Research Articles (Paediatrics and Child Health)

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Detection of the epidemic Pseudomonas aeruginosa AUST-03 (ST242) strain in people with cystic fibrosis in South Africa
(Wiley, 2024-12) Hamiwe, Thabo; White, Debbie A.; Kwenda, Stanford; Ismail, Arshad; Klugman, Susan; Van Bruwaene, Lore; Goga, Ameena Ebrahim; Kock, Marleen M.; Smith, Anthony Marius; Ehlers, Marthie Magdaleen; marthie.ehlers@up.ac.za
INTRODUCTION: Pseudomonas aeruginosa AUST-03 (ST242) has been reported to cause epidemics in people with CF (pwCF) from Australia and has been associated with multidrug resistance and increased morbidity and mortality. Here, we report an epidemic P. aeruginosa (AUST-03) strain in South African pwCF detected at a public hospital and characterize the genomic antibiotic resistance determinants. METHODS: The P. aeruginosa AUST-03 (ST242) study isolates were analysed with whole genome sequencing using the Illumina NextSeq2000 platform. Raw sequencing reads were processed using the Jekesa pipeline and multilocus sequence typing and genomic antibiotic resistance characterization was performed using public databases. Genetic relatedness between the study isolates and global P. aeruginosa ST242 from public databases was determined using a maximum-likelihood phylogenetic tree. Antibiotic susceptibility testing was performed using the disk diffusion and broth microdilution techniques. RESULTS: A total of 11 P. aeruginosa AUST-03 isolates were isolated from two children with CF. The majority (8/11) of these isolates were multidrug-resistant (MDR) or extensively drug resistant; and the multidrug efflux pumps MexAB-OprM, MexCD-OprJ, MexEF-OprN, and MexXY-OprM were the most clinically relevant antibiotic resistance determinants and were detected in all of the isolates. The study isolates were the most closely related to a 2020 P. aeruginosa AUST-03 (ST242) CF isolate from Russia. CONCLUSION: Epidemic MDR P. aeruginosa strains are present at South African public CF clinics and need to be considered when implementing segregation and infection control strategies to prevent possible spread and outbreaks.
SARS-CoV-2 infections in a triad of primary school learners (Grades 1-7), their parents, and teachers in KwaZulu-Natal, South Africa : protocol for a cross-sectional and nested case-cohort study
(JMIR Publications, 2024-12) Dassaye, Reshmi; Chetty, Terusha; Daniels, Brodie; Gaffoor, Zakir; Spooner, Elizabeth; Ramraj, Trisha; Mthethwa, Ncengani; Nsibande, Duduzile Faith; Pillay, Saresha; Bhana, Arvin; Magasana, Vuyolwethu; Reddy, Tarylee; Mohlabi, Khanya; Moore, Penelope Linda; Burgers, Wendy A.; De Oliveira, Tulio; Msomi, Nokukhanya; Goga, Ameena Ebrahim
BACKGROUND : In low- and middle-income countries (LMICs) such as South Africa, there is paucity of data on SARS-CoV-2 infections among children attending school, including seroprevalence and transmission dynamics. OBJECTIVE : This pilot study aims to assess (1) the prevalence of self-reported or confirmed SARS-CoV-2 prior infections, COVID-19 symptoms (including long COVID), seroprevalence of SARS-CoV-2 antibodies, and general/mental health, (2) longitudinal changes in SARS-CoV-2 seroprevalence, and (3) SARS-CoV-2 acute infections, immune responses, transmission dynamics, and symptomatic versus asymptomatic contacts in a unique cohort of unvaccinated primary school learners, their parents, teachers, and close contacts in semirural primary school settings. METHODS : Learners (grades 1-7) from primary schools in KwaZulu-Natal, South Africa, their parents, and teachers will be invited to enroll into the COVID kids school study (CoKiDSS). CoKiDSS comprises 3 parts: a cross-sectional survey (N=640), a follow-up survey (n=300), and a nested case-cohort substudy. Finger-prick blood and saliva samples will be collected for serological and future testing, respectively, in the cross-sectional (451 learners:147 parents:42 teachers) and follow-up (210 learners:70 parents:20 teachers) surveys. The nested case-cohort substudy will include cases from the cross-sectional survey with confirmed current SARS-CoV-2 infection (n=30) and their close contacts (n=up to 10 per infected participant). Finger-prick blood (from all substudy participants), venous blood (from cases), and nasal swabs (from cases and contacts) will be collected for serological testing, immunological testing, and viral genome sequencing, respectively. Questionnaires covering sociodemographic and general and mental health information, prior and current SARS-CoV-2 symptoms and testing information, vaccination status, preventative behavior, and lifestyle will be administered. Statistical methods will include generalized linear mixed models, intracluster correlation, descriptive analysis, and graphical techniques. RESULTS : A total of 645 participants were enrolled into the cross-sectional survey between May and August 2023. A subset of 300 participants were followed up in the follow-up survey in October 2023. Screening of the participants into the nested case-cohort substudy is planned between November 2023 and September 2024. Data cleanup and analysis for the cross-sectional survey is complete, while those for the follow-up survey and nested case substudy will be completed by the third quarter of 2024. The dissemination and publication of results is anticipated for the fourth quarter of 2024. CONCLUSIONS : This study provides data from an LMIC setting on the impact of SARS-CoV-2 on school-attending learners, their parents, and teachers 3 years after the SARS-CoV-2 pandemic was declared and 21-24 months after resumption of normal school attendance. In particular, this study will provide data on the prevalence of self-reported or confirmed SARS-CoV-2 prior infection, prior and current symptoms, seroprevalence, changes in seroprevalence, SARS-CoV-2 transmission, SARS-CoV-2 adaptive immune responses, and symptoms of long COVID and mental health among a triad of learners, their parents, and teachers. International Registered Report Identifier (IRRID): DERR1-10.2196/52713
Safety of a second homologous Ad26.COV2.S vaccine among healthcare workers in the phase 3b implementation Sisonke study in South Africa
(Elsevier, 2024-02) Takalani, Azwidihwi; Robinson, Michelle; Jonas, Phumeza; Bodenstein, Annie; Sambo, Vuyelo; Jacobson, Barry; Louw, Vernon; Opie, Jessica; Peter, Jonny G.; Rowji, Pradeep; Seocharan, Ishen; Reddy, Tarylee; Yende-Zuma, Nonhlanhla; Khutho, Kentse; Sanne, Ian; Bekker, Linda-Gail; Gray, Glenda; Garrett, N.; Goga, Ameena Ebrahim
The Sisonke 2 study provided a homologous boost at least 6 months after administration of the priming dose of Ad26.COV2.S for healthcare workers enrolled on the Sisonke phase 3b implementation study. Safety monitoring was via five reporting sources: (i.) self-report through a web-link; (ii.) paper-based case report forms; (iii.) a toll-free telephonic reporting line; (iv.) healthcare professionals-initiated reports; and (v.) active linkage with National Disease Databases. A total of 2350 adverse events were reported by 2117 of the 240 888 (0.88%) participants enrolled; 1625 of the 2350 reported events are reactogenicity events and 28 adverse events met seriousness criteria. No cases of thrombosis with thrombocytopaenia syndrome were reported; all adverse events including thromboembolic disorders occurred at a rate below the expected population rates apart from one case of Guillain Barre Syndrome and one case of portal vein thrombosis. The Sisonke 2 study demonstrates that two doses of Ad26.COV2.S is safe and well tolerated; and provides a feasible model for national pharmacovigilance strategies for low- and middle-income settings.
Machine learning to predict interim response in pediatric classical Hodgkin lymphoma using affordable blood tests
(American Society of Clinical Oncology, 2024-10-24) Geel, Jennifer A.; Hramyka, Artsiom; Du Plessis, Jan; Goga, Yasmin; Van Zyl, Anel; Hendricks, Marc G.; Naidoo, Thanushree; Mathew, Rema; Louw, Lizette; Neethling, Beverley; Schickerling, Tanya M.; Omar, Fareed E.; Du Plessis, Liezl; Madzhia, Elelwani; Netshituni, Vhutshilo; Eyal, Katherine; Ngcana, Thandeka V.Z.; Kelsey, Tom; Ballott, Daynia E.; Metzger, Monika L.
PURPOSE : Response assessment of classical Hodgkin lymphoma (cHL) with positron emission tomography-computerized tomography (PET-CT) is standard of care in well-resourced settings but unavailable in most African countries. We aimed to investigate correlations between changes in PET-CT findings at interim analysis with changes in blood test results in pediatric patients with cHL in 17 South African centers. METHODS : Changes in ferritin, lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), albumin, total white cell count (TWC), absolute lymphocyte count (ALC), and absolute eosinophil count were compared with PET-CT Deauville scores (DS) after two cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine in 84 pediatric patients with cHL. DS 1-3 denoted rapid early response (RER) while DS 4-5 denoted slow early response (SER). Missing values were imputed using the k-nearest neighbor algorithm. Baseline and follow-up blood test values were combined into a single difference variable. Data were split into training and testing sets for analysis using Python scikit-learn 1.2.2 with logistic regression, random forests, na¨ıve Bayes, and support vector machine classifiers. RESULTS : Random forest analysis achieved the best validated test accuracy of 73% when predicting RER or SER from blood samples. When applied to the full data set, the optimal model had a predictive accuracy of 80% and a receiver operating characteristic AUC of 89%. The most predictive variable was the differences in ALC, contributing 21% to the model. Differences in ferritin, LDH, and TWC contributed 15%-16%. Differences in ESR, hemoglobin, and albumin contributed 11%-12%. CONCLUSION : Changes in low-cost, widely available blood tests may predict chemosensitivity for pediatric cHL without access to PET-CT, identifying patients who may not require radiotherapy. Changes in these nonspecific blood tests should be assessed in combination with clinical findings and available imaging to avoid undertreatment.
Measurement of district health system strengthening efforts for maternal and newborn health service delivery: synchronized application of evaluation models in the West Nile region, Uganda, 2019-2021
(BMC, 2025-02) Muhumuza, Simon; Lutalo, Ibrahim M.; Ssendiwala, Julius; Latigi, Grace; Pirio, Patricia; Msukwa, Chimwemwe; Mwanyumba, Fabian; Gohar, Fatima; Hailegebriel, Tedbabe Degefie; Asfaw, Atnafu Getachew; Bergh, Anne-Marie
INTRODUCTION : Uganda has high maternal, neonatal, and under-five mortality rates. Between 2019 and 2021, the United Nations Children’s Fund (UNICEF), in collaboration with the Ministry of Health and other partners, implemented a maternal and newborn health (MNH) quality improvement programme in the West Nile region of Uganda to improve the delivery and utilization of MNH services. This study describes the application of health system evaluation models to monitor changes in health system capacity and the quality of MNH services. METHODS : We designed two novel health system evaluation models—the Progression and ServQual models—which progressively monitor changes in health system capacity and quality of health services. The progression model was designed to measure changes in health system capacity using a set of indicators and benchmarks. For each health system component, the tool generates scores as follows: > 90% for level 4 progression (surpasses basic expectations); 70–90% for level 3 (meets basic expectations); 50- < 70% for level 2 (needs improvement); and < 50% for level 1 progression (needs urgent attention). The quality of MNH services was monitored through annual client satisfaction surveys using the ServQual model. The identified health system capacity and service quality gaps were used to inform corrective actions. RESULTS : Overall, the average health system capacity scores across the 12 districts increased from 62.9% (level 2) in 2019 to 71.2% (level 3) in 2021. The capacity scores for each health system component increased: governance and leadership increased from 67.7% to 74.1%, health financing increased from 67.4% to 69.3%, access to essential medicines increased from 50.2% to 77.0%, the health information system increased from 71.8% to 74.9%, the health workforce increased from 56.8% to 66.9%, and MNH service delivery slightly increased from 63.5% to 64.5%. Client satisfaction with the quality of MNH services increased from 26.5% in 2019 to 39.8% in 2021. CONCLUSION : Synchronized application of the Progression and ServQual models is an important innovative strategy for monitoring changes in district health system capacity and quality of health services. The results of applying these models can be used to guide better targeting for health system capacity improvement.
Frequency, kinetics and determinants of viable SARS-CoV-2 in bioaerosols from ambulatory COVID-19 patients infected with the Beta, Delta or Omicron variants
(Nature Research, 2024-03-05) Jaumdally, S.; Tomasicchio, M.; Pooran, A.; Esmail, A.; Kotze, A.; Meier, S.; Wilson, L.; Oelofse, S.; Van der Merwe, C.; Roomaney, A.; Davids, M.; Suliman, T.; Joseph, R.; Perumal, T.; Scott, A.; Shaw, M.; Preiser, W.; Williamson, C.; Goga, Ameena Ebrahim; Mayne, E.; Gray, G.; Moore, P.; Sigal, A.; Limberis, J.; Metcalfe, J.; Dheda, K.
Airborne transmission of SARS-CoV-2 aerosol remains contentious. Importantly, whether cough or breath-generated bioaerosols can harbor viable and replicating virus remains largely unclarified. We performed size-fractionated aerosol sampling (Andersen cascade impactor) and evaluated viral culturability in human cell lines (infectiousness), viral genetics, and host immunity in ambulatory participants with COVID-19. Sixty-one percent (27/44) and 50% (22/44) of participants emitted variant-specific culture-positive aerosols <10μmand <5μm, respectively, for up to 9 days after symptom onset. Aerosol culturability is significantly associated with lower neutralizing antibody titers, and suppression of transcriptomic pathways related to innate immunity and the humoral response. A nasopharyngeal Ct <17 rules-in ~40% of aerosol culture-positives and identifies those who are probably highly infectious. A parsimonious three transcript blood-based biosignature is highly predictive of infectious aerosol generation (PPV > 95%). There is considerable heterogeneity in potential infectiousness i.e., only 29% of participants were probably highly infectious (produced culture-positive aerosols <5μm at ~6 days after symptom onset). These data, which comprehensively confirm variant-specific culturable SARS-CoV-2 in aerosol, informthe targeting of transmission-related interventions and public health containment strategies emphasizing improved ventilation.
Guest editorial : Inborn errors of immunity
(Allergy Society of South Africa, 2024-03) Van Niekerk, Andre
It was around 1973. Two years after the birth of David Vetter. David’s story captivated the mainstream media and the hearts of those who followed his sad case. He suffered from severe combined immunodeficiency (SCID) and his doctors tried to isolate him from microbes in a plastic bubble. NASA even made him a special ‘spacesuit’ for walkouts. David spent 12 years inside his bubble ... and he did not die from an overwhelming infection. He died from lymphoma.
Dr Spur's mystery case : connecting the dots in IEI : infections and tumours
(Allergy Society of South Africa, 2024-09) Teixeira, Miguel Jose; Nagel, Lizelle; Van den Berg, Sylvia
I am seeing a 25-year-old female patient who has a history of frequent respiratory infections since adolescence. She had an uneventful childhood, but started getting infections of increasing frequency and severity during her adolescence, to the point where she required several antibiotic prescriptions per year, and hospital admission at least twice a year for pneumonia. She had chronic productive cough between pneumonia episodes, with features of early bronchiectasis. We diagnosed common variable immunodeficiency (CVID) and prescribed a prophylactic antibiotic. The patient is not using corticosteroids, immunosuppressant medications or anticonvulsants. She receives 75 mcg of L-thyroxine daily for hypothyroidism. While she reports no family members with frequent or atypical infections, there is a history of thyroid disease, inflammatory bowel disease (IBD), leukaemia and gastric cancer affecting several relatives. I saw her again this week, and she reports only minor upper respiratory infections over the past six months. There are no signs of anaemia, jaundice, oedema, clubbing or lymphadenopathy. However, I palpated an enlarged spleen and sonographic investigation confirmed splenomegaly with an estimated spleen size of 18 cm × 15 cm. I ordered a thoracoabdominopelvic CT scan which excluded hepatobiliary disease and lymphadenopathy. A sonar-guided splenic biopsy revealed diffuse large B-cell lymphoma (DLBCL). It appears to me that several immune system processes are simultaneously compromised in different members of this family including infection immunity, immunological tolerance and anti-tumour immunity. Is this new cancer diagnosis linked to the patient's known CVID diagnosis? If so, how should we adjust our follow-up care plan for this patient in future? Your guidance is appreciated.
Dr Spur's mystery case HSV : can it be a clue to an underlying inborn error of immunity?
(Allergy Society of South Africa, 2024-12) Brauer, Marieke; Nagel, Lizelle; Van den Berg, Sylvia
HSV - can it be a clue to an underlying inborn error of immunity? I was recently contacted by a wife, concerned about her previously healthy 54-year-old husband, who suddenly complained of a severe headache. She noticed that he had difficulty speaking and seemed to be of balance. I arranged with a specialist physician at the nearest hospital for emergency admission. A diagnosis of herpes simplex virus (HSV) type-1 encephalitis was made. The patient made a full recovery after a full course of intravenous acyclovir.
Bronchiectasis in children in a high HIV and tuberculosis prevalence setting
(South African Medical Association, 2024-12) Juggernath, Pearline; Mopeli, Keketso; Masekela, Refiloe; Dangor, Ziyaad; Goga, Ameena Ebrahim; Gray, Diane M.; Verwey, Charl
BACKGROUND: Bronchiectasis, a chronic suppurative lung condition, is a largely neglected disease, especially in low- to middle-income countries (LMICs), from which there is a paucity of data. Post-infectious causes are more common in LMICs, while in high-income countries, inborn errors of immunity (IEIs), recurrent aspiration, primary ciliary dyskinesia (PCD) and cystic fibrosis are more common. Children living with HIV (CLWH), especially those who are untreated, are at increased risk of bronchiectasis. Data on risk factors, diagnosis and follow-up of children with bronchiectasis are required to inform clinical practice and policy. OBJECTIVES: To describe the demographics, medical history, aetiology, clinical characteristics and results of special investigations in children with bronchiectasis. METHODS: We undertook a retrospective descriptive study of children aged <16 years with chest computed tomography (CT) scan-confirmed bronchiectasis in Johannesburg, South Africa, over a 10-year period. Demographics, medical history, aetiology, clinical characteristics and results of special investigations were described and compared according to HIV status. RESULTS: A total of 91 participants (51% male, 98% black African) with a median (interquartile range) age of 7 (3 - 12) years were included in the study. Compared with HIV-uninfected children, CLWH were older at presentation (median 10 (6 - 13) years v. 4 (3 - 9) years; p<0.01), and more likely to be stunted (p<0.01), to have clubbing (p<0.01) and hepatosplenomegaly (p=0.03), and to have multilobar involvement on the chest CT scan (p<0.01). All children had a cause identified, and the majority (86%) of these were presumed to be post-infectious, based on a previous history of a severe lower respiratory tract infection. This group included all 38 CLWH. Only a small proportion of the participants had IEIs, secondary immune deficiencies or PCD. CONCLUSION: A post-infectious cause for bronchiectasis was the most common aetiology described in children from an LMIC in Africa, especially CLWH. With improved access to diagnostic techniques, the aetiology of bronchiectasis in LMICs is likely to change.
Vaccine stock-outs : a preventable health facility obstacle contributing to missed vaccinations in South African children
(Elsevier, 2025-01) Masemola, Natasha M.; Burnett, Rosemary J.; Makamba-Mutevedzi, Portia C.; Schonfeldt, Marione; Bamford, Lesley; Ismail, Zeenat; Madhi, Shabir A.; Meyer, Johanna C.
In 2019 the National Department of Health (NDoH) conducted a national immunisation coverage survey of caregivers of children aged 24–35 months in all 52 districts of South Africa, and reported a national fully immunised under one year-old coverage of 83.9 %, and 76.8 % coverage for all vaccines scheduled up to 18 months of age. This retrospective, descriptive study was a secondary data analysis of 3576 validated Microsoft Excel® records containing the reasons for missed vaccinations collected by field workers during the 2019 national survey. The reason “vaccine out of stock” had been captured by field workers from children's vaccination cards, while other reasons given by caregivers had been captured either as pre-defined codes or free text. Free text reasons were analysed and additional codes created, and all reasons were categorised. In total, 3576 caregivers gave 8116 reasons for 8056 doses that had been missed by their children. Reasons related to health facility obstacles (HFOs) (67.9 %; 2429/3576) and personal obstacles (34.6 %; 1237/3576) constituted the major categories of reasons for missed vaccinations. Of all vaccines missed because of HFO-related reasons, 57.8 % (1403/2429) were missed because of vaccine stock-outs, affecting 39.2 % (1403/3576) of children. Other important HFOs included lack of access to vaccination services (24.5 %; 595/2429); and information about missed vaccinations and the need to return for catch-up not being shared with caregivers (17.1 %; 416/2429). These results were stratified by district and shared with the NDoH, who have initiated several projects in collaboration with other stakeholders, focusing mainly on building capacity for effective vaccine management to prevent vaccine stock-outs, and ensuring that all children are able to access vaccination services. The results of this study can be used as a baseline against which the success of future interventions emanating from these projects can be measured.
Vaccine safety surveillance in South Africa through COVID-19 : a journey to systems strengthening
(Elsevier, 2025-02) Sankar, Chenoa; Meyer, Johanna C.; Schonfeldt, Marione; Gunter, Hannah; Dawood, Halima; Sekiti, Victoria; Pickard, Naseera; Mubaiwa, Lawrence; Mawela, Dini; Dlamini, Sipho; Peter, Jonny; Spencer, David; Gray, Clive; Patel, Vinod; Bamford, Lesley; Sehloho, Tohlang; McCarthy, Kerrigan
BACKGROUND : Surveillance systems for monitoring and reporting adverse events following immunisation (AEFI) and adverse events of special interest (AESI) are vital in understanding safety profiles of post-marketed vaccines. Evaluation of surveillance systems is necessary for systems strengthening. We conducted the first evaluation of the South African AEFI surveillance system in its current form, established in 2018. METHODS : Using CDC guidelines for evaluation of surveillance systems, we conducted a cross-sectional evaluation of system attributes, including quantitative analyses of AEFI/AESI data from 17 May 2021 to 31 December 2022 and qualitative analyses through semi-structured interviews with AEFI surveillance personnel. Findings were used to generate recommendations for system strengthening. RESULTS : The system collects and manages AEFI data, employs investigative tools and has an established AEFI review committee conducting causality assessment, thus meeting WHO minimal capacity for vaccine safety. System adaptation through inclusion of digital applications facilitated public reporting, whilst increasing complexity of database management. Respondents demonstrated engagement with the system through accounts of their roles in AEFI surveillance. Between 17 May 2021 and 31 December 2022, 37,537,009 COVID-19 vaccine doses (BNT162b2 and Ad26.COV2·S) were administered, and 3846 AEFI reported in relation to these vaccines (reporting rate: 10.2/100,000 doses). AEFI reporting rates varied considerably across provinces, ranging from 1.6 to 59.5 AEFI/100,000 doses. In this time period 283 AEFI were reported in relation to non-COVID-19 vaccines. By 31 December 2022, 73.5 % of severe cases that were investigated were causality assessed. CONCLUSION : We observed a functional, useful, flexible system with high reported stakeholder and public acceptability levels. System challenges included low reporting rates from particular provinces, weak co-ordination between paper and digital reporting and human resource constraints. Recommendations include integration of paper-based and digital surveillance reporting systems to enhance signal detection and eliminate data duplication, provision of dedicated human and financial resources at provincial level and inclusion of active AEFI surveillance through cohort event monitoring.
Dietary intake and growth of HIV exposed and unexposed 6-12 months old infants in South Africa
(Wiley, 2025-01) Tshiambara, Phumudzo; Hoffman, Marinel; Legodi, Heather; Balakrishna, Yusentha; Feucht, Ute Dagmar; phumudzo.mamphwe@up.ac.za
Factors affecting the growth of HIV‐exposed‐uninfected (HEU) children are multi‐factorial, with limited information available on the dietary intake from 6 months. This study compared the dietary intake, micronutrient composition of breastmilk, and growth of HEU and HIV‐unexposed‐uninfected (HUU) infants aged 6 and 12 months in an urban setting. A repeated cross‐sectional study used structured questionnaires to collect socio‐demographic, dietary intake, food group data, and anthropometric measurements in the Siyakhula study. The HEU (48%) and HUU (52%) infants were included (total n = 181). At 6 months, HEU infants had lower weight‐for‐age z‐scores (WAZ) (−0.6 ± 1.1 vs. 0.1 ± 1.2; p < 0.001), length‐for‐age z‐scores (−0.8 ± 1.4 vs. −0.1 ± 1.2; p < 0.001), and mid‐upper‐arm circumference‐forage z‐scores (MUACAZ) (0.5 ± 1.1 vs. 1.0 ± 0.9; p < 0.001) than HUU infants. At 12 months, HEU infants had lower WAZ, MUACAZ, and weight‐for‐length z‐scores compared to HUU infants (p < 0.05). Stunting was found at 6 (15%) and 12 (12%) months in HEU infants. The micronutrient composition of breastmilk fed to both groups was similar. Breastfeeding rates were lower in HEU than in HUU infants at 6 (49% vs. 64%; p = 0.005) and 12 (24% vs. 46%; p = 0.002) months. Less than 3% of HEU and HUU infants achieved minimal dietary diversity scores at 12 months. Dietary intake of fat was similar in all breastfed infants, but iron and vitamin B12 were higher in non‐breastfed HEU infants at 12 months. HEU infants had lower breastfeeding rates than HUU infants. A lack of dietary diversity was found in all infants. Nutrition education and counselling in the complementary feeding phase are essential for optimal growth.
Inborn errors of immunity in paediatric neurology
(Allergy Society of South Africa, 2024-03) Smuts, Izelle; Human, Freda P.; izelle.smuts@up.ac.za
Inborn errors of immunity has become a rapidly evolving medical field, with nearly 500 conditions; as a result, the sheer volume of information can be overwhelming. In order to make a sound diagnosis, clinicians must adopt an integrative approach and identify all related and seemingly unrelated features. It is therefore crucial to understand the complex networks and interactions between organelles, cells, pathways and organ systems thoroughly. The immune system is an important stakeholder in all these networks. It is designed to be our friend, defending and protecting us by regulating tolerance. However, it can also turn into an enemy. Every individual has their own unique combination of genetic predisposition, trigger factors and environmental factors that contribute to the spectrum of neurological diseases. The main objective of this article is to create a mind map that starts with the clinical presentation.
One-year anthropometric follow-up of South African preterm infants in kangaroo mother care : which early-life factors predict malnutrition?
(Wiley, 2024-04) Nel, Sanja; Wenhold, Friedeburg Anna Maria; Botha, Tanita; Feucht, Ute Dagmar; sanja.nel@up.ac.za
BACKGROUND : Preterm infants often have poor short- and long-term growth. Kangaroo mother care supports short-term growth, but longer-term outcomes are unclear. METHODS : This study analysed longitudinally collected routine clinical data from a South African cohort of preterm infants (born <37 weeks gestation) attending the outpatient follow-up clinic of a tertiary-level hospital (Tshwane District, South Africa) for 1 year between 2012 and 2019. At 1 year, small-for-gestational age (SGA) and appropriate-for-gestational age (AGA) infants were compared with regard to agecorrected anthropometric z-scores (weight-for-age [WAZ], length-for-age [LAZ], weight-for-length [WLZ] and BMI-for-age [BMIZ]) and rates of underweight (WAZ < 2), stunting (LAZ < 2), wasting (WLZ < 2) and overweight (BMIZ> + 2). Multiple regression analysis was used to investigate associations between maternal/infant characteristics and rates of underweight, stunting, wasting and overweight. RESULTS : At 1 year, compared with AGA infants (n = 210), SGA infants (n = 111) had lower WAZ (1.26 ± 1.32 vs. 0.22 ± 1.24, p < 0.001), LAZ (1.50 ± 1.11 vs. 0.60 ± 1.06, p < 0.001), WLZ (0.66 ± 1.31 vs. 0.11 ± 1.24, p < 0.001) and BMIZ (0.55 ± 1.31 vs. 1.06 ± 1.23, p < 0.001), despite larger WAZ gains from birth (+0.70 ± 1.30 vs. +0.05 ± 1.30, p < 0.001). SGA infants had significantly more stunting (34.2% vs. 9.1%; p < 0.001), underweight (31.2% vs. 7.2%; p < 0.001) and wasting (12.6% vs. 4.3%, p = 0.012), with no difference in overweight (4.5% vs. 7.7%, p = 0.397). In multiple regression analysis, birth weight-for-GA z-score more consistently predicted 1-year malnutrition than SGA. CONCLUSION : Preterm-born SGA infants remain more underweight, stunted and wasted than their preterm-born AGA peers at 1 year, despite greater WAZ gains. Interventions for appropriate catch-up growth especially for SGA preterm infants are needed.
Neonatal encephalopathy due to suspected hypoxic ischemic encephalopathy : pathophysiology, current, and emerging treatments
(Springer, 2024-11) Babbo, Carina Corte-Real; Mellet, Juanita; Van Rensburg, Jeanette; Pillay, Shakti; Horn, Alan Richard; Nakwa, Firdose Lambey; Velaphi, Sithembiso Christopher; Kali, Gugulabatembunamahlubi Tenjiwe Jabulile; Coetzee, Melantha; Masemola, Mogomane Yvonne Khomotso; Ballot, Daynia Elizabeth; Pepper, Michael Sean; michael.pepper@up.ac.za
BACKGROUND : Neonatal encephalopathy (NE) due to suspected hypoxic-ischemic encephalopathy (HIE), referred to as NESHIE, is a clinical diagnosis in late preterm and term newborns. It occurs as a result of impaired cerebral blood flow and oxygen delivery during the peripartum period and is used until other causes of NE have been discounted and HIE is confirmed. Therapeutic hypothermia (TH) is the only evidence-based and clinically approved treatment modality for HIE. However, the limited efficacy and uncertain benefits of TH in some low- to middle-income countries (LMICs) and the associated need for intensive monitoring have prompted investigations into more accessible and effective stand-alone or additive treatment options. DATA SOURCES : This review describes the rationale and current evidence for alternative treatments in the context of the pathophysiology of HIE based on literatures from Pubmed and other online sources of published data. RESULTS : The underlining mechanisms of neurotoxic effect, current clinically approved treatment, various categories of emerging treatments and clinical trials for NE are summarized in this review. Melatonin, caffeine citrate, autologous cord blood stem cells, Epoetin alfa and Allopurinal are being tested as potential neuroprotective agents currently. CONCLUSION : This review describes the rationale and current evidence for alternative treatments in the context of the pathophysiology of HIE. Neuroprotective agents are currently only being investigated in high- and middle-income settings. Results from these trials will need to be interpreted and validated in LMIC settings. The focus of future research should therefore be on the development of inexpensive, accessible monotherapies and should include LMICs, where the highest burden of NESHIE exists.
Retention in care of infants diagnosed with HIV at birth : beyond the diagnostic strategy
(AOSIS, 2024-03-30) Christie, Michael; Du Plessis, Nicolette Marie; michael.christie@up.ac.za
BACKGROUND : Birth HIV point-of-care (POC) tests curtail analytical testing issues and expedite diagnosis, potentially allowing for earlier mother-infant pair engagement and improved outcomes. Many children are lost post antiretroviral therapy (ART) initiation within the first 6 months of follow-up. OBJECTIVES : We compared 6-month retention in care, HIV viral load (VL) suppression and mortality among infants diagnosed with HIV at birth, using laboratory-based versus POC HIV PCR testing. METHOD : From 2018 to 2019, infants exposed to HIV underwent birth HIV PCR POC testing at Kalafong Provincial Tertiary Hospital in Tshwane District. Their outcomes were compared to a historical control born between 2014 and 2016, who exclusively underwent laboratory-based HIV PCR testing. Both groups received comparable HIV care following national guidelines. RESULTS : Fifty-seven infants were studied (POC: 27; Control: 30). The POC turnaround time was significantly shorter (POC: 15.5 h [IQR: 4.3–24.7], Control: 68.3 h [IQR 46.0–93.9]; p=<0.0001). Both populations had the same elapsed time from HIV diagnosis to ART initiation (median: 13 days, POC: IQR 8–21 days; Control: IQR 9–36 days). Six infants were never initiated (POC: 2 [7%]; Control: 4 [13%]). At 6 months, overall care retention was 72% (41/57), higher among the Control group (Control 23/30, 77%; POC: 18/27, 67%). HIV viral suppression at 6 months was higher among the POC group (POC: 14/18, 78%; Control: 9/19, 47%, p=0.09). No deaths were reported. CONCLUSION : Poor care retention at 6 months post ART initiation is concerning. Initial mother-infant visits should be effectively utilised to assess and manage potential risk factors for loss of follow-up. CONTRIBUTION : This study highlights the ongoing need to find workable solutions to improve retention in care, thereby ensuring the benefits of expedited HIV diagnosis and ART initiation.
Dr Spur’s mystery case : monthly fevers? Can you aid me with this family’s grievances?
(Allergy Society of South Africa, 2024-03-01) Nagel, Lizelle; Teixeira, Miguel Jose; Van den Berg, Sylvia; Van Niekerk, Andre
No abstract available.
How paediatric HIV services weathered the COVID-19 storm in Tshwane District, South Africa
(AOSIS, 2024-05-20) Christie, Michael; Mazanderani, Ahmad Haeri; Sherman, Gayle G.; Feucht, Ute Dagmar; michael.christie@up.ac.za
BACKGROUND : The coronavirus disease 2019 (COVID-19) pandemic disrupted paediatric HIV services across South Africa. Shortly before COVID-19, updated national HIV guidelines were released. OBJECTIVES : This study describes COVID-19’s impact on paediatric HIV services in Tshwane District, South Africa. METHOD : A retrospective review of National Institute for Communicable Diseases and District Health Information System data for Tshwane District from April 2019 to March 2022. Data included: Early Infant Diagnosis (EID), HIV viral load (VL) and CD4 monitoring and HIV management among children (< 15 years) living with HIV (CLHIV). Pre-pandemic (2019/2020) and pandemic periods (2020/2021, 2021/2022) were compared. RESULTS : Year-on-year, HIV testing improved at 10 weeks, 6 months, and 18 months, whereas birth testing decreased. HIV EID case rates were 485 (2019/2020), 410 (2020/2021) and 454 (2021/2022). HIV EID test positivity was 0.77% – 1.2%. Antiretroviral treatment initiation declined from 2019/2020 to 2020/2021, but improved in 2021/2022. Initial HIV VL and CD4 testing declined, with HIV VL testing increasing in 2021/2022, and CD4 testing further declining. HIV VL suppression rate among CLHIV ranged from 69% to 73%. CONCLUSION : Initially, COVID-19 resulted in reduced paediatric HIV services as children disengaged from care. Indicators eventually recovered to proximate pre-pandemic levels; however, compensatory increases did not occur. Thus, some children may not have returned to care.
Chronic beryllium disease : an unexpected occupational hazard for a jeweller
(Allergy Society of South Africa, 2024-09-01) Teixeira, Miguel Jose; Nagel, Lizelle; Plekker, Dante; Van der Merwe, Cassandre; Van den Berg, Sylvia; migzjteixeira@gmail.com
Beryllium is used widely in industry due to its favourable elemental properties. Its extraction and subsequent incorporation into alloys and composites generate hazardous fumes and dust. Chronic beryllium disease (CBD) is an occupational interstitial lung disease that clinically resembles sarcoidosis. We present a case of a 33-year-old jeweller who developed CBD from exposure to dust while grinding unfinished gemstones. While workplace protection exists for beryllium workers, the health risks in artisans are unrecognised. Most cases are diagnosed in industries primarily involved in the use of beryllium (Table I); however, in our case the exposure to beryllium was unexpected. Lymphocyte proliferation testing for beryllium is a key investigation in patients with suspected CBD. To our knowledge, this is the first reported case of CBD diagnosed in a jeweller in South Africa.

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