Identifying heat thresholds for South Africa towards the development of a heat-health warning system.

Exposure to heatwaves may result in adverse human health impacts. Heat alerts in South Africa are currently based on defined temperature-fixed threshold values for large towns and cities. However, heat-health warning systems (HHWS) should incorporate metrics that have been shown to be effective predictors of negative heat-related health outcomes. This study contributes to the development of a HHWS for South Africa that can potentially minimize heat-related mortality. Distributed lag nonlinear models (DLNM) were used to assess the association between maximum and minimum temperature and diurnal temperature range (DTR) and population-adjusted mortality during summer months, and the effects were presented as incidence rate ratios (IRR). District-level thresholds for the best predictor from these three metrics were estimated with threshold regression. The mortality dataset contained records of daily registered deaths (n = 8,476,532) from 1997 to 2013 and data for the temperature indices were for the same period. Maximum temperature appeared to be the most statistically significant predictor of all-cause mortality with strong associations observed in 40 out of 52 districts. Maximum temperature was associated with increased risk of mortality in all but three of the districts. Our results also found that heat-related mortality was influenced by regional climate because the spatial distribution of the thresholds varied according to the climate zones across the country. On average, districts located in the hot, arid interior provinces of the Northern Cape and North West experienced some of the highest thresholds compared to districts located in temperate interior or coastal provinces. As the effects of climate change become more significant, population exposure to heat is increasing. Therefore, evidence-based HHWS are required to reduce heat-related mortality and morbidity. The exceedance of the maximum temperature thresholds provided in this study could be used to issue heat alerts as part of effective heat health action plans.

Ambient Particulate Air Pollution and Daily Mortality in 652 Cities.

BACKGROUND: The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias. METHODS: We evaluated the associations of inhalable particulate matter (PM) with an aerodynamic diameter of 10 µm or less (PM10) and fine PM with an aerodynamic diameter of 2.5 µm or less (PM2.5) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived. RESULTS: On average, an increase of 10 µg per cubic meter in the 2-day moving average of PM10 concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval [CI], 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM2.5 concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations. CONCLUSIONS: Our data show independent associations between short-term exposure to PM10 and PM2.5 and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).

An analysis of past and future heatwaves based on a heat-associated mortality threshold: towards a heat health warning system.

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.

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.

The association between weather and crime in a township setting in South Africa.

The association between various meteorological parameters and crime is well-established in developed contexts. In contrast in this study, we investigated the association between three weather parameters (temperature, relative humidity and rainfall) and three categories of crime in the developing township of Khayelitsha, in the Western Cape Province of South Africa. Distributed lag non-linear modelling was used to identify temporal relationships between temperature, relative humidity and rainfall, and violent, property and sexual crime over a 10-year period (2006-2016). We found hot days (defined as [Formula: see text] 25 °C) increased the cumulative relative risk of violent crime by up to 32% but were also found to be associated with a lagged increase in violent crime for at least a week thereafter. On very cold days (defined as [Formula: see text]), the cumulative relative risk of property crime increased by up to 50% whereas on very rainy days (defined as [Formula: see text]) the risk of property crime surprisingly increased by 40%. These findings provide some additional evidence for the relationship between the atmospheric environment and human behaviour in a developing context.

Major climate change-induced risks to human health in South Africa.

There are many climatic changes facing South Africa which already have, or are projected to have, a detrimental impact on human health. Here the risks to health due to several alterations in the climate of South Africa are considered in turn. These include an increase in ambient temperature, causing, for example, a significant rise in morbidity and mortality; heavy rainfall leading to changes in the prevalence and occurrence of vector-borne diseases; drought-associated malnutrition; and exposure to dust storms and air pollution leading to the potential exacerbation of respiratory diseases. Existing initiatives and strategies to prevent or reduce these adverse health impacts are outlined, together with suggestions of what might be required in the future to safeguard the health of the nation. Potential roles for the health and non-health sectors as well as preparedness and capacity development with respect to climate change and health adaptation are considered.

Characterization of personal solar ultraviolet radiation exposure using detrended fluctuation analysis.

Studies of personal solar ultraviolet radiation (pUVR) exposure are important to identify populations at-risk of excess and insufficient exposure given the negative and positive health impacts, respectively, of time spent in the sun. Electronic UVR dosimeters measure personal solar UVR exposure at high frequency intervals generating large datasets. Sophisticated methods are needed to analyze these data. Previously, wavelet transform (WT) analysis was applied to high-frequency personal recordings collected by electronic UVR dosimeters. Those findings showed scaling behavior in the datasets that changed from uncorrelated to long-range correlated with increasing duration of time spent in the sun. We hypothesized that the WT slope would be influenced by the duration of time that a person spends in continuum outside. In this study, we address this hypothesis by using an experimental study approach. We aimed to corroborate this hypothesis and to characterize the extent and nature of influence time a person spends outside has on the shape of statistical functions that we used to analyze individual UVR exposure patterns. Detrended fluctuation analysis (DFA) was applied to personal sun exposure data. We analyzed sun exposure recordings from skiers (on snow) and hikers in Europe, golfers in New Zealand and outdoor workers in South Africa. Results confirmed validity of the DFA superposition rule for assessment of pUVR data and showed that pUVR scaling is determined by personal patterns of exposure on lower scales. We also showed that this dominance ends at the range of time scales comparable to the maximal duration of continuous exposure to solar UVR during the day; in this way the superposition rule can be used to quantify behavioral patterns, particularly accurate if it is determined on WT curves. These findings confirm a novel way in which large datasets of personal UVR data may be analyzed to inform messaging regarding safe sun exposure for human health.

COVID-19: urgent actions, critical reflections and future relevance of 'WaSH': lessons for the current and future pandemics.

The COVID-19 pandemic placed hygiene at the centre of disease prevention. Yet, access to the levels of water supply that support good hand hygiene and institutional cleaning, our understanding of hygiene behaviours, and access to soap are deficient in low-, middle- and high-income countries. This paper reviews the role of water, sanitation and hygiene (WaSH) in disease emergence, previous outbreaks, combatting COVID-19 and in preparing for future pandemics. We consider settings where these factors are particularly important and identify key preventive contributions to disease control and gaps in the evidence base. Urgent substantial action is required to remedy deficiencies in WaSH, particularly the provision of reliable, continuous piped water on-premises for all households and settings. Hygiene promotion programmes, underpinned by behavioural science, must be adapted to high-risk populations (such as the elderly and marginalised) and settings (such as healthcare facilities, transport hubs and workplaces). WaSH must be better integrated into preparation plans and with other sectors in prevention efforts. More finance and better use of financing instruments would extend and improve WaSH services. The lessons outlined justify no-regrets investment by government in response to and recovery from the current pandemic; to improve day-to-day lives and as preparedness for future pandemics.

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.

Climate change adaptation in South Africa: a case study on the role of the health sector.

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.

Circular economy and environmental health in low- and middle-income countries.

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.

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.

The association between ambient temperature and mortality in South Africa: A time-series analysis.

BACKGROUND: There is an extensive literature describing temperature-mortality associations in developed regions, but research from developing countries, and Africa in particular, is limited. METHODS: We conducted a time-series analysis using daily temperature data and a national dataset of all 8.8 million recorded deaths in South Africa between 1997 and 2013. Mortality and temperature data were linked at the district municipality level and relationships were estimated with a distributed lag non-linear model with 21 days of lag, and pooled in a multivariate meta-analysis. RESULTS: We found an association between daily maximum temperature and mortality. The relative risk for all-age all-cause mortality on very cold and hot days (1st and 99th percentile of the temperature distribution) was 1.14 (1.10,1.17) and 1.06 (1.03,1.09), respectively, when compared to the minimum mortality temperature. This "U" shaped relationship was evident for every age and cause group investigated, except among 25-44 year olds. The strongest associations were in the youngest (< 5) and oldest (> 64) age groups and for cardiorespiratory causes. Heat effects occurred immediately after exposure but diminished quickly whereas cold effects were delayed but persistent. Overall, 3.4% of deaths (~ 290,000) in South Africa were attributable to non-optimum temperatures over the study period. We also present results for the 52 district municipalities individually. CONCLUSIONS: An assessment of the largest-ever dataset for analyzing temperature-mortality associations in (South) Africa indicates mortality burdens associated with cold and heat, and identifies the young and elderly as particularly vulnerable.

'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).

Solar ultraviolet radiation in Africa: a systematic review and critical evaluation of the health risks and use of photoprotection.

Most information on the harmful health effects of solar ultraviolet radiation (UVR) has been obtained in populations in which the majority has fair skin. Here a systematic review of evidence on diseases related to solar UVR in Africa was undertaken, and the appropriateness of effective photoprotection for these people considered. There are few population-based studies on UV-induced skin cancers (melanoma, squamous and basal cell carcinomas) in Africa, although limited reports indicated that they occur, even in people with deeply pigmented skin. The incidence of melanoma is particularly high in the white population living in the Western Cape of South Africa and has increased significantly in recent years. Cataract is extremely common in people of all skin colours and is a frequent cause of blindness, particularly in the elderly. For both skin cancer and cataract, the proportion of the disease risk that is attributable to exposure to solar UVR in African populations, and therefore the health burden caused by UV irradiation is unclear. There was little published information on the use of sun protection in Africa. The potential disease burden attributable to solar UVR exposure of Africans is high, although accurate data to quantify this are sparse. Information is required on the incidence, prevalence and mortality for the range of UV-related diseases in different populations living throughout Africa. Photoprotection is clearly required, at least for those subpopulations at particularly high risk, but may be limited by cost and cultural acceptability.

Knowledge and practice of sun protection in schools in South Africa where no national sun protection programme exists.

Interventions in primary schools that increase sun-protective behaviours and decrease ultraviolet radiation exposure, sunburn incidence and skin cancer risk can be effective. SunSmart School Accreditation Programmes (SSAP) are recommended. Prior to SSAP implementation in South Africa, we explored the feasibility of obtaining national baseline information and investigated possible associations between strategies regarding sun protection in schools and students' responses to a questionnaire. Principals from randomly selected urban government schools in all nine South African provinces completed a questionnaire and 679 students were surveyed. The mean sun-related knowledge and behaviour scores of students were 4 (range: 1-7) and 3 (range-0-8) out of 9, respectively. The mean school sun protection effort score was 4 out of 14. There were no statistically significant correlations between students' knowledge or behaviour scores and their school score. The World Health Organization recommends an SSAP to address policy, practice and curriculum changes to support sun protection of students. This cross-sectional study demonstrates the feasibility of, and need for, a larger baseline study with longitudinal, multi-variable follow-up which includes other influential factors, such as parent support. Such research could quantify the impact of the SSAP and identify which key factors influence the sun-related knowledge and behaviours of students.

Modelling the healthcare costs of skin cancer in South Africa.

BACKGROUND: Skin cancer is a growing public health problem in South Africa due to its high ambient ultraviolet radiation environment. The purpose of this study was to estimate the annual health system costs of cutaneous melanoma, squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) in South Africa, incorporating both the public and private sectors. METHODS: A cost-of-illness study was used to measure the economic burden of skin cancer and a 'bottom-up' micro-costing approach. Clinicians provided data on the patterns of care and treatments while national costing reports and clinician fees provided cost estimates. The mean costs per melanoma and per SCC/BCC were extrapolated to estimate national costs using published incidence data and official population statistics. One-way and probabilistic sensitivity analyses were undertaken to address the uncertainty of the parameters used in the model. RESULTS: The estimated total annual cost of treating skin cancers in South Africa were ZAR 92.4 million (2015) (or US$15.7 million). Sensitivity analyses showed that the total costs could vary between ZAR 89.7 to 94.6 million (US$15.2 to $16.1 million) when melanoma-related variables were changed and between ZAR 78.4 to 113.5 million ($13.3 to $19.3 million) when non-melanoma-related variables were changed. The primary drivers of overall costs were the cost of excisions, follow-up care, radical lymph node dissection, cryotherapy and radiation therapy. CONCLUSION: The cost of managing skin cancer in South Africa is sizable. Since skin cancer is largely preventable through improvements to sun-protection awareness and skin cancer prevention programs, this study highlights these healthcare resources could be used for other pressing public health problems in South Africa.

Self-reported skin colour and erythemal sensitivity vs. objectively measured constitutive skin colour in an African population with predominantly dark skin.

BACKGROUND: Skin colour is an important factor in skin-related diseases. Accurate determination of skin colour is important for disease prevention and supporting healthy sun behaviour, yet such data are lacking for dark skin types. METHODS: Self-perceived, natural skin colour and sun-skin reaction were compared with objectively measured skin colour among an African population with predominantly dark skin. Unexposed skin of 556 adults (70.1% Black) was measured with a reflectance spectrophotometer to calculate an individual typology angle (°ITA). Participants reported self-perceived skin colour and erythemal sensitivity. RESULTS: There was a strong, positive monotonic correlation between self-reported and measured skin colour (Spearman ρ = 0.6438, P < 0.001), but only a weak correlation between self-reported erythemal sensitivity and measured skin colour (Spearman ρ = 0.2713, P < 0.001). Self-report biases in underestimation and overestimation of skin colour were evident. Many participants with 'dark brown' and 'black' skin had difficulty in classifying erythemal sensitivity. CONCLUSIONS: In Africa, self-reported skin colour could potentially be used in lieu of spectrophotometer measurements, but options for questions on sunburn and tanning require suitable adjustment. Our study provides evidence of range in °ITA values among residents in Africa and reinforces previous results that self-report may be reliable for determining skin colour, but not erythemal sensitivity, for dark skin individuals.

Self-reported sun-related knowledge, attitudes and behaviours among schoolchildren attending South African primary schools.

BACKGROUND: Skin cancer and other adverse health effects result from excess solar ultraviolet radiation exposure. Sun protective practices are important interventions for skin cancer prevention, particularly when implemented early in life. Several international studies have assessed children's sun-related knowledge, attitudes and behaviours in school settings but never before in Southern Africa, where multiethnic populations exist. PURPOSE: The purpose of this study is to describe the sun-related knowledge, attitudes and behaviours as self-reported by South African primary schoolchildren and consider the roles of sex and skin type. METHODS: A randomly selected sample of 707 schoolchildren from 24 government, urban schools in all nine provinces of South Africa were surveyed regarding their sun-related knowledge, attitudes and behaviours. RESULTS: Approximately 56% of students reported experience of sunburn last summer and 59% stated that they had got a suntan. Many students (64.5%) believed that one could protect oneself from getting skin cancer by avoiding getting sunburnt. Other means reported to do so by the students were to use sunscreen (65.4%), stay out of the summer sun (48.0%), cover up with clothing (45.5%) and eat the right foods (38.0%). Only about a quarter of the students (22.4%) wrongly agreed that it is safe to get sunburnt once or twice a year. Few students (8.7%) agreed that they like to have a suntan because they feel healthier and agreed that they think a suntan makes them feel more attractive to others (17.3%). Few also agreed that most of their friends (16.1%) and family (14.2%) think that a suntan is a good thing. Children reporting to have white/light brown skin (69.4%) were more likely to agree that they used sunscreen to protect themselves from getting sunburnt compared with children having brown/dark brown/black skin (54.8%) (P = 0.0005). CONCLUSION: South African schoolchildren at urban government schools do have some knowledge about sun protection, and they do have some positive sun behaviours; however, the reported occurrence of sunburn, a risk factor for skin cancer, was relatively high. There were few differences in responses by sex and some differences by skin type. These findings are important for the development of appropriate sun protection programmes aimed at schoolchildren in South Africa and other countries with similar multi-ethnic populations.