New vaccines to protect infants and unborn babies from contracting highly contagious seasonal Respiratory Syncytial Virus (RSV) were just approved in the United States. Speaking from South Africa, leading paediatric pulmonologist Professor Heather Zar is calling on global health authorities to bring these vaccines to resource-poor countries, where RSV-related illness and deaths are most severe.
"It's a key issue to get these products to low- and middle-income countries (LMICs)," says Zar. "This is where children are dying from RSV." Spotlight previously reported on the potential of one of the new vaccines here.
In a report before the World Health Organization's Vaccines Advisory Committee in December, Zar states that RSV is one of the world's leading causes of childhood mortality, with 99% of RSV deaths occurring in LMICs. It is the most common cause of paediatric hospitalisation due to lower respiratory tract infections, she adds, and nearly half of RSV-associated deaths occur in infants under six months of age. (Paediatrics is the medical field focused on children's health.)
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 - an interdisciplinary mix of clinicians, epidemiologists, and pharmaceutical development, with added motives around politics and profit - 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 says. The clinician-scientist holds an A1 rating with South Africa's 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 In the throes of the COVID-19 pandemic, Zar penned a petition - dated December 31, 2020 - calling on the Department of Health to urgently "implement vaccination, so as to reduce death and illness, and to bring the pandemic under control". The letter went viral, drumming up support countrywide with over 10 000 signatures, including scores of eminent local healthcare professionals. Soon after, on February 18, South Africa's COVID vaccination plan officially launched at the Khayelitsha District Hospital in Cape Town.
Twenty kilometres afield, at the Red Cross War Memorial Children's Hospital, Zar's office overlooks Rondebosch common. Her words are soft and precise as she details her research interests, which centres around childhood respiratory illnesses - pneumonia, tuberculosis (TB), asthma and HIV-associated lung diseases in impoverished settings.
Her bearing is one of optimism. "Paediatrics is about creating better futures," she says. Zar 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 there's so much to be done," she says. "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 500 ml 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). In his office, just along the corridor from Zar, AFSA chief executive officer Professor Mike Levin describes the AfriSpacer™ as "a highly effective asthma solution".
The remarkable Drakenstein Child Health Study
Of late 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 daycare centre in the primarily isiXhosa-speaking Mbekweni township between Paarl and Wellington, and the TC Newman community daycare centre in Paarl East. Opened in 1977, the TC Newman clinic is named after Dr Thomas Charles Newman, the first doctor of colour to open a medical practice in the area.
"The big question in the project is, what makes for a healthy child?" says 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 look very broadly to understand why some children get ill, why some children are healthy - children from the same communities."
Paediatrics is about creating better futures. - Prof Heather Zar
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. Over 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," says Zar. "So, of course, the mother is key in all of this. The mother's 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, children who have more lung disease, children who are less healthy."
They found that suffering from 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," says Zar.
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 amongst 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."
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'Where we could make a contribution'
For Zar, paediatrics was an easy choice. The eldest of five siblings, she grew up in a Johannesburg home always filled with young people. She completed 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 so much hope for the future. We felt that this is where we could make a contribution," she says.
Stein chairs the Department of Psychiatry and Mental Health at the University of Cape Town. The couple lives in Cape Town's city bowl and has three children, all in their twenties. Laughing, Zar recalls receiving her PhD practically with her son on her lap.
She describes their home as open. "We're not obsessive about things. We allow a bit of a mess." She adds that Stein is a wonderful husband and housekeeper.
In Zar's office, her ERS trophy sits next to a calabash, two chiselled dark wood figurines, and framed family photographs, including one taken on her PhD graduation day. On her walls, art recalls her own children's formative years. "I love you mum," states large letters scrawled at the top of one drawing, featuring stick figures in healthcare worker scrubs.
