dwellings of children; 2) to assess early childhood development; and 3) and to understand the relationship between water access/storage practices in relation to early childhood development. Methods: We used a questionnaire to assess household water risk factors and the International Development and Early Learning Assessment (IDELA) tool to assess child early learning / cognitive, socio-emotional and motor development. Results: Mean age of the children (N=192) was 4 years and 55% were female. The mean IDELA score was 48% (range: 36% - 54%) where the higher the score, the better the child’s development. Around 70% of households had a tap inside their dwelling and half said that they stored water with the largest percentage of storage containers (21%) being plastic/no lid. Child IDELA scores were lower for children living in households that did not have an indoor tap and for households who stored water. Conclusions: Given the risks associated with climate change and the already poor conditions many children face regarding water and sanitation, research is needed to further investigate these relations to provide evidence to support appropriate interventions and ensure healthy child development.

Abstract Exposure to heat and heatwaves are associated with mortality and may amplify morbidities. In a climate change context, projections suggest temperatures will likely rise in the foreseeable future. Our paper assesses the current knowledge on human health effects of heat exposure and gathered local knowledge of heat-health effects in a rural area of the Agincourt sub-district of South Africa. Existing, peer-reviewed published literature on heat effects on human health as well as heat-health indicators was reviewed. Interviews and structured observations to collect data on heat effects on human health in Agincourt sub-district were conducted. The Lancet Countdown heat-related indicators were applied as a framework against which to discuss our findings. A total of 93 participants who lived in Agincourt sub-district for 5 years and more were interviewed. Participants reported that temperatures, especially summertime temperatures, had been rising over the past years. Health effects of heat were deemed more apparent in relation to morbidity. Heatwaves were not easily comprehensible as singular ‘events’, and their effects were poorly understood. The population groups disproportionately affected by heat included infants, the elderly, those living with disability and outdoor workers. High ambient temperatures were deemed to be associated with reduced labour productivity of outdoor workers. Community-level perceptions of heat impacts on health were mainly related to illnesses and diseases, with no understanding of mortality risk. Future health awareness campaigns that encompass the full range of heat-health impacts are essential to reduce vulnerability, morbidity, and mortality. Our study provided location-specific, qualitative, and indicator-aligned data for a geographic area expected to undergo significant heat stress in the future. The study findings have significant research, policy, and practice implications in similar resource-limited settings.

Background: Despite being underreported, orofacial cleft lip/palate (CLP) remains in the top five of South Africa’s most common congenital disorders. Maternal air pollution exposure has been associated with CLP in neonates. South Africa has high air pollution levels due to domestic burning practices, coal-fired power plants, mining, industry, and traffic pollution, among other sources. We investigated air pollutant levels in geographic locations of CLP cases. Methods: In a retrospective case series study (2006–2020) from a combined dataset by a Gauteng surgeon and South African Operation Smile, the maternal address at pregnancy was obtained for 2,515 CLP cases. Data from the South African Air Quality Information System was used to calculate annual averages of particulate matter (PM) concentrations of particles < 10 µm (PM10) and < 2.5 µm (PM2.5). Correlation analysis determined the relationship between average PM2.5/PM10 concentrations and CLP birth prevalence. Hotspot analysis was done using the Average Nearest Neighbor tool in ArcGIS. Results: Correlation analysis showed an increasing trend of CLP birth prevalence to PM10 (CC = 0.61, 95% CI = 0.38–0.77, p < 0.001) and PM2.5 (CC = 0.63, 95% CI = 0.42–0.77, p < 0.001). Hot spot analysis revealed that areas with higher concentrations of PM10 and PM2.5 had a higher proclivity for maternal residence (z-score = –68.2, p < 0.001). CLP birth prevalence hotspot clusters were identified in district municipalities in the provinces of Gauteng, Limpopo, North-West, Mpumalanga, and Free State. KwaZulu-Natal and Eastern Cape had lower PM;10 and PM2.5 concentrations and were cold spot clusters. Conclusions: Maternal exposure to air pollution is known to impact the fetal environment and increase CLP risk. We discovered enough evidence of an effect to warrant further investigation. We advocate for a concerted effort by the government, physicians, researchers, non-government organizations working with CLP patients, and others to collect quality data on all maternal information and pollutant levels in all provinces of South Africa. Collaboration and data sharing for additional research will help us better understand the impact of air pollution on CLP in South Africa.

Temperature extremes vary across Africa. A continent-wide examination of the impacts of heat on health in Africa, and a synthesis of Africa-informed evidence is, however, lacking. A systematic review of articles published in peer-reviewed journals between January 1992 and April 2019 was conducted. To be eligible, articles had to be Africa-specific, in English, and focused on how heatwaves and high ambient temperatures affect morbidity and mortality. A secondary systematic analysis on policies and interventions comprising 17 studies was also conducted, and the findings synthesised together with those of the 20 primary studies. Eleven studies showed that high ambient temperatures and heat waves are linked with increased mortality rates in Africa. These linkages are characterised by complex, linear and non-linear (J or U) relationships. Eight of the nine primary studies of morbidity outcome reported that an increase in temperature was accompanied by raised disease incidence. Children and the elderly were the population groups most vulnerable to extreme heat exposure. Location-specific interventions and policy suggestions include developing early warning systems, creating heat-health plans, changing housing conditions and implementing heat-health awareness campaigns. In summary, this review demonstrates that, while heat-health relationships in Africa are complex, extreme temperatures are associated with high mortality and morbidity, especially amongst vulnerable populations. As temperatures increase across Africa, there is an urgent need to develop heat-health plans and implement interventions. Future studies must document intervention effectiveness and quantify the costs of action and inaction on extreme heatrelated mortality and morbidity. Significance: • Empirical evidence shows that the relationship between heat and human health is complex in the African This complexity has implications for the development of interventions and policies for heathealth on the continent. • This review is important for African policymakers, practitioners and others who support Africa’s adaptation to climate change. Through this review, a compendium of Africa-specific and relevant empirical information is aggregated and made readily available to various interested and affected parties.

Abstract Background The Black population has lower skin cancer incidence compared to White, Indian/Asian, and Mixed‐race populations in South Africa; however, skin cancer still exists in the Black population. The aim of this study is to identify risk factors associated with skin cancer among Black South Africans. Materials and Methods A case‐control study was conducted. Cases were patients with keratinocyte cancers (KCs) and/or melanoma skin cancers (MSCs) and controls were cardiovascular patients. Sociodemographic exposures, environmental health variables, smoking, and HIV status were assessed. Stepwise logistic regression was used to identify risk factors associated with KCs and MSCs. Results The KCs histological subtypes showed that there were more squamous cell carcinomas (SCCs) (78/160 in females, and 72/160 in males) than basal cell carcinomas (BCCs). The SCC lesions were mostly found on the skin of the head and neck in males (51%, 38/72) and on the trunk in females (46%, 36/78). MSC was shown to affect the skin of the lower limbs in both males (68%, 27/40) and females (59%, 36/61). Using females as a reference group, when age, current place of residency, type of cooking fuel used, smoking, and HIV status were adjusted for, males had an odds ratio (OR) of 2.04 for developing KCs (confidence interval [CI]: 1.08–3.84, p = .028). Similarly, when age, current place of residency, and place of cooking (indoors or outdoors) were adjusted for, males had an OR of 2.26 for developing MSC (CI: 1.19–4.29, p = .012). Conclusions Differences in the anatomical distribution of KCs by sex suggest different risk factors between sexes. There is a positive association between being male, smoking, rural dwelling, and a positive HIV status with KCs and being male and rural dwelling with MSC. The rural dwelling was a newly found association with skin cancer and warrants further investigation.

Background: Household air pollution (HAP) is associated with adverse human health impacts. During COVID-19 Lockdown Levels 5 and 4 (the most stringent levels), South Africans remained at home, potentially increasing their exposure to HAP. Objectives: To investigate changes in fuel use behaviours/patterns of use affecting HAP exposure and associated HAP-related respiratory health outcomes during COVID-19 Lockdown Levels 5 and 4. Methods: This was a cross-sectional online and telephonic survey of participants from an existing database. Logistic regression and McNemar’s test were used to analyse household-level data. Results: Among 2 505 participants, while electricity was the main energy source for cooking and heating the month before and during Lockdown Levels 5 and 4, some households used less electricity during Lockdown Levels 5 and 4 or switched to “dirty fuels.” One third of participants reported presence of environmental tobacco smoke in the home, a source of HAP associated with respiratory illnesses. Prevalence of HAP-related respiratory health outcomes were

Climate change and variability remain a pressing global challenge directly and indirectly affecting human health. This has increased the demand for usable climate information for adaptation to climate related health challenges and for building effective response strategies. Climate services for health can help to enhance human well-being and in extreme cases can save human lives by reducing morbidity and mortality. Very little has been done and understood about how we can enhance climate services for health. The main aim of this perspective article is to bring empirical evidence, conceptual clarity and interdisciplinary approaches to policy makers and practitioners dealing with this crucial issue. The article explores the application of a holistic, broadly termed ‘systems’ approach to climate services for health in the context of adaptation and resilience. It uses illustrative examples from Ethiopia, Bhutan and Germany to demonstrate and elaborate the application and merits of the systems approach to emerging climate services for health. The systems approach improves conceptual thinking about climate services for health. In addition, it is a valuable analytical framework that unifies the diverse stakeholders involved in health adaptation and resilience planning, interventions and policy making. This perspective article fills in the existing gaps in scientific literature on the subject and enhances conceptualisation of climate services for health. It makes suggestions to improve understanding of climate services for health.

Abstract Background The circular economy framework for human production and consumption is an alternative to the traditional, linear concept of ‘take, make, and dispose’. Circular economy (CE) principles comprise of ‘design out waste and pollution’, ‘retain products and materials in use’, and ‘regenerate natural systems’. This commentary considers the risks and opportunities of the CE for low- and middle-income countries (LMICs) in the context of the Sustainable Development Goals (SDGs), acknowledging that LMICs must identify their own opportunities, while recognising the potential positive and negative environmental health impacts. Main body The implementation of the CE in LMICs is mostly undertaken informally, driven by poverty and unemployment. Activities being employed towards extracting value from waste in LMICs are imposing environmental health risks including exposure to hazardous and toxic working environments, emissions and materials, and infectious diseases. The CE has the potential to aid towards the achievement of the SDGs, in particular SDG 12 (Responsible Consumption and Production) and SDG 11 (Sustainable Cities and Communities). However, since SDG 3 (Good Health and Well-Being) is critical in the pursuit of all SDGs, the negative implications of the CE should be well understood and addressed. We call on policy makers, industry, the health sector, and health-determining sectors to address these issues by defining mechanisms to protect vulnerable populations from the negative health impacts that may arise in LMICs as these countries domesticate the CE. Conclusion Striving towards a better understanding of risks should not undermine support for the CE, which requires the full agency of the public and policy communities to realise the potential to accelerate LMICs towards sustainable production and consumption, with positive synergies for several SDGs.

Abstract Background Globally, the response to climate change is gradually gaining momentum as the impacts of climate change unfold. In South Africa, it is increasingly apparent that delays in responding to climate change over the past decades have jeopardized human life and livelihoods. While slow progress with mitigation, especially in the energy sector, has garnered much attention, focus is now shifting to developing plans and systems to adapt to the impacts of climate change. Methods We applied systematic review methods to assess progress with climate change adaptation in the health sector in South Africa. This case study provides useful lessons which could be applied in other countries in the African region, or globally. We reviewed the literature indexed in PubMed and Web of Science, together with relevant grey literature. We included articles describing adaptation interventions to reduce the impact of climate change on health in South Africa. All study designs were eligible. Data from included articles and grey literature were summed thematically. Results Of the 820 publications screened, 21 were included, together with an additional xx papers. Very few studies presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country’s preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers. Conclusions Overall, the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. More effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as predominately a health issue, one necessitating an urgent, adequately-resourced response. Such a shift in South Africa, but also beyond the country, may play a key role in accelerating climate change adaptation and mitigation.

Abstract 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.

Exposure of outdoor workers to high levels of solar ultraviolet radiation (UVR) poses significant, well-known health risks including skin cancer and eye diseases. In South Africa, little is known about how many workers are potentially overexposed to solar UVR and what the associated impacts on their health might be. In this overview, the geography and solar UVR environment in South Africa are considered, as well as the different outdoor occupational groups likely to be affected by excessive solar UVR exposure. Sunburn, pterygium, cataract, keratinocyte cancers, and melanoma are discussed in the context of outdoor workers. Few studies in South Africa have considered these health issues and the most effective ways to reduce solar UVR exposure for those working outside. Several countries have developed policies and guidelines to support sun safety in the workplace which include training and education, in addition to the provision of personal protective equipment and managerial support. Several gaps in occupational sun protection and workplace sun safety for South Africa are identified. Legislation needs to recognize solar UVR exposure as an occupational health hazard, with sun safety guidelines and training provided for employers and employees.

Background: Shelter and safe housing is a basic human need that brings about a sense of ownership, self-sufficiency, and citizenship. Millions of people around the world live in inadequate dwellings in unhealthy areas, such as urban slums. These dwellings may experience indoor temperatures that impact inhabitants’ health. Indoor dwelling temperatures vary depending on many factors including geographic location, such as inland versus coastal. In an era of climate change, understanding how dwelling characteristics influence indoor temperature is important, especially in low- and middle-income countries, to protect health. Objective: To assess indoor temperature in low-cost dwellings located in a coastal setting in relation to dwelling characteristics. Methods: Indoor temperature and relative humidity loggers were installed from 1 June 2017 to 15 May 2018 in 50 dwellings in two settlements in a coastal town on the east coast of South Africa. Ambient outdoor temperature data were obtained from the national weather service, indoor temperature data were converted into apparent temperature, and heat index calculations were made to consider possible heat-health risks. A household questionnaire and dwelling observation assessment were administered. A mixed-effects linear regression model was constructed to consider the impact of dwelling characteristics on indoor apparent temperature. Findings: Among 17 dwellings with all data sets, indoor temperatures were consistently higher than, and well correlated (r = 0.92) with outdoor temperatures. Average differences in indoor and outdoor temperatures were about 4°C, with statistically significant differences in percentage difference of indoor/outdoor between seasons (p < 0.001). Heat indices for indoor temperatures were exceeded mostly in summer, thereby posing possible health risks. Dwellings with cement floors were statistically significantly cooler than any other floor type across all seasons. Conclusions: Low-cost dwellings experienced temperatures indoors higher than outdoor temperatures in part due to floor type. These results help inform interventions that consider housing and human health (n = 289).

Abstract 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.

Abstract 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)

No abstract available.

The editorial speaks to the Global Statement on Air Pollution and Health and How it may assist African countries to eliminate air pollution-related health impacts.

We describe the measurement and spatial variability of particulate matter (PM) chemical composition, PM10 and PM2.5 in the Greater Tubatse Municipality, South Africa. Monthly samples were collected over 12 months (July 2015 to June 2016) using the inexpensive and easy to operate passive samplers of the University of North Carolina. Sites for sample collection were located at private residences, a church, a hospital and a school. Concentrations of PM10, PM2.5 and PM chemical components were determined using computer-controlled scanning electron microscopy with energy-dispersive X-ray spectroscopy. The annual observed concentrations at all sites were below the South African National Ambient Air Quality Standards of 40 μg/m3 for PM10 and 25 μg/m3 for PM2.5. The Cr-rich and CrFe-rich particles showed substantial heterogeneity with high concentrations observed near the chrome smelters, and Si-rich particles were highest near the silicon mine. SiAl-rich particles were highest at sites close to busy roads, while SiAlFe-rich particles were less spatially distributed. The low spatial variability of SiAlFe-rich particles indicates that these elements are mainly found in crustal material. Using the synoptic meteorological parameters of The Air Pollution Model, we were unable to effectively determine correlations between PM10 and mixing height, Monin–Obukhov length, air pollution potential, or coefficient of divergence. Significance: • We have shown that the use of University of North Carolina passive samplers coupled with computer-controlled scanning electron microscopy is effective in determining the chemical composition of PM. • The use of passive samplers is a cheap and effective method to collect data in remote areas of South Africa which have limited or no electricity supply. • Assessment of the spatial distribution of PM and PM chemical components can assist in the development of effective air quality management strategies.

The city of Pretoria in South Africa receives considerable solar ultraviolet radiation (UVR) because of its low latitude (22–35°S) and relatively clear skies. Certain meteorological factors affect the amount of solar UVR that reaches the ground; the most dominant factors being stratospheric ozone, cloud cover and solar zenith angle. It is known that overexposure to solar UVR may lead to the development of adverse health conditions, the most significant being skin cancer. Outdoor workers spend a significant amount of time outside and are thus susceptible to this risk. In this case study, we estimated, for the first time, the realtime solar UVR exposure of an outdoor worker in Pretoria. Measurements were made on 27 and 28 May 2013 using a handheld ultraviolet index (UVI) meter calibrated against a science-grade biometer at the South African Weather Service in Pretoria. Personal exposure estimation was used to discern the pattern in diurnal and annual sunburn risk for the outdoor worker. Ambient UVR levels ranged from 0 UVI to 4.66 UVI and the outdoor worker’s potential exposure estimates regularly exceeded 80% of these levels depending on the time of day. The risk of sunburn was evident; however, actual incidents would depend on individual skin photosensitivity and melanin content, as well as sun protection used. Further research is needed to determine the personal exposure estimations of outdoor workers in other provinces in which solar UVR levels may be equally high, or higher than those in Pretoria.

Occupational exposure to heat and solar ultraviolet radiation (UVR) threatens the health and wellbeing of outdoor workers. These threats are likely to increase as a result of climate change. This study examined the perceptions of occupational heat and sun exposure and health risk prevention among forestry workers removing alien invasive vegetation in the Western Cape, South Africa. The linkages between workers’ perceptions of heat, solar UVR, and herbicide exposure and impacts under the current climate were investigated to better understand potential adaptation needs under a changing climate. Using focus group discussions and participatory risk mapping, heat stresses identified by workers were either environmental (e.g., lack of shade) or work-related (e.g., wearing required personal protective equipment). Several heat and solar UVR health impacts were reportedly experienced by workers; local indigenous knowledge and coping mechanisms, such as wearing ochre for sun protection, were used to prevent these impacts. Despite workers’ current efforts to protect their health, existing gaps and opportunities to improve working conditions were identified. Institutional structures for improved reporting of adverse events are imperative, together with awareness and education campaigns about the risks associated with working in hot and sunny environments.

Climate change is associated with shifts in global weather patterns, especially an increase in ambient temperature, and is deemed a formidable threat to human health. Skin cancer, a non-communicable disease, has been underexplored in relation to a changing climate. Exposure to solar ultraviolet radiation (UVR) is the major environmental risk factor for skin cancer. South Africa is situated in the mid-latitudes and experiences relatively high levels of sun exposure with summertime UV Index values greater than 10. The incidence of skin cancer in the population group with fair skin is considered high, with cost implications relating to diagnosis and treatment. Here, the relationship between skin cancer and several environmental factors likely to be affected by climate change in South Africa are discussed including airborne pollutants, solar UVR, ambient temperature and rainfall. Recommended strategies for personal sun protection, such as shade, clothing, sunglasses and sunscreen, may change as human behaviour adapts to a warming climate. Further research and data are required to assess any future impact of climate change on the incidence of skin cancer in South Africa.

Solar ultraviolet radiation (UVR) monitoring is important since it depends on several atmospheric parameters which are associated with climate change and since excess solar UVR exposure and has significant impacts on human health and wellbeing. The objective of this study was to investigate the trends in solar UVR during a decade (2009−2018) in Saint-Denis, Reunion Island (20.9°S, 55.5°E, 85 m ASL) and Cape Town, South Africa (33.97°S, 18.6°E, 42 m ASL). This comparison was done using total daily erythema exposure as derived from UVR sensors continuously at both sites. Climatology over the 10-year period showed extreme UVR exposure for both sites. Slight changes with opposite trends were found, +3.6% at Saint-Denis and −3.7% at Cape Town. However, these two sites often experience extreme weather conditions thereby making the trend evaluation difficult. Human exposure assessment was performed for hiking activities at two popular high-altitude hiking trails on the Maïdo−Grand Bénare (Reunion) and Table Mountain (Cape Town) with a handheld radiometer. Extreme exposure doses of 64 SED and 40 SED (Standard Erythemal Dose, 1 SED = 100 J.m−2) were recorded, respectively. These high exposure doses highlight the importance of raising public awareness on the risk related to excess UVR exposure at tourist sites, especially those at high altitude.

Background Outdoor and indoor air temperature affects human health and wellbeing. Climate change projections suggest that global temperatures will continue to increase, and this poses a threat to health. Buildings (for housing and business purposes) that can protect humans from the adverse effects of temperature are essential, especially in the context of climate change. Method In this cross-sectional study, we measured the indoor temperature inside shipping containers comprising a seven-storey block of apartments and businesses in Johannesburg, South Africa for 14 days. We assessed indoor temperature and relative humidity; evaluated measured temperatures in relation to thresholds known to be associated with adverse health risks; and sought to understand heat-health perceptions and symptoms of people living and working in shipping container units. Results Median indoor apparent temperature (AT) (a combination of temperature and relative humidity) was 16°C with values ranging from 6°C (observed at 8:00) to 42°C (observed at 17:00). Insulated units had temperatures between 2°C and 9°C cooler than the uninsulated unit. Heat-health risks from AT exposure were likely in all units, although there was variation in the number of occurrences that AT measurements exceeded the four symptom bands of caution, extreme caution, danger and extreme danger. Indoor AT was found to be 7°C higher on average when compared to outdoor AT. Some participants believed that their units were hot during hot weather and most people opened windows or did nothing during hot weather. Few participants reported experiencing adverse heat-health impacts, except for experiencing headaches (58%) and feeling tired or weak (40%). Conclusion Residents, tenants, or business owners using shipping containers should consider insulation installation and adequate windows/air conditioning for ventilation, especially in hot climates. Further research and awareness regarding heat-health risks of living or working in these spaces is needed.

Photoprotection messages and ‘SunSmart’ programmes exist mainly to prevent skin cancers and, more recently, to encourage adequate personal sun exposure to elicit a vitamin D response for healthy bone and immune systems. Several developed countries maintain intensive research networks and monitor solar UV radiation to support awareness campaigns and intervention development. The situation is different in sub-Saharan Africa. Adequate empirical evidence of the impact of solar UV radiation on human health, even for melanomas and cataracts, is lacking, and is overshadowed by other factors such as communicable diseases, especially HIV, AIDS and tuberculosis. In addition, the established photoprotection messages used in developed countries have been adopted and implemented in a limited number of sub-Saharan countries but with minimal understanding of local conditions and behaviours. In this review, we consider the current evidence for sun-related effects on human health in sub-Saharan Africa, summarise published research and identify key issues. Data on the prevalence of human diseases affected by solar UV radiation in all subpopulations are not generally available, financial support is insufficient and the infrastructure to address these and other related topics is inadequate. Despite these limitations, considerable progress may be made regarding the management of solar UV radiation related health outcomes in sub-Saharan Africa, provided researchers collaborate and resources are allocated appropriately.

There is still a pressing concern regarding the causes of poor indoor air quality and the consequent effects on health, because people spend a considerable amount of time indoors. Information about seasonal variation and the determinants of particulate matter (PM) concentrations could guide the design and implementation of intervention strategies. This study was conducted in Giyani, Limpopo province, South Africa. The main aim was to assess indoor air quality. Indoor PM and temperature were monitored to describe seasonal and diurnal patterns of indoor PM4 concentration and to estimate the association between PM concentrations and indoor as well as ambient conditions. Indoor PM4 was monitored hourly in kitchens for the duration of spring (September), summer (February) and winter (July). Indoor temperatures were monitored hourly in kitchens, living rooms and bedrooms. Outdoor temperature and outdoor relative humidity were also monitored for the same period. Indoor temperatures showed a large range in the three sampled seasons, with the maximum values raising the largest cause for concern. Maximum indoor temperatures in summer exceeded the threshold of 35 °C, which has been shown to have adverse health effects. Occupants of the sampled households were exposed to indoor PM4 concentrations that exceeded national and international guidelines. Hourly indoor temperature was statistically significantly correlated to PM4 concentrations in the summer and spring (r = 0.22 and 0.24 respectively, p < 0.001 for both) and negatively correlated to outdoor relative humidity (r = −0.27, p < 0.001). Diurnal PM4 variations showed pronounced patterns with morning and evening peaks. PM4 was consistently higher throughout the day in summer compared to spring and winter. Community-based intervention strategies should consider these seasonal differences in PM4 exposure and tailor awareness messages for exposure prevention accordingly.

Background Outdoor and indoor air temperature affects human health and wellbeing. Climate change projections suggest that global temperatures will continue to increase, and this poses a threat to health. Buildings (for housing and business purposes) that can protect humans from the adverse effects of temperature is essential, especially in the context of climate change. Method In this cross-sectional study, we measured indoor temperature inside shipping containers comprising a seven-storey block of apartments and businesses in Johannesburg, South Africa for 14 days. We assessed indoor temperature and relative humidity; evaluated measured temperatures in relation to thresholds known to be associated with adverse health risks; and sought to understand heat-health perceptions and symptoms of people living and working in shipping container units. Results Median indoor apparent temperature (AT) (a combination of temperature and relative humidity) was 16 °C with values ranging from 6 °C (observed at 8:00) to 42 °C (observed at 17:00). Insulated units had temperatures between 2°C and 9°C cooler than the uninsulated unit. Heat-health risks from AT exposure were likely in all units, although there was variation in the number of occurrences that AT measurements exceeded the four symptom bands of caution, extreme caution, danger and extreme danger. Some participants believed that their units were hot during hot weather and most people opened windows or did nothing during hot weather. Few participants reported experiencing adverse heat-health impacts, except for experiencing headaches (58%) and feeling tired or weak (40%). Conclusion Residents, tenants, or business owners using shipping containers should consider insulation installation and adequate windows/air conditioning for ventilation, especially in hot climates. Further research and awareness regarding heat-health risks of living or working in these spaces is needed.

Exposure to solar ultraviolet (UV) radiation is known to have both adverse and beneficial consequences for human health. Sunburn and skin cancer are probably the most well-known acute and chronic adverse health impacts. These themes have recently been discussed in the media for the general public; consequently interest in sun protection is growing. The promotion of the use of practical personal strategies to reduce adverse health risks, such as healthy sun behaviour, sun protection mechanisms and solar ultraviolet radiation awareness tools, is increasing. One such tool is the personal UV index (UVI) monitor, promoted commercially as a viable tool for sun awareness; however, such instruments have not been scientifically evaluated in a South African context. Here, two different types of personal UVI monitors, commercially available in South Africa, were compared with a research-grade UVB biometer for a continuous 7-h period on 02 March 2012 in Pretoria. One of the two personal UVI monitors showed reasonable agreement with the UVB biometer, whereas the other monitor overestimated UVI by up to 4 UVI units. When comparing two identical products manufactured by the same company, one monitor overestimated UVI twofold, suggesting inter-instrument variability may be a concern. Commercially available, personal UVI monitors should be used with caution as a public health tool for sun awareness in South Africa.

Background: Outdoor and indoor air temperature affects human health and wellbeing. Climate change projections suggest that global temperatures will continue to increase and this poses a threat to health. Housing that can protect humans from the adverse effects of temperature is essential, especially in the context of climate change. Method: In this cross-sectional study, we measured indoor temperature inside shipping containers comprising a seven-storey block of apartments and businesses in Johannesburg, South Africa. We assessed indoor temperature and relative humidity; evaluated measured temperatures in relation to thresholds known to be associated with adverse health risks; and sought to understand heat-health perceptions and symptoms of people living and working in shipping container units. Results: Median indoor apparent temperature (AT) (a combination of temperature and relative humidity) was 16 °C with values ranging from 6 °C (observed at 8:00) to 42 °C (observed at 17:00). Insulated units had temperatures between 2°C and 9°C cooler than uninsulated units. Heat-health risks from AT exposure were likely in all units, although there was variation in the number of occurrences that AT measurements exceeded the four symptom bands of caution, extreme caution, danger and extreme danger. Some participants believed that their units were hot during hot weather and most people opened windows or did nothing during hot weather. Few participants reported experiencing adverse heat-health impacts, except for experiencing headaches (n=62, 58%) and feeling tired or weak (40%). Conclusion: Container units should be insulated and have adequate windows for ventilation when used for residential and commercial purposes, especially in hot climates. Awareness regarding heat-health risks of living and working in hot spaces needs to be done, especially in the context of repurposed container units.