title: Sun protection to improve vaccine effectiveness in children in a high ambient ultraviolet radiation and rural environment: an intervention study.
abstract: 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.
  
  
  
  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.
  
  
  
  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).
authors.affiliation: Environment and Health Research Unit, South African Medical Research Council, 1 Soutpansberg Road, Pretoria, 0001, South Africa. cwright@mrc.ac.za.|Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa. cwright@mrc.ac.za.
authors.forename: Caradee Y
authors.initials: CY
authors.lastname: Wright
authors.affiliation: Environment and Health Research Unit, South African Medical Research Council, 1 Soutpansberg Road, Pretoria, 0001, South Africa.
authors.forename: Patricia N
authors.initials: PN
authors.lastname: Albers
authors.affiliation: Environment and Health Research Unit, South African Medical Research Council, Johannesburg, South Africa.|University of Johannesburg, Johannesburg, South Africa.
authors.forename: Angela
authors.initials: A
authors.lastname: Mathee
authors.affiliation: Environment and Health Research Unit, South African Medical Research Council, Johannesburg, South Africa.
authors.forename: Zamantimande
authors.initials: Z
authors.lastname: Kunene
authors.affiliation: National Centre for Epidemiology and Population Health Research School of Population Health, College of Medicine, Biology and Environment, The Australian National University, Canberra, Australia.
authors.forename: Catherine
authors.initials: C
authors.lastname: D'Este
authors.affiliation: The Canberra Hospital, Canberra, Australia.
authors.forename: Ashwin
authors.initials: A
authors.lastname: Swaminathan
authors.affiliation: National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University, Canberra, Australia.
authors.forename: Robyn M
authors.initials: RM
authors.lastname: Lucas
mesh_terms: D005260:Female; D006801:Humans; D017589:Immunization Programs / Q000379:methods*; D007223:Infant; D008297:Male; D008457:Measles / Q000276:immunology / Q000517:prevention & control*; D015397:Program Evaluation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012424:Rural Population; D013019:South Africa; D013473:Sunscreening Agents / Q000627:therapeutic use*; D014466:Ultraviolet Rays; D014612:Vaccines / Q000276:immunology*
chemical_list: D013473:Sunscreening Agents; D014612:Vaccines
keywords: Africa; Immunisation; Intervention study; Measles; Sun exposure; Vaccination