Tanapox, South Africa, 2022.

Tanapox is a rarely diagnosed zoonosis known to be endemic to equatorial Africa. All previously reported human cases were acquired within 10° north or south of the Equator, most recently 19 years ago. We describe a human case of tanapox in South Africa (24° south of the Equator). Expanded surveillance for this pathogen is warranted.

Wastewater-based SARS-CoV-2 airport surveillance: key trends at the Cape Town International Airport.

Monitoring of SARS-CoV-2 RNA in wastewater has revealed the role of mobility in the transmission of coronavirus disease (COVID-19), and the surveillance of airport wastewater in cities across the world has demonstrated how travel entry points can give an indication of trends in transmission. This study undertook wastewater surveillance at the Cape Town International Airport (CTIA) to assess the use of a WBE approach to provide supplementary information on the presence of COVID-19 at a key air travel entry point in South Africa. Grab wastewater samples (n = 55) were collected from the CTIA wastewater pump station and analysed using quantitative real-time polymerase chain reaction (qRT-PCR) method. The study found a correlation between the wastewater data and clinical cases reported in the City of Cape Town during various time periods and during the peak of a COVID-19 wave. Highly elevated viral loads in the wastewater were observed at times there was increased mobility through the airport. The study also revealed elevated viral load levels at the airport despite the stricter restrictions and through the lower restrictions. The study findings indicate wastewater surveillance and airports can provide supplementary information to airport authorities to assess the impacts of imposed travel restrictions.

Delineating the Spread and Prevalence of SARS-CoV-2 Omicron Sublineages (BA.1-BA.5) and Deltacron Using Wastewater in the Western Cape, South Africa.

This study was one of the first to detect Omicron sublineages BA.4 and BA.5 in wastewater from South Africa. Spearman rank correlation analysis confirmed a strong positive correlation between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA in wastewater samples and clinical cases (r = 0.7749, P < .0001). SARS-CoV-2 viral load detected in wastewater, resulting from the Delta-driven third wave, was significantly higher than during the Omicron-driven fourth wave. Whole-genome sequencing confirmed presence of Omicron lineage defining mutations in wastewater with the first occurrence reported 23 November 2021 (BA.1 predominant). The variant spread rapidly, with prevalence of Omicron-positive wastewater samples rising to >80% by 10 January 2022 with BA.2 as the predominant sublineage by 10 March 2022, whilst on 18 April 2022 BA.4 and BA.5 were detected in selected wastewater sites. These findings demonstrate the value of wastewater-based epidemiology to monitor the spatiotemporal spread and potential origin of new Omicron sublineages.

COVID-19 and a temporary ban on tobacco sales in South Africa: impact on smoking cessation.

OBJECTIVE: To evaluate the impact of COVID-19 plus a temporary ban on the sale of tobacco and vaping products, on smoking cessation in South Africa, by reviewing research surveys conducted while the prohibition was in place. METHOD: An internet search was conducted on 20 August 2020, using the key words: 'South Africa', 'survey', 'poll', 'smoking', 'cigarettes', 'tobacco", 'vaping', and 'COVID-19'. There were no language restrictions. Additional studies were identified through press reports. Only studies conducted between March and August 2020 were included. RESULTS: Four surveys which reported on smokers quitting behaviour were included. None had been published in a peer reviewed journal. The heterogeneity of the data did not allow pooling. Support for the ban on tobacco sales amongst smokers varied from 6% to 36%. Similarly, there were inconsistent findings about quitting behaviour. Nationally, between 16% to 49% of smokers reported not smoking during the ban. CONCLUSIONS: Cigarette smoking in SA dropped during the 2020 COVID-19 lockdown, but the estimates were inconsistent, probably because of survey design. There was evidence that the lockdown achieved the fastest rate of decline in smoking prevalence in the country's history. The true extent of the fall though is uncertain. Prevalence studies post lockdown, using probability sampling, may more accurately show how many people quit smoking.

A study protocol to evaluate the impact of a personal and domestic hygiene intervention on lead exposure in a community next to a mine dump.

BACKGROUND: Lead has been associated with adverse health effects, especially neurocognitive and behavioural effects, in children. Communities living close to mining land are at risk of elevated exposure to lead. METHODS: This paper outlines a before and after intervention study protocol to evaluate the impact of a personal and domestic hygiene intervention on lead exposure in a community located adjacent to a mine dump. In each participating household, parents or guardians will be interviewed using a structured questionnaire to obtain information on socio-demographic characteristics, living conditions, domestic hygiene practices and potential alternative sources of exposure to lead. A registered nurse will collect hand wipe samples from children aged one to five years, for whom parental consent and where possible child assent has been obtained. Environmental dust samples will be collected from the floors and/or windowsills of children's dwellings for lead content analysis. Soil samples will be collected from yards to determine lead content. An educational intervention will then be applied to the intervention group, including the engagement of households or guardians in an educational discussion on the sources, pathways of exposure, health effects of lead exposure and protective measures, with the aid of a specially designed educational brochure. Data will be analysed for descriptive and inferential statistics using Stata version 16. DISCUSSION: The study will determine whether the intervention led to a reduction in indoor dust lead levels, and if shown to be effective, will inform the development of an awareness campaign to reduce lead exposure in communities located in close proximity to mine dumps. TRIAL REGISTRATION: The study is retrospectively registered on ClinicalTrials.gov Protocol Registration and Results System with registration number NCT05265572 and first release date of 18th February 2022.

Respiratory health among adolescents living in the Highveld Air Pollution Priority Area in South Africa.

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.

Risk Factors and Perceptions of E-Cigarette Use Among Selected Users in Johannesburg, South Africa.

There is little scientific knowledge about e-cigarette use in South Africa. This study aimed to describe the risk factors and perceptions of selected Johannesburg-based users of e-cigarettes. A self-administered questionnaire was used to collect data from a convenient sample of 188 participants, of which 160 were males and 28 females. The survey results showed that participants used e-cigarettes at home (n = 28/ 14.8%), work (n = 76/ 40.4%), tertiary institutions (n = 50/ 26.5%) and in their vehicles (n = 24/ 12.7%), while (n = 96/ 51%) used the product in the presence of children. 57 participants (30.3%) started using e-cigarettes as a smoking cessation strategy, while 46 (24.4%) used it to manage smoking cravings. Most participants believed that e-cigarettes are addictive (n = 156/ 82.9%) and unhealthy (n = 139/ 73.9%). This study highlights the need and opportunity to improve public health action in the prevention and management of risks posed by e-cigarette products to users and non-users.

Exposure to lead and other toxic metals from informal foundries producing cookware from scrap metal.

Metal exposure remains a significant public health problem, particularly in the informal sector. The rise in informal foundries to cast scrap metal into artisanal cookware is widespread in low- and middle-income countries. The main aim of this study was to characterize metal exposure in artisanal cookware makers working in informal foundries in South Africa by measuring lead (Pb) in blood as well as sample metal concentrations on hands before and after work. The blood Pb distribution of the artisanal pot makers ranged from 1.1 to 4.6 µg/dl with the median blood Pb level being 2.1 µg/dl (IQR 1.7-2.5). The median blood Pb level in artisanal pot makers was 1.0 µg/dl higher compared with the non-exposed community members (p < 0.0001). Before-and-after handwipe sampling revealed a median increase in all 22 elements. Pre and post aluminum (Al) load on the handwipes revealed a 7.3 factor increase (0.53 and 3.9 mg Al/handwipe respectively) (p = 0.003). Hand Pb load before and after pot making revealed a 3.5-fold increase (median increase of 6.2 µg Pb/handwipe). An increase in backyard informal foundries may be linked to increased exposure to toxic metals for workers, family members and communities.

Recycled aluminium cooking pots: a growing public health concern in poorly resourced countries.

Lead exposure remains a significant public health problem, particularly in the informal sector. Recycling of scrap metal into artisanal pots is a growing concern in poorly resourced countries. Owing to the relatively light weight and low cost of the artisanal pots, as well as good conductivity which equates to lower usage of wood fuel, the pots are widely used. The aim of this article is to describe current insights and emerging evidence of health risks associated with artisanal pot making and usage. This thriving industry, particularly in poorly resourced communities, has multifaceted occupational, environmental and human health impacts. Given the complexity, innovative solutions need to be prioritized, evaluated and scaled up in relevant settings.

Spatial assessment of heavy metals contamination in household garden soils in rural Limpopo Province, South Africa.

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.

Overcrowding and health in two impoverished suburbs of Johannesburg, South Africa.

BACKGROUND: Rapid urbanization, unmatched by an associated supply of housing, has resulted in overcrowding in the cities of many developing countries, including in Johannesburg, South Africa. Household overcrowding has been associated with a range of ill-health outcomes, including acute respiratory infections and diarrhoeal diseases. The aim of this study was to describe the levels of household crowding, and examine associations with respiratory and gastrointestinal symptoms in selected two low-income neighbourhoods in Johannesburg. METHODS: Questionnaire data from a panel study conducted over an 11-year period between 2006 and 2016 were extracted to conduct the analyses. Structured questionnaires, designed to collect information on housing conditions, socio-economic and health status were administered to adult representatives of households occupying the primary dwelling on pre-selected study sites. RESULTS: Over the 11-year study period, levels of overcrowding remained unchanged. Around 57.6% of dwellings in the study neighbourhoods were determined to be overcrowded in relation to international guidelines. Results from the multiple logistic regression analyses indicated that crowded dwellings were associated with elevated levels of acute respiratory and gastrointestinal symptoms, as well as fever/chills. CONCLUSION: Respondent perceptions varied from objective measures of overcrowding. Crowded dwellings were associated with elevated reports of acute respiratory and gastrointestinal symptoms, as well as fever/chills.

A study protocol to determine the association between lifetime lead exposure and violent criminal behaviour in young males in conflict with the law.

BACKGROUND: Low-level lead exposure has harmful and persistent effects on behaviour. Recent studies have linked environmental lead exposure and the development of aggressive, violent and criminal behaviour. This protocol is designed to study an association between lifetime (bone) lead levels and violent criminal behaviour among young males in conflict with the law in Gauteng youth development centres. METHODS: This paper describes a study to determine a link between lifetime lead exposure and violent criminal behaviour. Lifetime lead exposure will be measured using bone lead measurement, while blood lead levels will be observed for current exposure. Thereafter, criminal records of participants will be reviewed whereas violent behaviour and risk factors will be observed using a questionnaire. The study focused on young males in conflict with the law in three centres within Gauteng Provence, South Africa. After stratifying the centres, we randomly selected participants. The researcher shall adhere to ethical requirements throughout the study. Data will be analysed for descriptive and inferential analysis using Statistical Package for Social Science (SPSS). DISCUSSION: The study will provide a strong foundation for an improved understanding of the relationship between environmental contamination from lead exposure and aggression/violent criminal behaviour. Beyond the health sector, the study findings may be able to inform new approaches to crime prevention through environmental action with an emphasis on the role of non-health sectors.

Environmental health practitioners potentially play a key role in helping communities adapt to climate change.

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.

Concentrations of arsenic and lead in residential garden soil from four Johannesburg neighborhoods.

The 2017 Lancet Commission on Pollution and Health identified soil as an important, daily route of public exposure to a variety of pollutants. Lead and arsenic are two potential soil contaminants associated with serious health effects including reductions in intelligence, behavioral effects and aggressive or violent behavior (lead), as well as skin changes, cancer of the skin, bladder, liver and lungs and developmental delays (arsenic). In this study soil samples were collected, using US EPA methods, from gardens in four Johannesburg neighborhoods, and analyzed for lead and arsenic content using a portable X-ray fluorescence spectrometer. The results showed widely varied concentrations of arsenic and lead in soil collected across the four neighborhoods. Concentrations of lead (range: 0.1-2141.0 mg/kg; mean: 241.7 mg/kg (SD 282.8); median 158.1 mg/kg) exceeding local and international reference levels were found in an inner city suburb, while raised arsenic concentrations (range: 0.1-65.3 mg/kg; mean: 18.3 mg/kg (SD 11.7); median: 19.1) were found in the gardens of a suburb located very close to a mine tailings facility. This study confirms the potential for high levels of exposure to toxic metals in residential gardens in an urban African setting. There is a pressing need for scaled up attention to the public health implications of exposure to soil pollution in developing countries.

Exposure to lead in South African shooting ranges.

INTRODUCTION: Lead exposure in shooting ranges has been under scrutiny for decades, but no information in this regard is available in respect of African settings, and in South Africa specifically. The aim of this study was to determine the blood lead levels in the users of randomly selected private shooting ranges in South Africa's Gauteng province. METHODS: An analytical cross sectional study was conducted, with participants recruited from four randomly selected shooting ranges and three archery ranges as a comparator group. RESULTS: A total of 118 (87 shooters and 31 archers) were included in the analysis. Shooters had significantly higher blood lead levels (BLL) compared to archers with 36/85 (42.4%) of shooters versus 2/34 (5.9%) of archers found to have a BLL ≥10µg/dl (p<0.001). CONCLUSION: Shooting ranges may constitute an import site of elevated exposure to lead. Improved ventilation, low levels of awareness of lead hazards, poor housekeeping, and inadequate personal hygiene facilities and practices at South African shooting ranges need urgent attention.

'My child did not like using sun protection': practices and perceptions of child sun protection among rural black African mothers.

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.

Sun protection to improve vaccine effectiveness in children in a high ambient ultraviolet radiation and rural environment: an intervention study.

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).

Incidence and transmission of respiratory syncytial virus in urban and rural South Africa, 2017-2018.

Data on respiratory syncytial virus (RSV) incidence and household transmission are limited. To describe RSV incidence and transmission, we conducted a prospective cohort study in rural and urban communities in South Africa over two seasons during 2017-2018. Nasopharyngeal swabs were collected twice-weekly for 10 months annually and tested for RSV using PCR. We tested 81,430 samples from 1,116 participants in 225 households (follow-up 90%). 32% (359/1116) of individuals had ≥1 RSV infection; 10% (37/359) had repeat infection during the same season, 33% (132/396) of infections were symptomatic, and 2% (9/396) sought medical care. Incidence was 47.2 infections/100 person-years and highest in children <5 years (78.3). Symptoms were commonest in individuals aged <12 and ≥65 years. Individuals 1-12 years accounted for 55% (134/242) of index cases. Household cumulative infection risk was 11%. On multivariable analysis, index cases with ≥2 symptoms and shedding duration >10 days were more likely to transmit; household contacts aged 1-4 years vs. ≥65 years were more likely to acquire infection. Within two South African communities, RSV attack rate was high, and most infections asymptomatic. Young children were more likely to introduce RSV into the home, and to be infected. Future studies should examine whether vaccines targeting children aged <12 years could reduce community transmission.

Lead exposure in young school children in South African subsistence fishing communities.

BACKGROUND: Lead is an established toxic substance, with wide-ranging health effects, including neurodevelopmental decrements and behavioural problems, even at low levels in blood. Anecdotal reports of lead melting to make fishing sinkers in South African subsistence fishing communities prompted the conduct of an epidemiological study in two South African fishing villages to investigate the extent of lead melting and the associated risks in children. OBJECTIVES: The objectives of the study were to determine the extent of lead melting, and the blood lead distributions and associated risk factors in children. METHODS: Cross-sectional, analytical studies were undertaken among 160 young school children in the fishing villages of Struis Bay and Elands Bay located along the south-eastern and western South African coastline, respectively. Blood samples were collected for lead content analysis, and anthropometric and hemoglobin measurements were taken. Questionnaires were administered to obtain information about socio-economic status and risk factors for lead exposure. RESULTS: Blood lead levels ranged from 2.2 to 22.4 µg/dl, with the mean blood lead level equalling 7.4. Around 74% of the children had blood lead levels ≥5 µg/dl and 16% had blood lead levels ≥10 µg/dl. Socio-economic factors, and lead melting practices were strongly associated with elevated blood lead levels. CONCLUSIONS: Blood lead levels in these remote subsistence fishing communities were unexpectedly elevated, given the absence of local lead industries or other obvious sources of lead exposure. Lead exposure and poisoning is an important, yet neglected, public health concern in South African subsistence fishing communities, and potentially on the entire African continent.

Rodent control in urban communities in Johannesburg, South Africa: from research to action.

INTRODUCTION: Rodents are troublesome urban pests, with potentially serious health implications. Preventive efforts require greater understanding of social contexts in which they are prevalent. This study aimed to determine rodent prevalence and identify factors associated with rodent infestations in urban residential settings. METHODS: The Health, Environment and Development study is a longitudinal panel study conducted in five settlements across Johannesburg. Data on socio-economic status, domestic behaviour and housing quality are collected annually. Logistic regression revealed risk factors for rodent prevalence at household level. RESULTS: Rodents are a major household problem in all study areas (prevalence 54%). Factors associated with increased prevalence of rats included lower income, living in informal areas, overcrowding, cracks in dwelling walls and internal damp. CONCLUSION: Socio-economic status, housing quality, domestic behaviour and environmental health services are associated with exposure to rodents in urban Johannesburg communities. This information served as a platform to launch rodent awareness campaigns at study sites.