In the northern hemisphere, children born in October are most likely to be vaccinated for the flu in October – and are least likely to be diagnosed with influenza, according to results of the first large-scale study of optimal timing for the flu shot.
The study, by researchers from the Department of Health Care Policy in the Blavatnik Institute at Harvard Medical School, amplifies public health guidance that encourages getting flu vaccinations in October for those in the northern hemisphere. The findings appear in the BMJ.
“There are a lot of variables when it comes to the timing and severity of flu season or a person’s risk of getting sick, and many of those are out of our control,” said Anupam Jena, the Joseph P. Newhouse Professor of Health Care Policy at HMS, physician at Massachusetts General Hospital, and senior author of the study. Christopher Worsham, HMS assistant professor of medicine and critical care physician at Mass General, led the study.
“One thing we have some control over is the timing of the shot,” Jena said, “and it looks like October is indeed the best month for kids to get vaccinated against the flu.”
In January the U.S. Centers for Disease Control and Prevention reported at least 150,000 hospitalizations and 9,400 deaths due to flu as of the time of the report and noted that high demand for hospital care for influenza has contributed to strained hospital capacity in some parts of the country. Over the past decade in the U.S., between one and 199 children have died of influenza each flu season. Across the years, most children who die are not fully vaccinated against the flu.
Part of the reason the timing of the shot is tricky is the way the immune system responds to a vaccine. If a person gets the shot too early, their immunity may fade by the time flu season peaks. If they wait too long, their body may not have time to build immunity strong enough to protect against the peak level of infections.
How soon is too soon, and how late is too late?
While public health recommendations in the U.S. have long promoted September and October flu shots, there has never been a randomised clinical trial to test the best timing, nor a large-scale effort to see how likely people who get vaccinated in other months are to get sick, Jena said.
When Jena was at a late summer meeting in 2022, he mentioned that his arm was sore from getting his flu shot. A colleague asked whether he was concerned about his immunity waning before flu season.
“It hadn’t occurred to me to check if one month or the other might make a big difference,” Jena said. “When we looked at the science, we were surprised that no one had ever looked at the question in a big population.”
Organising a clinical trial would require a lot of time and resources to coordinate the random distribution of flu jabs across hundreds or thousands of people.
But Jena, Worsham, and study co-author Charles Bray, HMS research assistant in health care policy, had a good idea where they could find an already randomized study population.
The surprising link between birth dates and childhood flu vaccination
In prior research reported in the New England Journal of Medicine in 2020, Jena and Worsham documented the way birth month determines how likely it is that children get the flu shot at all.
Young children in the U.S. tend to get their yearly checkup around their birthday, and it’s also when they get most of their vaccines. Children with spring and summer birthdays often don’t get the flu shot because it’s not available when they go for their annual visit, and many parents don’t make an extra trip for it.
The NEJM research was meant to highlight the importance of promoting the flu vaccine in the fall for children with birthday months that make it less likely that they will get the vaccine. Jena and Worsham realized they could also leverage this quirk of health care to study a ready-made distribution of children who get checkups – and flu shots – across all the months when the vaccine is commonly available.
Randomised by birthday
Studying children who got a flu shot in their birth month minimised certain factors related to the risk of infection that would have made it harder to measure the true impact of the timing of the shot.
For instance, families who proactively sought out shots in a non-birthday month might have done so because the child had a higher risk of catching the flu or because family members were more cautious and more likely to take actions that would protect them from the flu, such as handwashing and disinfecting.
For the BMJ study, Jena, Worsham, and Bray analysed the anonymised commercial health insurance records of more than 800 000 children in the U.S. from 2 to 5 years old who received influenza vaccines from 2011 to 2018.
The analysis showed that children born in October had the lowest rate of influenza diagnosis. For example, 2.7% of children born and vaccinated in October were diagnosed with the flu that season, compared to 3% of those born and vaccinated in August or January, 2.9% of those born and vaccinated in September or December, and 2.8% of those born and vaccinated in November.
The findings suggest that U.S. public health interventions focused on vaccination of young children in October may yield the best protection in typical flu seasons, the authors said.
“This study can help people pinpoint the best time to get flu vaccines for their children – especially the ones who weren’t born in October,” Worsham said.
“We’ve had several rough winters in a row for respiratory viruses, between COVID-19, RSV, and the flu,” Worsham said. “We need all the help we can get to keep people safe from these diseases.”
Finance Minister Enoch Godongwana tables his 2024 Budget during a joint seating of the National Assembly in the Cape Town City Hall. (Photo: National Treasury)
By Wanga Zembe, Donela Besada, Funeka Bango, Tanya Doherty, Catherine Egbe, Charles Parry, Darshini Govindasamy, Renee Street, Caradee Wright and Tamara Kredo
The 2024 national budget offers some glimmers but allocations for direct health benefits fall short of making a difference to people’s health and wellbeing. These include a ring-fenced allocation to crack down on corruption in health to inspire trust for theNational Health Insurance, taxing accessories for e-cigarettes, a jacked up child-support grant, clarity on plans dealing with climate change and its impacts on human health, and finally greater investment to enhance women’s capabilities alongside the Covid-19 grant, researchers from the South African Medical Research Council write exclusively for Spotlight.
The 2024 national budget presented last week by Finance Minister Enoch Godongwana contained several key elements that have an impact on systems, services and wellbeing from a health perspective.
Importantly, not only direct health spend, but budget allocated to social protection and climate infrastructure has implications for health outcomes such as nutrition, growth and food security. Health taxes, to address illness caused by alcohol, cigarettes and e-cigarettes amongst others, are also key revenue streams with taxation intended to deter use.
As researchers at the South African Medical Research Council we are dedicated to improving the health of people in South Africa through research and innovation. We wish to share some insights into positive areas in the budget and to point out areas where there are gaps with potentially dire consequences for the health of our nation.
In real terms, the health budget is shrinking.
Health has been allocated a total of R848-billion over the medium-term expenditure framework. This includes R11.6-billion to address the 2023 wage agreement, R27.3-billion for infrastructure and R1.4-billion for the National Health Insurance (NHI) grant. Compared to the medium-term budget policy statement in October last year, government is now adding R57.6-billion to pay salaries of teachers, nurses and doctors, among other critical services.
In real terms, the health budget is shrinking. The allocation to cover last year’s higher-than-anticipated wage settlement is a positive step to try to fill posts for essential health workers. But this allocation falls short of fully funding the centrally agreed wage deal, meaning that provincial health departments will be unable to fill all essential posts.
Treasury’s Chief Director for Health and Social Development, Mark Blecher, was quoted as saying that the “extra money would not be sufficient to hire all the recently qualified doctors who have been unable to secure jobs with the state, and provincial Health Departments will need to determine which posts should be prioritised”. He added: “There will be less downsizing, and more posts will be filled, but it is unlikely they all will be.”
South Africa has a ratio of only 7.9 physicians per 100 000 people in the public health system, while it has been estimated that there are more than 800 unemployed newly qualified doctors. Considering the health-workforce shortfalls, the amount of money allocated appears optimistic for service coverage for the increasing population.
The World Health Organization (WHO) considers building a health workforce a highly cost-effective strategy. Salaries continue to consume the largest share of provincial health budgets, estimated at 64% since 2018. The Human Resources for Health strategy lacks clarity on the implementation of workforce-planning approaches with significant implications for how provinces prioritise workforce cadres to keep up with the increasing needs – particularly in light of NHI.
Nutrition support on the decline
The Minister described protecting the budgets of critical programmes such as school-nutrition programmes, which includes almost 20 000 schools. He noted that the early childhood development (ECD) grant will be allocated R1.6-billion rising to R2-billion over the medium term.
Ensuring nutrition support to children under-five for optimal physical and cognitive growth is vital. The 2023 National Food and Nutrition Security Survey by the Human Sciences Research Council found that 29% of children under five in South Africa are stunted (short for their age). The proportion of children experiencing both acute and chronic under-nutrition has increased over the past decade. Stunted children are more likely to earn less and have a higher risk of obesity and non-communicable diseases such as diabetes and heart disease as adults.
Currently, only registered or conditionally registered Early Learning Programmes (ELPs) serving poor children (determined by income-means testing) are eligible to receive the ECD subsidy. This is not aligned with inflation and the real value of the R17 per child per day subsidy and the contribution to nutrition costs have decreased over time. The subsidy is not enough to cover the costs of running quality programmes, let alone the costs of providing nutritious meals. The World Bank suggests a minimum of R31 per child per day.
There is also concern about the children missed who attend informal or unregistered programmes. According to the 2021 Early Childhood Development Census, only 41% of ELPs are registered and only 33%, registered or not, receive the subsidy. Unregistered ELPs are more likely to be based in vulnerable communities and attended by children from vulnerable households. Further, although about 1.7 million children are enrolled in ELPs, enrolment rates vary across provinces from 40% in Gauteng to 26% in the Eastern Cape. This means many young children are not enrolled, and, of those enrolled, most do not benefit from the subsidy.
Child grants increase not keeping up with inflation
Child grants appear in the budget every year, but the increases do not keep up with inflation, and particularly not with the basket of goods needed for a growing child. In real terms grant amounts are decreasing – visible in the way hunger is increasing throughout the country, particularly in the Eastern Cape where uptake of social grants is very high.
The Social Relief of Distress Grant and women’s economic empowerment
As part of pandemic recovery efforts, we commend government for the roll-out of the Social Relief of Distress (SRD) grant and its plans to extend this beyond March 2025. While SRD continues to suffer implementation challenges related to the amount and roll-out; it presents an opportunity for renewed attention to a comprehensive and inclusive approach to women’s economic empowerment.
The recent Stats SA labour survey reported a higher unemployment rate among women (35.7%) versus men (30.7%). Our research also finds that women caregivers of children and adolescents living with HIV are particularly vulnerable to poor health and economic outcomes. Greater investment in programmes that enhance women’s opportunities alongside the SRD could promote the sustainability of pandemic-recovery efforts.
The NHI, health-system reforms and dealing with corruption in health
The Minister indicated that the allocation for NHI – government’s policy for implementing universal health coverage – demonstrates commitment to this policy. He also noted that there are a range of system-strengthening activities, that are key enablers of an improved public healthcare system, including strengthening the health-information system; upgrading facilities; enhancing management at district and facility level; and developing reference pricing and provider payment mechanisms for hospitals. He recognised that these require further development before NHI can be rolled out at scale.
The NHI allocation must show a tangible commitment to health-system reforms. Funding needs to be allocated for the creation of organisational infrastructure that ensures transparent, trustworthy decisions will be made about the benefits package and programmes to be funded. Specifically, funding for conducting Health Technology Assessments with credible processes that manage interests and ensure coverage decisions are informed by independent appraisal of the best-available evidence, measures of affordability, and with public input. Some areas of government already undertake such work, for example the National Essential Medicine Committee, but how these processes will expand beyond medicine to include decisions about health-systems arrangements and public-health interventions remain unclear, and apparently unfunded.
Undoubtedly, facilities need to be upgraded. It’s positive to see this as a named activity. It is however unclear how the upgrade of health facilities and quality of care will be ensured, given that tertiary infrastructure grants have been reduced due to underspending of conditional grants. Currently, health facilities’ quality is assessed by the Office of Health Standards Compliance whose role is to inspect and certify facilities. This is a prerequisite for accreditation under NHI. This means the watchdog agency will need adequate budget. Implementation research is also required to test out the different NHI public-private contracting models. Furthermore, a ring-fenced allocation to deal with corruption in health, would be welcomed and inspire trust for NHI.
‘Sin’ taxes vs ’health taxes’
The Minister proposed excise duties and above-inflation increases of between 6.7 and 7.2% for 2024/25 for alcohol products and indicated that tobacco-excise duties will be increased by 4.7% for cigarettes and cigarette tobacco and by 8.2% for pipe tobacco and cigars. And, based on inputs from citizens, the Minister also tabled an increase in excise duties on electronic nicotine and non-nicotine delivery systems (vapes).
While there may be a concern that increasing taxes on products consumed by the poor is regressive, there are ways to direct revenue gained back to those sub-populations and it’s not fair to deny them the benefits of consuming less alcohol products.
It is notable that excise taxes on wine have been increased to a greater percentage than spirits, but the health effects of alcohol come from the ethanol not the type of liquor product so it would make more sense to make the excise tax rate per litre of absolute alcohol equal across all products. The budget has not moved this forward in any meaningful way.
The proposed tax on tobacco products is not in line with WHO recommendations and is below inflation. This should be at least 70% of the retail price to have a positive impact on public health by reducing tobacco use, especially in a country with one of the highest tobacco-use rates in the region. In South Africa, the tax is currently between 50 – 60%. Although the tax on electronic cigarettes has increased, it is still below inflation. We hope that this increase will deter more young people from starting to use e-cigarettes and encourage current users to quit. We also hope that this increase is not just once-off and that future increases are made with the goal of reducing e-cigarette use.
Overall, the taxes on tobacco products and electronic nicotine and non-nicotine delivery systems are below inflation. This means that manufacturers can absorb the increases, and consumers may not be deterred from using them. This is a missed opportunity, as there is a clear link between these products and the development of non-communicable diseases, like hypertension, and the worsening of communicable diseases, like tuberculosis.
The impact of climate change on lives and livelihoods
Climate and health are closely related, with more attention being paid by the global research community to potential impacts of climate change and natural disasters on lives and livelihoods. The Minister noted a multi-layered risk-based approach to manage some of the fiscal risks associated with climate change. These include a Climate Change Response Fund; disaster-response grants; support and funding from multilateral development banks and international funders to support climate adaptation, mitigation, energy transition and sustainability initiatives; and, municipal-level adaptation and mitigation initiatives.
There are numerous health co-benefits to these strategies. For example, investing in renewable energy sources can improve air quality, leading to reduced respiratory illness. There is a need to highlight these co-benefits and to foster intersectoral collaboration.
Overall, from the perspective of health researchers, we note the mention of NHI plans, social protection, nutrition, health workforce, health taxes and climate. However, we all agree that the allocations for direct health benefits and to address social determinants of health, such as education and poverty-alleviation, fall short of what is recommended, from global and national research evidence, to make a difference to people’s health and wellbeing.
People living in ancient Eastern Arabia appear to have developed resistance to malaria following the appearance of agriculture in the region around five thousand years ago, a new study published its in Cell Genomics reveals.
DNA analysis of the remains of four individuals from Tylos-period Bahrain (300 BCE to 600 CE) – the first ancient genomes from Eastern Arabia – revealed the malaria-protective G6PD Mediterranean mutation in three samples.
The discovery of the G6PD Mediterranean mutation in ancient Bahrainis suggests that many people in the region’s ancient populations may have enjoyed protection from malaria.
In the present day, among the populations examined, the G6PD mutation is detected at its peak frequency in the Emirates, the study indicates.
Researchers discovered that the ancestry of Tylos-period inhabitants of Bahrain comprises sources related to ancient groups from Anatolia, the Levant and Caucasus/Iran.
The four Bahrain individuals were genetically more like present-day populations from the Levant and Iraq than to Arabians.
Experts from Liverpool John Moores University, the University of Birmingham Dubai, and the University of Cambridge worked with the Bahrain Authority for Culture and Antiquities and other Arabian institutes such as the Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, as well as research centres in Europe.
Lead researcher Rui Martiniano, from Liverpool John Moores University, commented: “According to our estimates, the G6PD Mediterranean mutation rose in frequency around five-to-six thousand years ago — coinciding with the onset of agriculture in the region, which would have created ideal conditions for the proliferation of malaria.”
Due to poor ancient DNA preservation in hot and humid climates, no ancient DNA from Arabia has been sequenced until now — preventing the direct examination of the genetic ancestry of its past populations.
Marc Haber, from the University of Birmingham Dubai, commented: “By obtaining the first ancient genomes from Eastern Arabia, we provide unprecedented insights into human history and disease progression in this region. This knowledge goes beyond historical understanding, providing predictive capabilities for disease susceptibility, spread, and treatment, thus promoting better health outcomes.”
“The rich population history of Bahrain, and more generally of Arabia, has been severely understudied from a genetic perspective. We provide the first genetic snapshot of past Arabian populations – obtaining important insights about malaria adaptation, which was historically endemic in the region,” commented Fatima Aloraifi, from the Mersey and West Lancashire NHS Trust.
Salman Almahari, Director of Antiquities and Museums at the Bahrain Authority for Culture and Antiquities, states, “Our study also paves the way for future research that will shed light on human population movements in Arabia and other regions with harsh climates where it is difficult to find well-preserved sources of DNA.”
Data gathered from the analysis of the four individuals’ remains allowed researchers to characterise the genetic composition of the region’s pre-Islamic inhabitants – insights that could only have been obtained by directly examining ancient DNA sequences.
Researchers collected ancient human remains from archaeological collections stored at the Bahrain National Museum, gathering DNA from 25 of them. Only four samples were sequenced to higher coverage due to poor preservation.
The finding of malaria adaptation agrees with archaeological and textual evidence that suggested malaria was historically endemic in Eastern Arabia, whilst the DNA ancestry of Tylos-period inhabitants of Bahrain corroborates archaeological evidence of interactions between Bahrain and neighbouring regions.
A report from the world’s leading scientific and medical experts on hormone-related health conditions raises new concerns about the profound threats to human health from endocrine disrupting chemicals (EDCs) that are ubiquitous in our surroundings and everyday lives.
The report, “Endocrine Disrupting Chemicals: Threats to Human Health” provides a comprehensive update on the state of the science around EDCs, with increasing evidence that this large group of toxic substances may be implicated in rising global health concerns.
The report from the Endocrine Society, co-produced with the International Pollutants Elimination Network (IPEN), includes detailed analyses on exposure to EDCs from four sources: plastics, pesticides, consumer products (including children’s products), and per-and polyfluoroalkyl substances (PFAS), a class of thousands of chemicals known or suspected to be EDCs.
The Endocrine Society-IPEN report is being released during the U.N. Environment Assembly (UNEA-6) meeting in Nairobi.
At UNEA key agenda items include welcoming the newly adopted Global Framework on Chemicals, advancing global action on highly hazardous pesticides, and threats to the circular economy from plastics and toxic chemicals.
The groups’ report anticipates an update from UNEP and the WHO expected later this year on their 2012 Report on State of the Science of Endocrine Disrupting Chemicals.
“A well-established body of scientific research indicates that endocrine-disrupting chemicals that are part of our daily lives are making us more susceptible to reproductive disorders, cancer, diabetes, obesity, heart disease, and other serious health conditions,” said the report’s lead author, Andrea C. Gore, PhD, of the University of Texas at Austin, and a member of the Endocrine Society’s Board of Directors.
“These chemicals pose particularly serious risks to pregnant women and children. Now is the time for the UN Environment Assembly and other global policymakers to take action to address this threat to public health.”
By interfering with hormones and their actions, EDC exposure can impact many health-related functions, with consequences for increased risks of many serious conditions.
Evidence suggests that EDCs in the environment contribute to disorders such as diabetes, neurological disorders, reproductive disorders, inflammation, and compromised immune functioning.
Two of the four analyses in the report look at EDCs used in plastics and as pesticides.
Global production of plastics and pesticides is increasing even as scientists warn that chemical and plastic pollution is an escalating crisis. Glyphosate is the world’s most widely used herbicide, and a recent study found that glyphosate has eight of ten key characteristics of an EDC. Other studies have found links between glyphosate and adverse reproductive health outcomes.
Plastics are made with thousands of known toxic substances, some of which are known or suspected EDCs. The report examines bisphenols and phthalates, two toxic chemical groups found in many plastics. Exposures to EDCs from plastics occur at all phases of plastics production, use, disposal, and even from recycled plastics.
The Endocrine Society-IPEN report notes that, while evidence of health threats from EDCs is mounting, current regulations have not kept pace.
“EDCs are different than other toxic chemicals, but most regulations fail to address these differences,” said IPEN Science Advisor Sara Brosché, PhD. “For example, we know that even very low doses of endocrine disrupting chemicals can cause health problems and there may be no safe dose for exposure to EDCs. However, regulations typically do not protect against low-dose effects. We need a global approach to controlling EDCs based on the latest science with a goal of protecting the human right to a healthy environment.”
At the UNEA-6 meeting, IPEN is also releasing a new report on “The Global Threat from Highly Hazardous Pesticides,” highlighting ongoing health and environmental risks from HHPs, especially in low- and middle-income countries.
DDT, glyphosate, and chorpyrifos, three HHPs reviewed in the Endocrine Society report, are also highlighted in the new IPEN report as they continue to pose health threats especially in the Global South.
In addition to plastics and pesticides, the report looks at EDC exposures from arsenic and lead, and from widely used per- and polyfluoroalkyl substances (PFAS), humanmade “forever chemicals” used as oil and water repellents and coatings. Lead remains in use in paint in many countries, as documented in recent IPEN reports. Endocrine-related conditions from lead exposure may include delayed onset of puberty and early menopause. Arsenic is a common metal that has long been linked to cancer and other health conditions, and more recent evidence shows that arsenic can disrupt multiple endocrine systems. PFAS are used in hundreds of products including clothing and food packaging, but recent studies show that some PFAS can disrupt hormones such as oestrogen and testosterone and impair thyroid hormone functions.
Cedars-Sinai investigators have discovered why some injured kidneys heal while others develop scarring that can lead to kidney failure. Their findings, detailed in a paper published in the peer-reviewed journal Science, could lead to the development of noninvasive tests to detect kidney scarring and, eventually, new therapies to reverse the condition.
“The key to this discovery was our ability to directly compare injured kidney cells that successfully regenerated with those that did not,” said Sanjeev Kumar, MD, PhD, a nephrologist-scientist in the Board of Governors Regenerative Medicine Institute and the Department of Medicine at Cedars-Sinai and senior author of the study.
“Injured cells activate a protein called SOX9 to regenerate themselves. When they have healed, the cells silence this protein. Cells that aren’t able to regenerate leave SOX9 active, and this leads to a type of scarring called fibrosis. But when we deactivate SOX9 in a timely fashion, the scarring literally goes away.”
The kidneys can be injured by diabetes and high blood pressure, serious infections such as COVID-19, and overuse of antibiotics and non-steroidal anti-inflammatory pain medications, said Kumar, who is also part of the Department of Biomedical Sciences at Cedars-Sinai.
The SOX9 protein plays a major role in organ development but is not active in healthy adult kidneys.
In previous work at another institution, Kumar and team found that when kidneys are injured, the surviving cells reactivate SOX9 as part of the healing process.
In this study, Kumar and fellow investigators studied kidney damage in laboratory mice.
They labeled individual cells at the point of injury, then followed how the cells’ progeny evolved over time.
“At Day 10, some cells’ descendants were fully healed while others were not,” Kumar said.
“The cell lineage that healed had switched off SOX9 expression, while the unhealed lineage, in a continuing attempt to fully regenerate, maintained SOX9 activity. It’s like a sensor that switches on when cells want to regenerate, and off when they are restored, and we are the first to identify this.”
Further, investigators discovered that cells that were unable to regenerate began recruiting proteins called Wnts, another key player in organ development. Over time, this accumulation of Wnts triggered scarring. And they found that deactivating SOX9 a week after injury promoted kidney recovery.
Investigators observed the same process in patient databases from collaborating institutions in Switzerland and Belgium.
“We could see that by Day 7, human patients with transplanted kidneys that were slow to begin working also activated SOX9,” Kumar said.
“And in our collaborators’ database, we were able to distinguish that patients who had sustained SOX9 activation had lower kidney function and more scarring than those who did not. Human kidneys with cells that maintained SOX9 were also enriched with Wnts and showed increased fibrosis.”
These discoveries provide targets for drug development, as well as for noninvasive biomarker discovery permitting diagnosis of kidney fibrosis through the urine, Kumar said.
Currently, the only available test for kidney fibrosis is a biopsy, which carries many risks.
“Elucidating the mechanisms of scarless healing versus fibrosis has eluded investigators for decades and has implications beyond the kidney, including for certain cancers,” said Paul Noble, MD, chair of the Department of Medicine and director of the Women’s Guild Lung Institute at Cedars-Sinai and a co-author of the study.
