A leading paediatric pulmonologist has called for global health authorities to bring to South Africa – among other resource-poor countries – new vaccines that protect infants and unborn babies from contracting the highly contagious seasonal Respiratory Syncytial Virus (RSV).
The jabs were recently approved in the United States, and Cape Town’s Professor Heather Zar wants these vaccines to be made available in countries where RSV-related illness and deaths are most severe: 99% of RSV deaths are in low- and middle-income countries.
“It’s a key issue to get these products to these regions,” Zar told Biénne Huisman from Spotlight. “This is where children are dying from RSV.”
It is the most common cause of paediatric hospitalisation due to lower respiratory tract infections, she added, with nearly half of RSV-associated deaths occurring in infants under six-months-old.
However, as with most medical innovations, wealthy countries will be the initial beneficiaries of these new vaccines, for example, Pfizer’s Abrysvo to be given to pregnant mothers to protect their infants and AstraZeneca’s Beyfortus for infants up to two-years-old.
Lifetime achievement award
In the cut-throat global health sphere, Zar is a renowned advocate for social justice and equal access for all children.
This earned her the European Respiratory Society’s Lifetime Achievement Award in paediatrics, which she accepted in Milan last month.
Zar heads the University of Cape Town’s Department of Paediatrics and Child Health, where she established a national curriculum in paediatric pulmonology and founded the African Paediatric Fellowship Programme in 2007.
Partnering with academic institutions across Africa, “we’ve trained a lot of people from Kenya, Ghana, Malawi, Zimbabwe, Namibia, Uganda, (and) a whole lot from Sudan”, she said.
The clinician-scientist holds an A1 rating with the SA National Research Foundation and an H-index of 96 on Google Scholar, making her one of the university’s most widely-cited scholars.
Three years ago, during the pandemic, Zar penned a petition – 31 December 2020 – urging the Department of Health to “implement vaccination, so as to reduce death and illness, and bring the pandemic under control”.
The letter went viral, drumming up support countrywide with more than 10 000 signatures, including scores of eminent local healthcare professionals.
Soon after, on 18 February, South Africa’s Covid vaccination plan officially launched at the Khayelitsha District Hospital in Cape Town.
Optimistic
Zar’s research interests centres around childhood respiratory illnesses – pneumonia, tuberculosis (TB), asthma and HIV-associated lung diseases in impoverished settings.
“Paediatrics is about creating better futures,” she said.
She is determined that child mortality and illness in South Africa (and other LMICs) can be transformed with the right policies and strategies.
“There’s so much respiratory disease and so much to be done. I was always very interested in the potential public health impact; I wanted to be in an area in which you could turn things around. In pulmonology, there’s a lot of immediate change – oxygen, antibiotics, those sorts of interventions, plus interventions on a longer timeframe.”
Early in her career, after witnessing the inadequate treatment of asthma in children, Zar developed a low-cost spacer for inhaling asthma medicine using a modified 500ml plastic drink bottle.
A spacer is a device or holding chamber that makes it easier to use an inhaler. After several clinical trials to prove efficacy of the device, it now forms part of the Global Initiative for Asthma guidelines and this year was commercially launched as the AfriSpacer™ by the Allergy Foundation of South Africa (AFSA).
Drakenstein Child Health Study
Lately, Zar’s focus has shifted to the intersection between acute children’s infections and socio-economic early life determinants, as exemplified in the project nearest to her heart – the Drakenstein Child Health Study, which has followed 1 000 mother and child pairs living in high-risk communities in the Cape Winelands region over the past 12 years.
Zar leads a team of researchers who recruited pregnant women seeking antenatal care at two government clinics – the community day-care centre in the primarily isiXhosa-speaking Mbekweni township between Paarl and Wellington, and the TC Newman community day-care centre in Paarl East
“The big question is, what makes for a healthy child?” said Zar. “So we enrolled pregnant women, moms in these peri-urban poor areas, following them through pregnancy, through childbirth, and now we are following the children, who are turning 11-years-old.
“We wanted to understand why some children get ill, why some are healthy – children from the same communities.”
A 2018 paper published in The British Medical Journal, Paediatrics Open, outlines the project’s objectives.
“There is growing awareness that psycho-social risk and resilience factors in early life play a key role in influencing later health…Such work may inform effective intervention strategies.”
The paper notes that across both communities, mothers were on average 26-years-old. Only 27% were employed, while 40% were married or cohabiting with a partner. More than 65% of the pregnancies were unplanned, with mothers and children in both communities frequently exposed to violence.
“We looked at growth, at neurodevelopment, and now as the children are getting older, we are starting to look at non-communicable diseases like cardiometabolic disease and asthma,” Zar said.
“So, of course, the mother is key in all of this. Her health, both physical and psychological, factors like depression and anxiety . . . We looked at the home environment, we visited the homes before the children were born, and after. We looked at child and maternal nutrition, at allergies. I mean, we even looked at things like parenting style…”
Some of their findings were predictable. “For example, mothers who smoke in pregnancy have children who are smaller, who have more lung disease, who are less healthy.”
They found that pneumonia at a very early age severely impairs lung health, possibly causing structural damage that can last into adulthood.
In addition, they found that RSV was the most common cause of pneumonia in the children. “Now this is very important because of the new vaccines, which we really need to access for our children,” she said.
An article she co-authored, published earlier this year on Wellcome Open Research, the platform for research funded by the Wellcome Trust, looked at early violence exposure among the youngsters enrolled in the Drakenstein study.
The article states that by the age of 3.5 years, 72% of the children had been exposed to some form of violence, with “witnessing community violence” as the most prevalent form.
“Many pre-schoolers in our sample experience a pervasive threat of danger in their homes and communities,” reads the article.
“Interventions aimed at the community, family, and individual levels are crucial – not only to stop the cycle of violence but to help children deal with this trauma.”
‘Where we could contribute’
For Zar, paediatrics was an easy choice. The eldest of five siblings, she grew up in Johannesburg, completing medical school at the University of the Witwatersrand in 1985.
Thereafter she furthered her training at the Chris Hani Baragwanath Academic Hospital, which deeply impressed on her the injustices of apartheid and, she says, “children suffering from diseases of poverty”.
In the late 1980s, she left for the United States, further specialising in paediatric pulmonology at Columbia University in New York City.
By the end of apartheid, Zar and her husband, Professor Dan Stein, decided to return home.
“When Mandela was freed, there was so much euphoria and hope for the future. We felt this is where we could make a contribution,” she said.
Stein chairs the Department of Psychiatry and Mental Health at the University of Cape Town. The couple has three children, all in their 20s. Laughing, Zar recalls receiving her PhD practically with her son on her lap.
Study details
Early Childhood Violence Exposure Patterns in The Drakenstein Child Health Study (DCHS)
Lucinda Tsunga, Marilyn Lake, Heather Zar, Dan Stein, et al.
Published in Wellcome Open Research on 19 September 2023
Abstract
Background
Research has highlighted high rates of exposure to violence among South African youth. However, work to date has been largely cross-sectional, focused on violence exposure during the adolescence period, and has been limited to specific types of violence exposure. We examined violence exposure in South African preschool children between 3 and 6 years of age, capturing both direct and indirect forms of violence, and tested for potential sex differences across the several types of exposures.
Methods
Lifetime direct and indirect exposure to domestic and community violence was measured by parental report when children were 3.5 years (N = 530), 4.5 years (N = 749) and 6 years of age (N= 417) in a South African birth cohort located in a peri-urban community.
Results
There are three main findings. First, a large proportion of children (72%-75%) were reported as having been exposed to some form of direct or indirect violent experience in their homes or communities from a young age. Second, there was significant polyvictimisation, with 49% of the children being exposed to more than one type of violence by age 6. Third, by 4.5 years of age, there was evidence that boys were more likely than girls to be exposed to domestic victimisation (28% vs. 17%) and polyvictimisation (38% vs. 28%).
Conclusions
These findings highlight the high levels of violence exposure in young South African children, particularly among boys, and the need for prevention at both the community and individual levels.
See more from MedicalBrief archives:
Significant drop in newborns’ RSV risk with vaccine for pregnant women
UK approves one-shot RSV vaccine for babies
Respiratory virus killing 100,000 children a year – systemic analysis
High number of South African children with severe asthma – experts